Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
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/HistoryandPhysical | Version: 4.0.0-ballot | |||
| Active as of 2024-11-21 | Computable Name: HistoryandPhysical | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.1.3:2024-05-01 | ||||
A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.
The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.
Although document templates may contain any section, the following sections are specifically called out by this template:
Required Sections
Recommended Sections
Additional Sections
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalDocument |
C | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) category-34117-2: If category is present, then there shall be a category with LOINC code '34117-2'. |
 templateId |
2..* | II | ||
  Slices for templateId |
Content/Rules for all slices | |||
   templateId:history-physical |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
  @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| sdtcCategory |
0..* | CD | Used to categorize the document as a History and Physical. If present, there SHALL be a category of 34117-2 (History and physical note). | |
| code |
1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: HPDocumentType  (required) | |
| informationRecipient |
0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
 intendedRecipient |
1..1 | IntendedRecipient | ||
| participant |
C | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
| inFulfillmentOf |
0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
| componentOf |
1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
 encompassingEncounter |
1..1 | EncompassingEncounter | ||
| id |
1..* | II | ||
| effectiveTime |
1..1 | USRealmDateTimeInterval | The effectiveTime represents the time interval or point in time in which the encounter took place. | |
| responsibleParty |
C | 0..1 | InfrastructureRoot | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
| encounterParticipant |
C | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
| location |
0..1 | InfrastructureRoot | ||
| component |
1..1 | Component | ||
| structuredBody |
C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. ccrfv-or-cc-or-rfv: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. should-section-hpi: SHOULD contain a History of Present Illness Section |
| Slices for component |
12..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
 component:allergies |
1..1 | InfrastructureRoot | ||
  section |
1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:assessment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AssessmentSection | Base for all types and resources | |
| component:planOfTreatment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:assessmentAndPlan |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:chiefComplaint |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:chiefComplaintRFV |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:familyHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | FamilyHistorySection | Base for all types and resources | |
| component:generalStatus |
1..1 | InfrastructureRoot | ||
| section |
1..1 | GeneralStatusSection | Base for all types and resources | |
| component:pastMedicalHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PastMedicalHistory | Base for all types and resources | |
| component:historyPresentIllness |
0..1 | InfrastructureRoot | ||
| section |
1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:immunizations |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ImmunizationsSection | Base for all types and resources | |
| component:instructions |
0..1 | InfrastructureRoot | ||
| section |
1..1 | InstructionsSection | Base for all types and resources | |
| component:medications |
1..1 | InfrastructureRoot | ||
| section |
1..1 | MedicationsSection | Base for all types and resources | |
| component:physicalExam |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PhysicalExamSection | Base for all types and resources | |
| component:problems |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ProblemSection | Base for all types and resources | |
| component:procedures |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ProceduresSection | Base for all types and resources | |
| component:reasonForVisit |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:results |
1..1 | InfrastructureRoot | ||
| section |
1..1 | ResultsSection | Base for all types and resources | |
| component:reviewOfSystems |
1..1 | InfrastructureRoot | ||
| section |
1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns |
1..1 | InfrastructureRoot | ||
| section |
1..1 | VitalSignsSection | Base for all types and resources | |
| component:advDirectives |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ClinicalDocument.code | required | HPDocumentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.22 |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8333 | warning | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. : | |
| 1198-8343 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant | An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-8348 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty | The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| ap-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| ap-or-a-and-p | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2) | |
| category-34117-2 | error | ClinicalDocument | If category is present, then there shall be a category with LOINC code '34117-2'. : sdtcCategory.empty() or sdtcCategory.exists(code = '34117-2' and codeSystem = '2.16.840.1.113883.6.1') | |
| cc-rfv-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| ccrfv-or-cc-or-rfv | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection').exists()).exists() | |
| should-section-hpi | warning | ClinicalDocument.component.structuredBody | SHOULD contain a History of Present Illness Section : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection')) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument |
C | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant category-34117-2: If category is present, then there shall be a category with LOINC code '34117-2'. |
| realmCode |
1..1 | CS | ||
 @code |
1..1 | cs | Required Pattern: US | |
| typeId |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId |
2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| templateId:history-physical |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| id |
1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Used to categorize the document as a History and Physical. If present, there SHALL be a category of 34117-2 (History and physical note). XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: HPDocumentType (required) | |
| @code |
1..1 | cs | ||
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| confidentialityCode |
1..1 | CE | ||
| @code |
1..1 | cs | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode |
1..1 | CS | Binding: AllLanguages (required) | |
| recordTarget |
1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
| patientRole |
1..1 | PatientRole | ||
| id |
1..* | II | ||
| addr |
C | 1..* | USRealmAddress | 𝗨𝗦𝗖𝗗𝗜: Address shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | 𝗨𝗦𝗖𝗗𝗜: Phone Number / Email should-use: SHOULD contain @use |
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient |
C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| name |
C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159). shall-given: SHALL contain at least one [1..*] given (CONF:81-7157). shall-max-suffix: There may be at most one suffix 81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278). |
| administrativeGenderCode |
1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime |
C | 1..1 | TS | 𝗨𝗦𝗖𝗗𝗜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| raceCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Race Binding: Race Category Excluding Nulls (required) | |
| ethnicGroupCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Ethnicity Binding: Ethnicity (required) | |
| author |
1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| assignedAuthor |
C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| Slices for id |
1..* | II | Slice: Unordered, Open by value:root | |
| id:npi |
C | 0..1 | II | should-extension: SHOULD contain extension |
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| Slices for informant |
0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider |
0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
 assignedEntity |
1..1 | AssignedEntity | ||
| id |
1..* | II | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| assignedPerson |
1..1 | Person | ||
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| informant:non-provider |
0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. | |
| relatedEntity |
1..1 | RelatedEntity | ||
| custodian |
1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
| assignedCustodian |
1..1 | AssignedCustodian | ||
| representedCustodianOrganization |
1..1 | CustodianOrganization | ||
| id |
1..* | II | ||
| name |
1..1 | ON | ||
| telecom |
C | 1..1 | TEL | should-use: SHOULD contain @use |
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr |
C | 1..1 | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| informationRecipient |
0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
| intendedRecipient |
1..1 | IntendedRecipient | ||
| participant |
C | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) | |
| associatedEntity |
1..1 | AssociatedEntity | ||
| inFulfillmentOf |
0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
| order |
1..1 | Order | ||
| id |
1..* | II | ||
| componentOf |
1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
| encompassingEncounter |
C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| id |
1..* | II | ||
| effectiveTime |
C | 1..1 | USRealmDateTimeInterval | The effectiveTime represents the time interval or point in time in which the encounter took place. ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| responsibleParty |
C | 0..1 | InfrastructureRoot | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
| assignedEntity |
C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant |
C | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
| location |
0..1 | InfrastructureRoot | ||
| healthCareFacility |
1..1 | HealthCareFacility | ||
| component |
1..1 | Component | ||
| structuredBody |
C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. ccrfv-or-cc-or-rfv: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. should-section-hpi: SHOULD contain a History of Present Illness Section |
| Slices for component |
12..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices |
Content/Rules for all slices | |||
 section |
1..1 | Section | ||
| component:allergies |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act |
| component:assessment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AssessmentSection | Base for all types and resources | |
| component:planOfTreatment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:assessmentAndPlan |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | AssessmentandPlanSection | Base for all types and resources no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. |
| component:chiefComplaint |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:chiefComplaintRFV |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. |
| component:familyHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | FamilyHistorySection | Base for all types and resources | |
| component:generalStatus |
1..1 | InfrastructureRoot | ||
| section |
1..1 | GeneralStatusSection | Base for all types and resources | |
| component:pastMedicalHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PastMedicalHistory | Base for all types and resources | |
| component:historyPresentIllness |
0..1 | InfrastructureRoot | ||
| section |
1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:immunizations |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ImmunizationsSection | Base for all types and resources shall-immunization-activity: If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity |
| component:instructions |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | InstructionsSection | Base for all types and resources shall-instruction: If section/@nullFlavor is not present, SHALL contain at least one Instruction |
| component:medications |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | MedicationsSection | Base for all types and resources shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity |
| component:physicalExam |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PhysicalExamSection | Base for all types and resources | |
| component:problems |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ProblemSection | Base for all types and resources shall-problem-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act |
| component:procedures |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ProceduresSection | Base for all types and resources shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure |
| component:reasonForVisit |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:results |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ResultsSection | Base for all types and resources shall-result-org: If section/@nullFlavor is not present, SHALL contain at least one Result Organizer |
| component:reviewOfSystems |
1..1 | InfrastructureRoot | ||
| section |
1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | SocialHistorySection | Base for all types and resources should-smoking-status: SHOULD contain Smoking Status |
| component:vitalSigns |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | VitalSignsSection | Base for all types and resources shall-vital-signs-org: If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer |
| component:advDirectives |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | AdvanceDirectivesSection | Base for all types and resources shall-adv-directive-existence: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ClinicalDocument.code | required | HPDocumentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.22 | |
| ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
| ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8333 | warning | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. : | |
| 1198-8343 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant | An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-8348 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty | The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). : sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists() | |
| 81-9372 | error | ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| ap-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| ap-or-a-and-p | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2) | |
| category-34117-2 | error | ClinicalDocument | If category is present, then there shall be a category with LOINC code '34117-2'. : sdtcCategory.empty() or sdtcCategory.exists(code = '34117-2' and codeSystem = '2.16.840.1.113883.6.1') | |
| cc-rfv-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| ccrfv-or-cc-or-rfv | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection').exists()).exists() | |
| ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| no-a-p | error | ClinicalDocument.component.structuredBody.component:assessmentAndPlan.section | When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| no-cc-rfv | error | ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.section | When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty() | |
| shall-adv-directive-existence | error | ClinicalDocument.component.structuredBody.component:advDirectives.section | If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveExistenceObservation')).exists() | |
| shall-allergy-concern | error | ClinicalDocument.component.structuredBody.component:allergies.section | If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists() | |
| shall-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-immunization-activity | error | ClinicalDocument.component.structuredBody.component:immunizations.section | If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity')).exists() | |
| shall-instruction | error | ClinicalDocument.component.structuredBody.component:instructions.section | If section/@nullFlavor is not present, SHALL contain at least one Instruction : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHALL have at most one of each: state, city, postalCode, and country : (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1) | |
| shall-max-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-med-activity | error | ClinicalDocument.component.structuredBody.component:medications.section | If section/@nullFlavor is not present, SHALL contain at least one Medication Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists() | |
| shall-problem-concern-act | error | ClinicalDocument.component.structuredBody.component:problems.section | If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct')).exists() | |
| shall-procedure-act-procedure | error | ClinicalDocument.component.structuredBody.component:procedures.section | If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure : nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists() | |
| shall-result-org | error | ClinicalDocument.component.structuredBody.component:results.section | If section/@nullFlavor is not present, SHALL contain at least one Result Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer')).exists() | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| shall-vital-signs-org | error | ClinicalDocument.component.structuredBody.component:vitalSigns.section | If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer')).exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AverageBloodPressureOrganizer')).exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-section-hpi | warning | ClinicalDocument.component.structuredBody | SHOULD contain a History of Present Illness Section : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection')) | |
| should-smoking-status | warning | ClinicalDocument.component.structuredBody.component:socialHistory.section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | |
| should-us-code | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-shall-year | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to at least the year : nullFlavor.exists() or value.toString().length() >= 4 | |
| ts-should-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-should-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument |
C | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant category-34117-2: If category is present, then there shall be a category with LOINC code '34117-2'. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @classCode |
0..1 | cs | Binding: CDAActClass (example) Fixed Value: DOCCLIN | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| realmCode |
1..1 | CS | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: US | |
| @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) | |
| typeId |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId |
2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm |
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: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| templateId:history-physical |
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: 2.16.840.1.113883.10.20.22.1.3 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| id |
1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Used to categorize the document as a History and Physical. If present, there SHALL be a category of 34117-2 (History and physical note). XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: HPDocumentType (required) | |
| @code |
1..1 | cs | ||
| @codeSystem |
1..1 | oid, uuid, ruid | 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 | ||
| translation |
0..* | CD | ||
| title |
1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| sdtcStatusCode |
0..1 | CS | XML Namespace: urn:hl7-org:sdtc XML: statusCode (urn:hl7-org:sdtc) Binding: ActStatus (required) | |
| effectiveTime |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| confidentialityCode |
1..1 | CE | ||
| @code |
1..1 | cs | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| languageCode |
1..1 | CS | Binding: AllLanguages (required) | |
| setId |
0..1 | II | ||
| versionNumber |
0..1 | INT | ||
| copyTime |
0..1 | TS | ||
| recordTarget |
1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: RCT | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| patientRole |
1..1 | PatientRole | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| id |
1..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr |
C | 1..* | USRealmAddress | 𝗨𝗦𝗖𝗗𝗜: Address shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | 𝗨𝗦𝗖𝗗𝗜: Phone Number / Email should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
 useablePeriod |
0..* | |||
 useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient |
C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
0..1 | II | ||
| name |
C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159). shall-given: SHALL contain at least one [1..*] given (CONF:81-7157). shall-max-suffix: There may be at most one suffix 81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode |
1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime |
C | 1..1 | TS | 𝗨𝗦𝗖𝗗𝗜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd |
0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime |
C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc 𝗨𝗦𝗖𝗗𝗜: Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcMultipleBirthInd |
0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber |
0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode |
0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode |
0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode |
0..* | CE | XML Namespace: urn:hl7-org:sdtc 𝗨𝗦𝗖𝗗𝗜: Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required) | |
| ethnicGroupCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode |
0..* | CE | XML Namespace: urn:hl7-org:sdtc 𝗨𝗦𝗖𝗗𝗜: Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian |
C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr |
C | 0..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 0..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| guardianOrganization |
0..1 | Organization | ||
| birthplace |
0..1 | Birthplace | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| place |
1..1 | Place | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
0..1 | EN | ||
| addr |
C | 1..1 | AD | 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402). 4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). should-country: SHOULD contain country |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @isNotOrdered |
0..1 | bl | ||
| @use |
0..* | cs | Binding: CDAPostalAddressUse (required) | |
| item |
C | 0..* | Base | Choice Group: This is a repeating choice group that does not appear directly in the instance AD-1: Can only have only one of the possible item elements in each choice |
| (Choice of one) |
1..1 | |||
| delimiter |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DEL | |
| country |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CNT | |
| state |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STA | |
| county |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CPA | |
| city |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CTY | |
| postalCode |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: SAL | |
| houseNumber |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: BNN | |
| direction |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DIR | |
| streetName |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STR | |
| streetNameBase |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STB | |
| streetNameType |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STTYP | |
| additionalLocator |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: ADL | |
| unitID |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: UNID | |
| unitType |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: UNIT | |
| careOf |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CAR | |
| censusTract |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: BNS | |
| postBox |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: POB | |
| precinct |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: PRE | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| languageCommunication |
C | 0..* | LanguageCommunication | 𝗨𝗦𝗖𝗗𝗜: Preferred Language should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| languageCode |
1..1 | CS | Binding: Language codes with language and optionally a region modifier (required) | |
| modeCode |
0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode |
0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd |
0..1 | BL | ||
| providerOrganization |
0..1 | Organization | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| name |
1..* | ON | ||
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| standardIndustryClassCode |
0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf |
0..1 | OrganizationPartOf | ||
| author |
1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: AUT | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| functionCode |
0..1 | CE | ||
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| assignedAuthor |
C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| Slices for id |
1..* | II | Slice: Unordered, Open by value:root | |
| id:npi |
C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor |
0..1 | cs | If NPI is unknown, set @nullFlavor to UNK Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: CDARoleCode (example) | |
| @code |
1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| (Choice of one) |
1..1 | |||
| assignedPerson |
0..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| assignedAuthoringDevice |
0..1 | AuthoringDevice | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| manufacturerModelName |
1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName |
1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity |
0..* | MaintainedEntity | ||
| representedOrganization |
0..1 | Organization | ||
| dataEnterer |
0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: ENT | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| time |
C | 0..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| Slices for informant |
0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider |
0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
0..1 | II | ||
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: INF | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). | |
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
0..* | TEL | ||
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| informant:non-provider |
0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: INF | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| relatedEntity |
1..1 | RelatedEntity | ||
| custodian |
1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CST | |
| assignedCustodian |
1..1 | AssignedCustodian | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| representedCustodianOrganization |
1..1 | CustodianOrganization | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| name |
1..1 | ON | ||
| telecom |
C | 1..1 | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| sdtcTelecom |
0..* | TEL | XML Namespace: urn:hl7-org:sdtc The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization. XML: telecom (urn:hl7-org:sdtc) | |
| addr |
C | 1..1 | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| informationRecipient |
0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: XInformationRecipient (2.0.0) (required) | |
| intendedRecipient |
1..1 | IntendedRecipient | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAInformationRecipientRole (required) | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| informationRecipient |
0..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| receivedOrganization |
0..1 | Organization | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
0..* | II | ||
| name |
1..1 | ON | ||
| telecom |
0..* | TEL | ||
| addr |
0..* | AD | ||
| standardIndustryClassCode |
0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf |
0..1 | OrganizationPartOf | ||
| legalAuthenticator |
0..1 | LegalAuthenticator | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: LA | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| signatureCode |
C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: S | |
| @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) | |
| sdtcSignatureText |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| authenticator |
0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: AUTHEN | |
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| signatureCode |
C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: S | |
| @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) | |
| sdtcSignatureText |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| participant |
C | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| functionCode |
0..1 | CE | ||
| time |
C | 0..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| associatedEntity |
1..1 | AssociatedEntity | ||
| inFulfillmentOf |
0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipFulfills (2.0.0) (required) Fixed Value: FLFS | |
| order |
1..1 | Order | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMoodIntent (required) Fixed Value: RQO | |
| id |
1..* | II | ||
| code |
0..1 | CE | Binding: v3 Code System ActCode (example) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| documentationOf |
0..* | DocumentationOf | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: DOC | |
| serviceEvent |
C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-us-performer: SHOULD contain performer |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
0..* | II | ||
| code |
0..1 | CE | ||
| effectiveTime |
C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Either @value or low/high should be present, but not both Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
C | 1..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive |
0..1 | bl | ||
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
C | 0..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive |
0..1 | bl | ||
| performer |
0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode |
C | 0..1 | CE | should-code-attr: SHOULD contain @code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| time |
C | 0..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| assignedEntity |
C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| assignedPerson |
0..1 | Person | ||
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| relatedDocument |
0..* | RelatedDocument | ||
| authorization |
0..* | Authorization | The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipAuthorizedBy (required) Fixed Value: AUTH | |
| consent |
1..1 | Consent | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) Fixed Value: CONS | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
0..* | II | ||
| code |
0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (example) | |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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) | |
| componentOf |
1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter |
C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) Fixed Value: ENC | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime |
C | 1..1 | USRealmDateTimeInterval | The effectiveTime represents the time interval or point in time in which the encounter took place. ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| sdtcAdmissionReferralSourceCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode |
0..1 | CE | Binding: USEncounterDischargeDisposition (example) | |
| responsibleParty |
C | 0..1 | InfrastructureRoot | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: RESP | |
| assignedEntity |
C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant |
C | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
| location |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility |
1..1 | HealthCareFacility | ||
| component |
1..1 | Component | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| nonXMLBody |
0..1 | NonXMLBody | ||
| structuredBody |
C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. ccrfv-or-cc-or-rfv: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. should-section-hpi: SHOULD contain a History of Present Illness Section |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| confidentialityCode |
0..1 | CE | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| Slices for component |
12..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices |
Content/Rules for all slices | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | Section | ||
| component:allergies |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act |
| component:assessment |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | AssessmentSection | Base for all types and resources | |
| component:planOfTreatment |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:assessmentAndPlan |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | AssessmentandPlanSection | Base for all types and resources no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. |
| component:chiefComplaint |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:chiefComplaintRFV |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. |
| component:familyHistory |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | FamilyHistorySection | Base for all types and resources | |
| component:generalStatus |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | GeneralStatusSection | Base for all types and resources | |
| component:pastMedicalHistory |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | PastMedicalHistory | Base for all types and resources | |
| component:historyPresentIllness |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:immunizations |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ImmunizationsSection | Base for all types and resources shall-immunization-activity: If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity |
| component:instructions |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | InstructionsSection | Base for all types and resources shall-instruction: If section/@nullFlavor is not present, SHALL contain at least one Instruction |
| component:medications |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | MedicationsSection | Base for all types and resources shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity |
| component:physicalExam |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | PhysicalExamSection | Base for all types and resources | |
| component:problems |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ProblemSection | Base for all types and resources shall-problem-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act |
| component:procedures |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ProceduresSection | Base for all types and resources shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure |
| component:reasonForVisit |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:results |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ResultsSection | Base for all types and resources shall-result-org: If section/@nullFlavor is not present, SHALL contain at least one Result Organizer |
| component:reviewOfSystems |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | SocialHistorySection | Base for all types and resources should-smoking-status: SHOULD contain Smoking Status |
| component:vitalSigns |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | VitalSignsSection | Base for all types and resources shall-vital-signs-org: If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer |
| component:advDirectives |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | AdvanceDirectivesSection | Base for all types and resources shall-adv-directive-existence: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClinicalDocument.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.classCode | example | Fixed Value: DOCCLINhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.realmCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.templateId:history-physical.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.code | required | HPDocumentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.22 | |
| ClinicalDocument.sdtcStatusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
| ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| ClinicalDocument.recordTarget.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.recordTarget.patientRole.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAThttp://terminology.hl7.org/ValueSet/v3-RoleClassRelationshipFormal | |
| ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.patient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212 | |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185 | |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914 | |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877 | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAgent | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPLhttp://terminology.hl7.org/ValueSet/v3-RoleClassPassive | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLChttp://terminology.hl7.org/ValueSet/v3-EntityClassPlace | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.use | required | CDAPostalAddressUsehttp://hl7.org/cda/stds/core/ValueSet/CDAPostalAddressUse | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | LanguageCodesWithLanguageAndOptionallyARegionModifierhttp://hl7.org/fhir/us/core/ValueSet/simple-language | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249 | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199 | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
| ClinicalDocument.author.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.typeCode | required | Fixed Value: AUThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.author.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.author.assignedAuthor.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEVhttp://terminology.hl7.org/ValueSet/v3-EntityClassDevice | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | example | CDAEntityCodehttp://hl7.org/cda/stds/core/ValueSet/CDAEntityCode | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExamplehttp://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExamplehttp://terminology.hl7.org/ValueSet/v3-SoftwareNameExample | |
| ClinicalDocument.dataEnterer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.dataEnterer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.informant:provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.informant:provider.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:non-provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:non-provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:non-provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.informant:non-provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.custodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.typeCode | required | Fixed Value: CSThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.custodian.assignedCustodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.typeCode | required | XInformationRecipienthttp://terminology.hl7.org/ValueSet/v3-xInformationRecipient|2.0.0 | |
| ClinicalDocument.informationRecipient.intendedRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.classCode | required | CDAInformationRecipientRolehttp://hl7.org/cda/stds/core/ValueSet/CDAInformationRecipientRole | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
| ClinicalDocument.legalAuthenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LAhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
| ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.typeCode | required | Fixed Value: AUTHENhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.authenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
| ClinicalDocument.authenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.authenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
| ClinicalDocument.authenticator.assignedEntity.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.participant.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.participant.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.inFulfillmentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFShttp://terminology.hl7.org/ValueSet/v3-ActRelationshipFulfills|2.0.0 | |
| ClinicalDocument.inFulfillmentOf.order.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQOhttp://hl7.org/cda/stds/core/ValueSet/CDAActMoodIntent | |
| ClinicalDocument.inFulfillmentOf.order.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| ClinicalDocument.inFulfillmentOf.order.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| ClinicalDocument.documentationOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOChttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| ClinicalDocument.documentationOf.serviceEvent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601 | |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30 | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.authorization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTHhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipAuthorizedBy | |
| ClinicalDocument.authorization.consent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.consent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONShttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.authorization.consent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| ClinicalDocument.authorization.consent.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent | |
| ClinicalDocument.componentOf.encompassingEncounter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENChttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5 | |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | example | USEncounterDischargeDispositionhttp://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition | |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESPhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOChttp://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation | |
| ClinicalDocument.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent | |
| ClinicalDocument.component.structuredBody.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODYhttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.component.structuredBody.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| ClinicalDocument.component.structuredBody.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:allergies.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:allergies.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:planOfTreatment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:planOfTreatment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessmentAndPlan.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaint.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaint.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:familyHistory.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:generalStatus.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:generalStatus.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:pastMedicalHistory.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:pastMedicalHistory.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:historyPresentIllness.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:historyPresentIllness.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:immunizations.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:immunizations.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:instructions.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:instructions.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:medications.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:medications.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:physicalExam.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:problems.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:problems.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:procedures.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:procedures.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reasonForVisit.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reasonForVisit.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:results.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:results.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reviewOfSystems.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:socialHistory.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:vitalSigns.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:advDirectives.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:advDirectives.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8333 | warning | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. : | |
| 1198-8343 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant | An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-8348 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty | The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.empty() or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). : sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists() | |
| 81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| AD-1 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item | Can only have only one of the possible item elements in each choice : (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1 | |
| ap-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| ap-or-a-and-p | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2) | |
| category-34117-2 | error | ClinicalDocument | If category is present, then there shall be a category with LOINC code '34117-2'. : sdtcCategory.empty() or sdtcCategory.exists(code = '34117-2' and codeSystem = '2.16.840.1.113883.6.1') | |
| cc-rfv-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| ccrfv-or-cc-or-rfv | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection').exists()).exists() | |
| ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| no-a-p | error | ClinicalDocument.component.structuredBody.component:assessmentAndPlan.section | When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| no-cc-rfv | error | ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.section | When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty() | |
| shall-adv-directive-existence | error | ClinicalDocument.component.structuredBody.component:advDirectives.section | If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveExistenceObservation')).exists() | |
| shall-allergy-concern | error | ClinicalDocument.component.structuredBody.component:allergies.section | If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists() | |
| shall-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-immunization-activity | error | ClinicalDocument.component.structuredBody.component:immunizations.section | If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity')).exists() | |
| shall-instruction | error | ClinicalDocument.component.structuredBody.component:instructions.section | If section/@nullFlavor is not present, SHALL contain at least one Instruction : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL have at most one of each: state, city, postalCode, and country : (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1) | |
| shall-max-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-med-activity | error | ClinicalDocument.component.structuredBody.component:medications.section | If section/@nullFlavor is not present, SHALL contain at least one Medication Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists() | |
| shall-problem-concern-act | error | ClinicalDocument.component.structuredBody.component:problems.section | If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct')).exists() | |
| shall-procedure-act-procedure | error | ClinicalDocument.component.structuredBody.component:procedures.section | If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure : nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists() | |
| shall-result-org | error | ClinicalDocument.component.structuredBody.component:results.section | If section/@nullFlavor is not present, SHALL contain at least one Result Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer')).exists() | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| shall-vital-signs-org | error | ClinicalDocument.component.structuredBody.component:vitalSigns.section | If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer')).exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AverageBloodPressureOrganizer')).exists() | |
| should-code-attr | warning | ClinicalDocument.documentationOf.serviceEvent.performer.functionCode | SHOULD contain @code : code.exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-section-hpi | warning | ClinicalDocument.component.structuredBody | SHOULD contain a History of Present Illness Section : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection')) | |
| should-smoking-status | warning | ClinicalDocument.component.structuredBody.component:socialHistory.section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X' | |
| text-null | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct | xmlText and nullFlavor are mutually exclusive (one must be present) : (xmlText | nullFlavor).count() = 1 | |
| ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-shall-year | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | **SHALL** be precise to at least the year : nullFlavor.exists() or value.toString().length() >= 4 | |
| ts-should-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-should-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
This structure is derived from USRealmHeader
Summary
Mandatory: 15 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument |
C | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) category-34117-2: If category is present, then there shall be a category with LOINC code '34117-2'. |
| templateId |
2..* | II | ||
| Slices for templateId |
Content/Rules for all slices | |||
| templateId:history-physical |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| sdtcCategory |
0..* | CD | Used to categorize the document as a History and Physical. If present, there SHALL be a category of 34117-2 (History and physical note). | |
| code |
1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: HPDocumentType (required) | |
| informationRecipient |
0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
| intendedRecipient |
1..1 | IntendedRecipient | ||
| participant |
C | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
| inFulfillmentOf |
0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
| componentOf |
1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
| encompassingEncounter |
1..1 | EncompassingEncounter | ||
| id |
1..* | II | ||
| effectiveTime |
1..1 | USRealmDateTimeInterval | The effectiveTime represents the time interval or point in time in which the encounter took place. | |
| responsibleParty |
C | 0..1 | InfrastructureRoot | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
| encounterParticipant |
C | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
| location |
0..1 | InfrastructureRoot | ||
| component |
1..1 | Component | ||
| structuredBody |
C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. ccrfv-or-cc-or-rfv: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. should-section-hpi: SHOULD contain a History of Present Illness Section |
| Slices for component |
12..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:allergies |
1..1 | InfrastructureRoot | ||
| section |
1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:assessment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AssessmentSection | Base for all types and resources | |
| component:planOfTreatment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:assessmentAndPlan |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:chiefComplaint |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:chiefComplaintRFV |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:familyHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | FamilyHistorySection | Base for all types and resources | |
| component:generalStatus |
1..1 | InfrastructureRoot | ||
| section |
1..1 | GeneralStatusSection | Base for all types and resources | |
| component:pastMedicalHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PastMedicalHistory | Base for all types and resources | |
| component:historyPresentIllness |
0..1 | InfrastructureRoot | ||
| section |
1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:immunizations |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ImmunizationsSection | Base for all types and resources | |
| component:instructions |
0..1 | InfrastructureRoot | ||
| section |
1..1 | InstructionsSection | Base for all types and resources | |
| component:medications |
1..1 | InfrastructureRoot | ||
| section |
1..1 | MedicationsSection | Base for all types and resources | |
| component:physicalExam |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PhysicalExamSection | Base for all types and resources | |
| component:problems |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ProblemSection | Base for all types and resources | |
| component:procedures |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ProceduresSection | Base for all types and resources | |
| component:reasonForVisit |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:results |
1..1 | InfrastructureRoot | ||
| section |
1..1 | ResultsSection | Base for all types and resources | |
| component:reviewOfSystems |
1..1 | InfrastructureRoot | ||
| section |
1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns |
1..1 | InfrastructureRoot | ||
| section |
1..1 | VitalSignsSection | Base for all types and resources | |
| component:advDirectives |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ClinicalDocument.code | required | HPDocumentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.22 |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8333 | warning | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. : | |
| 1198-8343 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant | An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-8348 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty | The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| ap-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| ap-or-a-and-p | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2) | |
| category-34117-2 | error | ClinicalDocument | If category is present, then there shall be a category with LOINC code '34117-2'. : sdtcCategory.empty() or sdtcCategory.exists(code = '34117-2' and codeSystem = '2.16.840.1.113883.6.1') | |
| cc-rfv-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| ccrfv-or-cc-or-rfv | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection').exists()).exists() | |
| should-section-hpi | warning | ClinicalDocument.component.structuredBody | SHOULD contain a History of Present Illness Section : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection')) |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument |
C | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant category-34117-2: If category is present, then there shall be a category with LOINC code '34117-2'. |
| realmCode |
1..1 | CS | ||
| @code |
1..1 | cs | Required Pattern: US | |
| typeId |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId |
2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| templateId:history-physical |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| id |
1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Used to categorize the document as a History and Physical. If present, there SHALL be a category of 34117-2 (History and physical note). XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: HPDocumentType (required) | |
| @code |
1..1 | cs | ||
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| confidentialityCode |
1..1 | CE | ||
| @code |
1..1 | cs | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode |
1..1 | CS | Binding: AllLanguages (required) | |
| recordTarget |
1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
| patientRole |
1..1 | PatientRole | ||
| id |
1..* | II | ||
| addr |
C | 1..* | USRealmAddress | 𝗨𝗦𝗖𝗗𝗜: Address shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | 𝗨𝗦𝗖𝗗𝗜: Phone Number / Email should-use: SHOULD contain @use |
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient |
C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| name |
C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159). shall-given: SHALL contain at least one [1..*] given (CONF:81-7157). shall-max-suffix: There may be at most one suffix 81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278). |
| administrativeGenderCode |
1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime |
C | 1..1 | TS | 𝗨𝗦𝗖𝗗𝗜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| raceCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Race Binding: Race Category Excluding Nulls (required) | |
| ethnicGroupCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Ethnicity Binding: Ethnicity (required) | |
| author |
1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| assignedAuthor |
C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| Slices for id |
1..* | II | Slice: Unordered, Open by value:root | |
| id:npi |
C | 0..1 | II | should-extension: SHOULD contain extension |
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| Slices for informant |
0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider |
0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
| assignedEntity |
1..1 | AssignedEntity | ||
| id |
1..* | II | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| assignedPerson |
1..1 | Person | ||
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| informant:non-provider |
0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. | |
| relatedEntity |
1..1 | RelatedEntity | ||
| custodian |
1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
| assignedCustodian |
1..1 | AssignedCustodian | ||
| representedCustodianOrganization |
1..1 | CustodianOrganization | ||
| id |
1..* | II | ||
| name |
1..1 | ON | ||
| telecom |
C | 1..1 | TEL | should-use: SHOULD contain @use |
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr |
C | 1..1 | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| informationRecipient |
0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
| intendedRecipient |
1..1 | IntendedRecipient | ||
| participant |
C | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) | |
| associatedEntity |
1..1 | AssociatedEntity | ||
| inFulfillmentOf |
0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
| order |
1..1 | Order | ||
| id |
1..* | II | ||
| componentOf |
1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
| encompassingEncounter |
C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| id |
1..* | II | ||
| effectiveTime |
C | 1..1 | USRealmDateTimeInterval | The effectiveTime represents the time interval or point in time in which the encounter took place. ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| responsibleParty |
C | 0..1 | InfrastructureRoot | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
| assignedEntity |
C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant |
C | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
| location |
0..1 | InfrastructureRoot | ||
| healthCareFacility |
1..1 | HealthCareFacility | ||
| component |
1..1 | Component | ||
| structuredBody |
C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. ccrfv-or-cc-or-rfv: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. should-section-hpi: SHOULD contain a History of Present Illness Section |
| Slices for component |
12..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices |
Content/Rules for all slices | |||
| section |
1..1 | Section | ||
| component:allergies |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act |
| component:assessment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | AssessmentSection | Base for all types and resources | |
| component:planOfTreatment |
0..1 | InfrastructureRoot | ||
| section |
1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:assessmentAndPlan |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | AssessmentandPlanSection | Base for all types and resources no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. |
| component:chiefComplaint |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:chiefComplaintRFV |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. |
| component:familyHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | FamilyHistorySection | Base for all types and resources | |
| component:generalStatus |
1..1 | InfrastructureRoot | ||
| section |
1..1 | GeneralStatusSection | Base for all types and resources | |
| component:pastMedicalHistory |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PastMedicalHistory | Base for all types and resources | |
| component:historyPresentIllness |
0..1 | InfrastructureRoot | ||
| section |
1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:immunizations |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ImmunizationsSection | Base for all types and resources shall-immunization-activity: If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity |
| component:instructions |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | InstructionsSection | Base for all types and resources shall-instruction: If section/@nullFlavor is not present, SHALL contain at least one Instruction |
| component:medications |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | MedicationsSection | Base for all types and resources shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity |
| component:physicalExam |
1..1 | InfrastructureRoot | ||
| section |
1..1 | PhysicalExamSection | Base for all types and resources | |
| component:problems |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ProblemSection | Base for all types and resources shall-problem-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act |
| component:procedures |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ProceduresSection | Base for all types and resources shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure |
| component:reasonForVisit |
0..1 | InfrastructureRoot | ||
| section |
1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:results |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | ResultsSection | Base for all types and resources shall-result-org: If section/@nullFlavor is not present, SHALL contain at least one Result Organizer |
| component:reviewOfSystems |
1..1 | InfrastructureRoot | ||
| section |
1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | SocialHistorySection | Base for all types and resources should-smoking-status: SHOULD contain Smoking Status |
| component:vitalSigns |
1..1 | InfrastructureRoot | ||
| section |
C | 1..1 | VitalSignsSection | Base for all types and resources shall-vital-signs-org: If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer |
| component:advDirectives |
0..1 | InfrastructureRoot | ||
| section |
C | 1..1 | AdvanceDirectivesSection | Base for all types and resources shall-adv-directive-existence: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ClinicalDocument.code | required | HPDocumentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.22 | |
| ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
| ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8333 | warning | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. : | |
| 1198-8343 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant | An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-8348 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty | The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). : sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists() | |
| 81-9372 | error | ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| ap-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| ap-or-a-and-p | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2) | |
| category-34117-2 | error | ClinicalDocument | If category is present, then there shall be a category with LOINC code '34117-2'. : sdtcCategory.empty() or sdtcCategory.exists(code = '34117-2' and codeSystem = '2.16.840.1.113883.6.1') | |
| cc-rfv-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| ccrfv-or-cc-or-rfv | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection').exists()).exists() | |
| ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| no-a-p | error | ClinicalDocument.component.structuredBody.component:assessmentAndPlan.section | When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| no-cc-rfv | error | ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.section | When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty() | |
| shall-adv-directive-existence | error | ClinicalDocument.component.structuredBody.component:advDirectives.section | If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveExistenceObservation')).exists() | |
| shall-allergy-concern | error | ClinicalDocument.component.structuredBody.component:allergies.section | If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists() | |
| shall-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-immunization-activity | error | ClinicalDocument.component.structuredBody.component:immunizations.section | If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity')).exists() | |
| shall-instruction | error | ClinicalDocument.component.structuredBody.component:instructions.section | If section/@nullFlavor is not present, SHALL contain at least one Instruction : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHALL have at most one of each: state, city, postalCode, and country : (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1) | |
| shall-max-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-med-activity | error | ClinicalDocument.component.structuredBody.component:medications.section | If section/@nullFlavor is not present, SHALL contain at least one Medication Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists() | |
| shall-problem-concern-act | error | ClinicalDocument.component.structuredBody.component:problems.section | If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct')).exists() | |
| shall-procedure-act-procedure | error | ClinicalDocument.component.structuredBody.component:procedures.section | If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure : nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists() | |
| shall-result-org | error | ClinicalDocument.component.structuredBody.component:results.section | If section/@nullFlavor is not present, SHALL contain at least one Result Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer')).exists() | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| shall-vital-signs-org | error | ClinicalDocument.component.structuredBody.component:vitalSigns.section | If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer')).exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AverageBloodPressureOrganizer')).exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-section-hpi | warning | ClinicalDocument.component.structuredBody | SHOULD contain a History of Present Illness Section : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection')) | |
| should-smoking-status | warning | ClinicalDocument.component.structuredBody.component:socialHistory.section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | |
| should-us-code | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-shall-year | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to at least the year : nullFlavor.exists() or value.toString().length() >= 4 | |
| ts-should-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-should-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument |
C | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant category-34117-2: If category is present, then there shall be a category with LOINC code '34117-2'. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @classCode |
0..1 | cs | Binding: CDAActClass (example) Fixed Value: DOCCLIN | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| realmCode |
1..1 | CS | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: US | |
| @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) | |
| typeId |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId |
2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm |
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: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| templateId:history-physical |
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: 2.16.840.1.113883.10.20.22.1.3 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| id |
1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Used to categorize the document as a History and Physical. If present, there SHALL be a category of 34117-2 (History and physical note). XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: HPDocumentType (required) | |
| @code |
1..1 | cs | ||
| @codeSystem |
1..1 | oid, uuid, ruid | 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 | ||
| translation |
0..* | CD | ||
| title |
1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| sdtcStatusCode |
0..1 | CS | XML Namespace: urn:hl7-org:sdtc XML: statusCode (urn:hl7-org:sdtc) Binding: ActStatus (required) | |
| effectiveTime |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| confidentialityCode |
1..1 | CE | ||
| @code |
1..1 | cs | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| languageCode |
1..1 | CS | Binding: AllLanguages (required) | |
| setId |
0..1 | II | ||
| versionNumber |
0..1 | INT | ||
| copyTime |
0..1 | TS | ||
| recordTarget |
1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: RCT | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| patientRole |
1..1 | PatientRole | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| id |
1..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr |
C | 1..* | USRealmAddress | 𝗨𝗦𝗖𝗗𝗜: Address shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | 𝗨𝗦𝗖𝗗𝗜: Phone Number / Email should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient |
C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
0..1 | II | ||
| name |
C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159). shall-given: SHALL contain at least one [1..*] given (CONF:81-7157). shall-max-suffix: There may be at most one suffix 81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode |
1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime |
C | 1..1 | TS | 𝗨𝗦𝗖𝗗𝗜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd |
0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime |
C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc 𝗨𝗦𝗖𝗗𝗜: Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcMultipleBirthInd |
0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber |
0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode |
0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode |
0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode |
0..* | CE | XML Namespace: urn:hl7-org:sdtc 𝗨𝗦𝗖𝗗𝗜: Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required) | |
| ethnicGroupCode |
1..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode |
0..* | CE | XML Namespace: urn:hl7-org:sdtc 𝗨𝗦𝗖𝗗𝗜: Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian |
C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr |
C | 0..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 0..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| guardianOrganization |
0..1 | Organization | ||
| birthplace |
0..1 | Birthplace | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| place |
1..1 | Place | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
0..1 | EN | ||
| addr |
C | 1..1 | AD | 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402). 4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). should-country: SHOULD contain country |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @isNotOrdered |
0..1 | bl | ||
| @use |
0..* | cs | Binding: CDAPostalAddressUse (required) | |
| item |
C | 0..* | Base | Choice Group: This is a repeating choice group that does not appear directly in the instance AD-1: Can only have only one of the possible item elements in each choice |
| (Choice of one) |
1..1 | |||
| delimiter |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DEL | |
| country |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CNT | |
| state |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STA | |
| county |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CPA | |
| city |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CTY | |
| postalCode |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: SAL | |
| houseNumber |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: BNN | |
| direction |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DIR | |
| streetName |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STR | |
| streetNameBase |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STB | |
| streetNameType |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: STTYP | |
| additionalLocator |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: ADL | |
| unitID |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: UNID | |
| unitType |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: UNIT | |
| careOf |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CAR | |
| censusTract |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: BNS | |
| postBox |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: POB | |
| precinct |
C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| @representation |
0..1 | cs | Fixed Value: TXT | |
| @mediaType |
0..1 | cs | Fixed Value: text/plain | |
| @language |
0..1 | cs | ||
| @partType |
0..1 | cs | Fixed Value: PRE | |
| xmlText |
0..1 | st | Allows for mixed text content | |
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| languageCommunication |
C | 0..* | LanguageCommunication | 𝗨𝗦𝗖𝗗𝗜: Preferred Language should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| languageCode |
1..1 | CS | Binding: Language codes with language and optionally a region modifier (required) | |
| modeCode |
0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode |
0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd |
0..1 | BL | ||
| providerOrganization |
0..1 | Organization | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| name |
1..* | ON | ||
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| standardIndustryClassCode |
0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf |
0..1 | OrganizationPartOf | ||
| author |
1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: AUT | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| functionCode |
0..1 | CE | ||
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| assignedAuthor |
C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| Slices for id |
1..* | II | Slice: Unordered, Open by value:root | |
| id:npi |
C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor |
0..1 | cs | If NPI is unknown, set @nullFlavor to UNK Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: CDARoleCode (example) | |
| @code |
1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| (Choice of one) |
1..1 | |||
| assignedPerson |
0..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| assignedAuthoringDevice |
0..1 | AuthoringDevice | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| manufacturerModelName |
1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName |
1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity |
0..* | MaintainedEntity | ||
| representedOrganization |
0..1 | Organization | ||
| dataEnterer |
0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: ENT | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| time |
C | 0..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| Slices for informant |
0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider |
0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: INF | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). | |
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
0..* | TEL | ||
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| informant:non-provider |
0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: INF | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| relatedEntity |
1..1 | RelatedEntity | ||
| custodian |
1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CST | |
| assignedCustodian |
1..1 | AssignedCustodian | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| representedCustodianOrganization |
1..1 | CustodianOrganization | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| name |
1..1 | ON | ||
| telecom |
C | 1..1 | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| sdtcTelecom |
0..* | TEL | XML Namespace: urn:hl7-org:sdtc The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization. XML: telecom (urn:hl7-org:sdtc) | |
| addr |
C | 1..1 | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| informationRecipient |
0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: XInformationRecipient (2.0.0) (required) | |
| intendedRecipient |
1..1 | IntendedRecipient | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAInformationRecipientRole (required) | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| informationRecipient |
0..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| receivedOrganization |
0..1 | Organization | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id |
0..* | II | ||
| name |
1..1 | ON | ||
| telecom |
0..* | TEL | ||
| addr |
0..* | AD | ||
| standardIndustryClassCode |
0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf |
0..1 | OrganizationPartOf | ||
| legalAuthenticator |
0..1 | LegalAuthenticator | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: LA | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| signatureCode |
C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: S | |
| @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) | |
| sdtcSignatureText |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| authenticator |
0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: AUTHEN | |
| time |
C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| signatureCode |
C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: S | |
| @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) | |
| sdtcSignatureText |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| addr |
C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
| telecom |
C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson |
1..1 | Person | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name |
C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
| sdtcDesc |
0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
1..1 | cs | Fixed Value: PRS | |
| @determinerCode |
0..1 | cs | Fixed Value: INSTANCE | |
| code |
1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| participant |
C | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| functionCode |
0..1 | CE | ||
| time |
C | 0..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| associatedEntity |
1..1 | AssociatedEntity | ||
| inFulfillmentOf |
0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipFulfills (2.0.0) (required) Fixed Value: FLFS | |
| order |
1..1 | Order | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMoodIntent (required) Fixed Value: RQO | |
| id |
1..* | II | ||
| code |
0..1 | CE | Binding: v3 Code System ActCode (example) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| documentationOf |
0..* | DocumentationOf | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: DOC | |
| serviceEvent |
C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-us-performer: SHOULD contain performer |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
0..* | II | ||
| code |
0..1 | CE | ||
| effectiveTime |
C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Either @value or low/high should be present, but not both Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
C | 1..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive |
0..1 | bl | ||
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
C | 0..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive |
0..1 | bl | ||
| performer |
0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode |
C | 0..1 | CE | should-code-attr: SHOULD contain @code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| translation |
0..* | CD | ||
| time |
C | 0..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| assignedEntity |
C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension |
0..1 | st | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| assignedPerson |
0..1 | Person | ||
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| relatedDocument |
0..* | RelatedDocument | ||
| authorization |
0..* | Authorization | The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipAuthorizedBy (required) Fixed Value: AUTH | |
| consent |
1..1 | Consent | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) Fixed Value: CONS | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
0..* | II | ||
| code |
0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (example) | |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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) | |
| componentOf |
1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter |
C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: CDAActClass (required) Fixed Value: ENC | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime |
C | 1..1 | USRealmDateTimeInterval | The effectiveTime represents the time interval or point in time in which the encounter took place. ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
| sdtcAdmissionReferralSourceCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode |
0..1 | CE | Binding: USEncounterDischargeDisposition (example) | |
| responsibleParty |
C | 0..1 | InfrastructureRoot | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: RESP | |
| assignedEntity |
C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant |
C | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
| location |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility |
1..1 | HealthCareFacility | ||
| component |
1..1 | Component | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| nonXMLBody |
0..1 | NonXMLBody | ||
| structuredBody |
C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. ccrfv-or-cc-or-rfv: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. should-section-hpi: SHOULD contain a History of Present Illness Section |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @classCode |
0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| confidentialityCode |
0..1 | CE | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| Slices for component |
12..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices |
Content/Rules for all slices | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | Section | ||
| component:allergies |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act |
| component:assessment |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | AssessmentSection | Base for all types and resources | |
| component:planOfTreatment |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:assessmentAndPlan |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | AssessmentandPlanSection | Base for all types and resources no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. |
| component:chiefComplaint |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:chiefComplaintRFV |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. |
| component:familyHistory |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | FamilyHistorySection | Base for all types and resources | |
| component:generalStatus |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | GeneralStatusSection | Base for all types and resources | |
| component:pastMedicalHistory |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | PastMedicalHistory | Base for all types and resources | |
| component:historyPresentIllness |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:immunizations |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ImmunizationsSection | Base for all types and resources shall-immunization-activity: If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity |
| component:instructions |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | InstructionsSection | Base for all types and resources shall-instruction: If section/@nullFlavor is not present, SHALL contain at least one Instruction |
| component:medications |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | MedicationsSection | Base for all types and resources shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity |
| component:physicalExam |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | PhysicalExamSection | Base for all types and resources | |
| component:problems |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ProblemSection | Base for all types and resources shall-problem-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act |
| component:procedures |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ProceduresSection | Base for all types and resources shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure |
| component:reasonForVisit |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:results |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | ResultsSection | Base for all types and resources shall-result-org: If section/@nullFlavor is not present, SHALL contain at least one Result Organizer |
| component:reviewOfSystems |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | SocialHistorySection | Base for all types and resources should-smoking-status: SHOULD contain Smoking Status |
| component:vitalSigns |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | VitalSignsSection | Base for all types and resources shall-vital-signs-org: If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer |
| component:advDirectives |
0..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
C | 1..1 | AdvanceDirectivesSection | Base for all types and resources shall-adv-directive-existence: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClinicalDocument.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.classCode | example | Fixed Value: DOCCLINhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.realmCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.templateId:history-physical.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.code | required | HPDocumentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.22 | |
| ClinicalDocument.sdtcStatusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
| ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| ClinicalDocument.recordTarget.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.recordTarget.patientRole.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAThttp://terminology.hl7.org/ValueSet/v3-RoleClassRelationshipFormal | |
| ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.patient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212 | |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185 | |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914 | |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877 | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAgent | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPLhttp://terminology.hl7.org/ValueSet/v3-RoleClassPassive | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLChttp://terminology.hl7.org/ValueSet/v3-EntityClassPlace | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.use | required | CDAPostalAddressUsehttp://hl7.org/cda/stds/core/ValueSet/CDAPostalAddressUse | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | LanguageCodesWithLanguageAndOptionallyARegionModifierhttp://hl7.org/fhir/us/core/ValueSet/simple-language | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249 | |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199 | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
| ClinicalDocument.author.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.typeCode | required | Fixed Value: AUThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.author.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.author.assignedAuthor.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEVhttp://terminology.hl7.org/ValueSet/v3-EntityClassDevice | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | example | CDAEntityCodehttp://hl7.org/cda/stds/core/ValueSet/CDAEntityCode | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExamplehttp://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample | |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExamplehttp://terminology.hl7.org/ValueSet/v3-SoftwareNameExample | |
| ClinicalDocument.dataEnterer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.dataEnterer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.informant:provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.informant:provider.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:non-provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:non-provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informant:non-provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.informant:non-provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.custodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.typeCode | required | Fixed Value: CSThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.custodian.assignedCustodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.typeCode | required | XInformationRecipienthttp://terminology.hl7.org/ValueSet/v3-xInformationRecipient|2.0.0 | |
| ClinicalDocument.informationRecipient.intendedRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.classCode | required | CDAInformationRecipientRolehttp://hl7.org/cda/stds/core/ValueSet/CDAInformationRecipientRole | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
| ClinicalDocument.legalAuthenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LAhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
| ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.typeCode | required | Fixed Value: AUTHENhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.authenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
| ClinicalDocument.authenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.authenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
| ClinicalDocument.authenticator.assignedEntity.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.participant.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.participant.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| ClinicalDocument.inFulfillmentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFShttp://terminology.hl7.org/ValueSet/v3-ActRelationshipFulfills|2.0.0 | |
| ClinicalDocument.inFulfillmentOf.order.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQOhttp://hl7.org/cda/stds/core/ValueSet/CDAActMoodIntent | |
| ClinicalDocument.inFulfillmentOf.order.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| ClinicalDocument.inFulfillmentOf.order.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| ClinicalDocument.documentationOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOChttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| ClinicalDocument.documentationOf.serviceEvent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601 | |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30 | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
| ClinicalDocument.authorization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTHhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipAuthorizedBy | |
| ClinicalDocument.authorization.consent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.consent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONShttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.authorization.consent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| ClinicalDocument.authorization.consent.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent | |
| ClinicalDocument.componentOf.encompassingEncounter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENChttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5 | |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | example | USEncounterDischargeDispositionhttp://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition | |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESPhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOChttp://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation | |
| ClinicalDocument.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent | |
| ClinicalDocument.component.structuredBody.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODYhttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| ClinicalDocument.component.structuredBody.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| ClinicalDocument.component.structuredBody.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:allergies.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:allergies.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:planOfTreatment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:planOfTreatment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:assessmentAndPlan.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaint.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaint.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:familyHistory.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:generalStatus.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:generalStatus.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:pastMedicalHistory.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:pastMedicalHistory.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:historyPresentIllness.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:historyPresentIllness.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:immunizations.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:immunizations.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:instructions.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:instructions.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:medications.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:medications.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:physicalExam.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:problems.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:problems.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:procedures.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:procedures.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reasonForVisit.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reasonForVisit.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:results.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:results.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:reviewOfSystems.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:socialHistory.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:vitalSigns.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:advDirectives.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| ClinicalDocument.component.structuredBody.component:advDirectives.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8333 | warning | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. : | |
| 1198-8343 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant | An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-8348 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty | The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). : assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists() | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.empty() or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). : sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists() | |
| 81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| AD-1 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item | Can only have only one of the possible item elements in each choice : (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1 | |
| ap-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| ap-or-a-and-p | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2) | |
| category-34117-2 | error | ClinicalDocument | If category is present, then there shall be a category with LOINC code '34117-2'. : sdtcCategory.empty() or sdtcCategory.exists(code = '34117-2' and codeSystem = '2.16.840.1.113883.6.1') | |
| cc-rfv-combo | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| ccrfv-or-cc-or-rfv | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12). : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection').exists() or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection').exists()).exists() | |
| ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| no-a-p | error | ClinicalDocument.component.structuredBody.component:assessmentAndPlan.section | When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty() | |
| no-cc-rfv | error | ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.section | When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used. : %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty() | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty() | |
| shall-adv-directive-existence | error | ClinicalDocument.component.structuredBody.component:advDirectives.section | If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Existence Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveExistenceObservation')).exists() | |
| shall-allergy-concern | error | ClinicalDocument.component.structuredBody.component:allergies.section | If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists() | |
| shall-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-immunization-activity | error | ClinicalDocument.component.structuredBody.component:immunizations.section | If section/@nullFlavor is not present, SHALL contain at least one Immunization Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity')).exists() | |
| shall-instruction | error | ClinicalDocument.component.structuredBody.component:instructions.section | If section/@nullFlavor is not present, SHALL contain at least one Instruction : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL have at most one of each: state, city, postalCode, and country : (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1) | |
| shall-max-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-med-activity | error | ClinicalDocument.component.structuredBody.component:medications.section | If section/@nullFlavor is not present, SHALL contain at least one Medication Activity : nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists() | |
| shall-problem-concern-act | error | ClinicalDocument.component.structuredBody.component:problems.section | If section/@nullFlavor is not present, SHALL contain at least one Problem Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct')).exists() | |
| shall-procedure-act-procedure | error | ClinicalDocument.component.structuredBody.component:procedures.section | If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure : nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists() | |
| shall-result-org | error | ClinicalDocument.component.structuredBody.component:results.section | If section/@nullFlavor is not present, SHALL contain at least one Result Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer')).exists() | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| shall-vital-signs-org | error | ClinicalDocument.component.structuredBody.component:vitalSigns.section | If section/@nullFlavor is not present, SHALL contain at least one Vital Signs Organizer or Average Blood Pressure Organizer : nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer')).exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AverageBloodPressureOrganizer')).exists() | |
| should-code-attr | warning | ClinicalDocument.documentationOf.serviceEvent.performer.functionCode | SHOULD contain @code : code.exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-section-hpi | warning | ClinicalDocument.component.structuredBody | SHOULD contain a History of Present Illness Section : component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection')) | |
| should-smoking-status | warning | ClinicalDocument.component.structuredBody.component:socialHistory.section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X' | |
| text-null | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct | xmlText and nullFlavor are mutually exclusive (one must be present) : (xmlText | nullFlavor).count() = 1 | |
| ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-shall-year | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | **SHALL** be precise to at least the year : nullFlavor.exists() or value.toString().length() >= 4 | |
| ts-should-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-should-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
This structure is derived from USRealmHeader
Summary
Mandatory: 15 elements
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 2024-11-21
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