Consolidated CDA (C-CDA)
4.0.0 - STU4
Consolidated CDA (C-CDA)
4.0.0 - 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 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/NoteActivity | Version: 4.0.0 | |||
| Draft as of 2025-10-02 | Computable Name: NoteActivity | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.202:2016-11-01 | ||||
The Note Activity represents a clinical note. Notes require authorship, authentication, timing information, and references to other discrete data such as encounters. Similar to the Comment Activity, the Note Activity permits a more specific code to characterize the type of information available in the note. The Note Activity template SHOULD NOT be used in place of a more specific C-CDA entry. Note information included needs to be relevant and pertinent to the information being communicated in the document. When the note information augments data represented in a more specific entry template, the Note Activity can be used in an entryRelationship to the associated standard C-CDA entry. For example, a Procedure Note added as an entryRelationship to a Procedure Activity Procedure entry). The Note Activity template can be used as a standalone entry within a standard C-CDA section (e.g., a note about various procedures which have occurred during a visit as an entry in the Procedures Section) when it does not augment another standard entry. It may also be used to provide additional data about the source of a currently narrative-only section, such as Hospital Course. Finally, if the type of data in the note is not known or no single C-CDA section is appropriate enough, the Note Activity should be placed in a Notes Section. (e.g., a free-text consultation note or a note which includes subjective, objective, assessment, and plan information combined). An alternative is to place the Note Activity as an entryRelationship to an Encounter Activity entry in the Encounters Section, but implementers may wish to group notes categorically into a separate location in CDA documents rather than overloading the Encounters Section.
The narrative Clinical Notes required in USCDI, along with their associated LOINC codes, are outlined below. These note types are included in the Note Types Value Set, which is bound to Act.code.translation.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 3.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:note-activity |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.202 | |
  @extension |
1..1 | st | Required Pattern: 2016-11-01 | |
 @classCode |
1..1 | cs | Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| code |
C | 1..1 | CD | Constraints: should-translation |
| @code |
1..1 | cs | Required Pattern: 34109-9 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
 translation |
0..* | CD | If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). Binding: Note Types  (preferred) | |
| text |
C | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry Constraints: 3250-16912 |
| @mediaType |
0..1 | cs | If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative. Binding: SupportedFileFormats (preferred) | |
 reference |
C | 1..1 | TEL | Constraints: value-starts-octothorpe |
| @nullFlavor |
0..0 | |||
| @value |
1..1 | url | ||
| statusCode |
1..1 | CS | Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. | |
| effectiveTime |
C | 1..1 | IVL_TS | The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time. Constraints: should-value-att |
| @value |
0..1 | ts | ||
 author |
1..* | AuthorParticipation | Represents the person(s) who wrote the note. | |
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:legalAuthenticator |
0..* | Participant2 | Represents the person(s) legally responsible for the contents of the note. | |
| @typeCode |
1..1 | cs | Fixed Value: LA | |
| time |
1..1 | USRealmDateTimeInterval | Indicates the time of signing the note. | |
 participantRole |
C | 1..1 | ParticipantRole | Constraints: 3250-16930 |
| id |
1..* | II | This may be the ID of the note author. If so, no additional information in this participant is required. | |
| playingEntity |
0..1 | PlayingEntity | ||
| name |
1..* | USRealmPersonNamePNUSFIELDED | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by exists:encounter | |
| entryRelationship:encounter |
0..* | EntryRelationship | Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter. | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @negationInd |
0..1 | bl | To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter. | |
| encounter |
1..1 | Encounter | ||
| id |
C | 1..* | II | Constraints: 3250-16914 |
| Slices for reference |
0..* | Reference | Slice: Unordered, Open by exists:externalDocument | |
| reference:externalDocument |
0..* | Reference | Represents an unstructured C-CDA document containing the original contents of the note in the original format. | |
| externalDocument |
C | 1..1 | ExternalDocument | Constraints: should-code |
| id |
1..1 | II | ||
| code |
0..1 | CD | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Act.code.translation | Base | preferred |
Note Types
|
📦20240606 | VSAC v0.23 |
| Act.text.mediaType | Base | preferred |
SupportedFileFormats
|
📦20240606 | VSAC v0.23 |
| Id | Grade | Path(s) | Description | Expression |
| 3250-16912 | error | Act.text | If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912). |
mediaType.exists() implies (representation = 'B64' and xmlText.exists())
|
| 3250-16914 | error | Act.entryRelationship:encounter.encounter.id | If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914). |
|
| 3250-16930 | error | Act.participant:legalAuthenticator.participantRole | If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930). |
|
| should-code | warning | Act.reference:externalDocument.externalDocument | SHOULD contain code |
code.exists()
|
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Act.code | SHOULD contain translation |
translation.exists()
|
| should-value-att | warning | Act.effectiveTime | SHOULD contain @value |
value.exists()
|
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
value.exists() implies value.startsWith('#')
|
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value |
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:note-activity |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.202 | |
| @extension |
1..1 | st | Required Pattern: 2016-11-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
0..* | II | ||
| code |
C | 1..1 | CD | Binding: v3 Code System ActCode (example) Constraints: should-translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 34109-9 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). Binding: Note Types (preferred) | |
| text |
C | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry Constraints: 3250-16912 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative. Binding: SupportedFileFormats (preferred) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 1..1 | TEL | Constraints: value-starts-octothorpe |
| @value |
1..1 | url | ||
 useablePeriod |
0..* | |||
 useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..* | cs | Binding: TelecommunicationAddressUse (2.0.0) (required) | |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. Binding: ActStatus (required) | |
| effectiveTime |
C | 1..1 | IVL_TS | The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time. Constraints: should-value-att |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
0..1 | IVXB_TS | ||
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
0..1 | IVXB_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
1..* | AuthorParticipation | Represents the person(s) who wrote the note. | |
| informant |
0..* | Informant | ||
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:legalAuthenticator |
0..* | Participant2 | Represents the person(s) legally responsible for the contents of the note. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
C | 0..1 | II | Constraints: II-1 |
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) Fixed Value: LA | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
1..1 | USRealmDateTimeInterval | Indicates the time of signing the note. | |
| awarenessCode |
0..1 | CE | ||
| participantRole |
C | 1..1 | ParticipantRole | Constraints: 3250-16930 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDARoleClassRoot (required) | |
| id |
1..* | II | This may be the ID of the note author. If so, no additional information in this participant is required. | |
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: EntityClassRoot (required) | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
1..* | USRealmPersonNamePNUSFIELDED | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by exists:encounter | |
| entryRelationship:encounter |
0..* | EntryRelationship | Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter. | |
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
1..1 | Encounter | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | Binding: CDAActClass (required) Fixed Value: ENC | |
| @moodCode |
1..1 | cs | Binding: XDocumentEncounterMood (2.0.0) (required) | |
| id |
C | 1..* | II | Constraints: 3250-16914 |
| code |
0..1 | CD | Binding: ActEncounterCode (example) | |
| text |
0..1 | ED | ||
| statusCode |
0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime |
0..1 | IVL_TS | ||
| sdtcDischargeDispositionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| observation |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| Slices for reference |
0..* | Reference | Slice: Unordered, Open by exists:externalDocument | |
| reference:externalDocument |
0..* | Reference | Represents an unstructured C-CDA document containing the original contents of the note in the original format. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipExternalReference (required) | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocument | Constraints: should-code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: ActClassDocument (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
1..1 | II | ||
| code |
0..1 | CD | Binding: FHIRDocumentTypeCodes (example) | |
| text |
0..1 | ED | ||
| setId |
0..1 | II | ||
| versionNumber |
0..1 | INT | ||
| sdtcAuthor |
0..* | Author | XML Namespace: urn:hl7-org:sdtc XML: author (urn:hl7-org:sdtc) | |
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Act.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.templateId:note-activity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.classCode | Base | required | x_ActClassDocumentEntryAct | 📍2.0.0 | THO v5.2 |
| Act.moodCode | Base | required | x_DocumentActMood | 📍2.0.0 | THO v5.2 |
| Act.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Act.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.code.translation | Base | preferred |
Note Types
|
📦20240606 | VSAC v0.23 |
| Act.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Act.text.mediaType | Base | preferred |
SupportedFileFormats
|
📦20240606 | VSAC v0.23 |
| Act.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.reference.use | Base | required | TelecommunicationAddressUse | 📍2.0.0 | THO v5.2 |
| Act.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.effectiveTime.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.effectiveTime.operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Act.participant:legalAuthenticator.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.classCode | Base | required | CDAActClass | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.moodCode | Base | required | x_DocumentEncounterMood | 📍2.0.0 | THO v5.2 |
| Act.entryRelationship:encounter.​encounter.code | Base | example | ActEncounterCode | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeCode | Base | required | x_ActRelationshipExternalReference | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.classCode | Base | required | ActClassDocument | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.code | Base | example | FHIR Document Type Codes | 📦5.0.0 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 3250-16912 | error | Act.text | If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912). |
mediaType.exists() implies (representation = 'B64' and xmlText.exists())
|
| 3250-16914 | error | Act.entryRelationship:encounter.encounter.id | If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914). |
|
| 3250-16930 | error | Act.participant:legalAuthenticator.participantRole | If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930). |
|
| II-1 | error | Act.typeId, Act.participant:legalAuthenticator.typeId, Act.participant:legalAuthenticator.participantRole.typeId, Act.participant:legalAuthenticator.participantRole.playingEntity.typeId, Act.entryRelationship:encounter.typeId, Act.entryRelationship:encounter.encounter.typeId, Act.reference:externalDocument.typeId, Act.reference:externalDocument.externalDocument.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-code | warning | Act.reference:externalDocument.externalDocument | SHOULD contain code |
code.exists()
|
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Act.code | SHOULD contain translation |
translation.exists()
|
| should-value-att | warning | Act.effectiveTime | SHOULD contain @value |
value.exists()
|
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
value.exists() implies value.startsWith('#')
|
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:note-activity |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.202 | |
| @extension |
1..1 | st | Required Pattern: 2016-11-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
0..* | II | ||
| code |
C | 1..1 | CD | Binding: v3 Code System ActCode (example) Constraints: should-translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 34109-9 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). Binding: Note Types (preferred) | |
| text |
C | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry Constraints: 3250-16912 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative. Binding: SupportedFileFormats (preferred) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 1..1 | TEL | Constraints: value-starts-octothorpe |
| @value |
1..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..* | cs | Binding: TelecommunicationAddressUse (2.0.0) (required) | |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. Binding: ActStatus (required) | |
| effectiveTime |
C | 1..1 | IVL_TS | The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time. Constraints: should-value-att |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
0..1 | IVXB_TS | ||
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
0..1 | IVXB_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
1..* | AuthorParticipation | Represents the person(s) who wrote the note. | |
| informant |
0..* | Informant | ||
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:legalAuthenticator |
0..* | Participant2 | Represents the person(s) legally responsible for the contents of the note. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) Fixed Value: LA | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
1..1 | USRealmDateTimeInterval | Indicates the time of signing the note. | |
| awarenessCode |
0..1 | CE | ||
| participantRole |
C | 1..1 | ParticipantRole | Constraints: 3250-16930 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDARoleClassRoot (required) | |
| id |
1..* | II | This may be the ID of the note author. If so, no additional information in this participant is required. | |
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: EntityClassRoot (required) | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
1..* | USRealmPersonNamePNUSFIELDED | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by exists:encounter | |
| entryRelationship:encounter |
0..* | EntryRelationship | Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter. | |
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
1..1 | Encounter | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | Binding: CDAActClass (required) Fixed Value: ENC | |
| @moodCode |
1..1 | cs | Binding: XDocumentEncounterMood (2.0.0) (required) | |
| id |
C | 1..* | II | Constraints: 3250-16914 |
| code |
0..1 | CD | Binding: ActEncounterCode (example) | |
| text |
0..1 | ED | ||
| statusCode |
0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime |
0..1 | IVL_TS | ||
| sdtcDischargeDispositionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| observation |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| Slices for reference |
0..* | Reference | Slice: Unordered, Open by exists:externalDocument | |
| reference:externalDocument |
0..* | Reference | Represents an unstructured C-CDA document containing the original contents of the note in the original format. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipExternalReference (required) | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocument | Constraints: should-code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: ActClassDocument (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
1..1 | II | ||
| code |
0..1 | CD | Binding: FHIRDocumentTypeCodes (example) | |
| text |
0..1 | ED | ||
| setId |
0..1 | II | ||
| versionNumber |
0..1 | INT | ||
| sdtcAuthor |
0..* | Author | XML Namespace: urn:hl7-org:sdtc XML: author (urn:hl7-org:sdtc) | |
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Act.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.templateId:note-activity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.classCode | Base | required | x_ActClassDocumentEntryAct | 📍2.0.0 | THO v5.2 |
| Act.moodCode | Base | required | x_DocumentActMood | 📍2.0.0 | THO v5.2 |
| Act.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Act.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.code.translation | Base | preferred |
Note Types
|
📦20240606 | VSAC v0.23 |
| Act.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Act.text.mediaType | Base | preferred |
SupportedFileFormats
|
📦20240606 | VSAC v0.23 |
| Act.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.reference.use | Base | required | TelecommunicationAddressUse | 📍2.0.0 | THO v5.2 |
| Act.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.effectiveTime.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.effectiveTime.operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Act.participant:legalAuthenticator.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.classCode | Base | required | CDAActClass | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.moodCode | Base | required | x_DocumentEncounterMood | 📍2.0.0 | THO v5.2 |
| Act.entryRelationship:encounter.​encounter.code | Base | example | ActEncounterCode | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeCode | Base | required | x_ActRelationshipExternalReference | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.classCode | Base | required | ActClassDocument | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.code | Base | example | FHIR Document Type Codes | 📦5.0.0 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 3250-16912 | error | Act.text | If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912). |
mediaType.exists() implies (representation = 'B64' and xmlText.exists())
|
| 3250-16914 | error | Act.entryRelationship:encounter.encounter.id | If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914). |
|
| 3250-16930 | error | Act.participant:legalAuthenticator.participantRole | If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930). |
|
| II-1 | error | Act.typeId, Act.participant:legalAuthenticator.typeId, Act.participant:legalAuthenticator.participantRole.typeId, Act.participant:legalAuthenticator.participantRole.playingEntity.typeId, Act.entryRelationship:encounter.typeId, Act.entryRelationship:encounter.encounter.typeId, Act.reference:externalDocument.typeId, Act.reference:externalDocument.externalDocument.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-code | warning | Act.reference:externalDocument.externalDocument | SHOULD contain code |
code.exists()
|
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Act.code | SHOULD contain translation |
translation.exists()
|
| should-value-att | warning | Act.effectiveTime | SHOULD contain @value |
value.exists()
|
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
value.exists() implies value.startsWith('#')
|
This structure is derived from Act
Summary
Mandatory: 12 elements(8 nested mandatory elements)
Fixed: 5 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:note-activity |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.202 | |
| @extension |
1..1 | st | Required Pattern: 2016-11-01 | |
| @classCode |
1..1 | cs | Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| code |
C | 1..1 | CD | Constraints: should-translation |
| @code |
1..1 | cs | Required Pattern: 34109-9 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| translation |
0..* | CD | If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). Binding: Note Types (preferred) | |
| text |
C | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry Constraints: 3250-16912 |
| @mediaType |
0..1 | cs | If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative. Binding: SupportedFileFormats (preferred) | |
| reference |
C | 1..1 | TEL | Constraints: value-starts-octothorpe |
| @nullFlavor |
0..0 | |||
| @value |
1..1 | url | ||
| statusCode |
1..1 | CS | Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. | |
| effectiveTime |
C | 1..1 | IVL_TS | The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time. Constraints: should-value-att |
| @value |
0..1 | ts | ||
| author |
1..* | AuthorParticipation | Represents the person(s) who wrote the note. | |
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:legalAuthenticator |
0..* | Participant2 | Represents the person(s) legally responsible for the contents of the note. | |
| @typeCode |
1..1 | cs | Fixed Value: LA | |
| time |
1..1 | USRealmDateTimeInterval | Indicates the time of signing the note. | |
| participantRole |
C | 1..1 | ParticipantRole | Constraints: 3250-16930 |
| id |
1..* | II | This may be the ID of the note author. If so, no additional information in this participant is required. | |
| playingEntity |
0..1 | PlayingEntity | ||
| name |
1..* | USRealmPersonNamePNUSFIELDED | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by exists:encounter | |
| entryRelationship:encounter |
0..* | EntryRelationship | Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter. | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @negationInd |
0..1 | bl | To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter. | |
| encounter |
1..1 | Encounter | ||
| id |
C | 1..* | II | Constraints: 3250-16914 |
| Slices for reference |
0..* | Reference | Slice: Unordered, Open by exists:externalDocument | |
| reference:externalDocument |
0..* | Reference | Represents an unstructured C-CDA document containing the original contents of the note in the original format. | |
| externalDocument |
C | 1..1 | ExternalDocument | Constraints: should-code |
| id |
1..1 | II | ||
| code |
0..1 | CD | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Act.code.translation | Base | preferred |
Note Types
|
📦20240606 | VSAC v0.23 |
| Act.text.mediaType | Base | preferred |
SupportedFileFormats
|
📦20240606 | VSAC v0.23 |
| Id | Grade | Path(s) | Description | Expression |
| 3250-16912 | error | Act.text | If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912). |
mediaType.exists() implies (representation = 'B64' and xmlText.exists())
|
| 3250-16914 | error | Act.entryRelationship:encounter.encounter.id | If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914). |
|
| 3250-16930 | error | Act.participant:legalAuthenticator.participantRole | If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930). |
|
| should-code | warning | Act.reference:externalDocument.externalDocument | SHOULD contain code |
code.exists()
|
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Act.code | SHOULD contain translation |
translation.exists()
|
| should-value-att | warning | Act.effectiveTime | SHOULD contain @value |
value.exists()
|
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
value.exists() implies value.startsWith('#')
|
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:note-activity |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.202 | |
| @extension |
1..1 | st | Required Pattern: 2016-11-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
0..* | II | ||
| code |
C | 1..1 | CD | Binding: v3 Code System ActCode (example) Constraints: should-translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 34109-9 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). Binding: Note Types (preferred) | |
| text |
C | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry Constraints: 3250-16912 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative. Binding: SupportedFileFormats (preferred) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 1..1 | TEL | Constraints: value-starts-octothorpe |
| @value |
1..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..* | cs | Binding: TelecommunicationAddressUse (2.0.0) (required) | |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. Binding: ActStatus (required) | |
| effectiveTime |
C | 1..1 | IVL_TS | The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time. Constraints: should-value-att |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
0..1 | IVXB_TS | ||
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
0..1 | IVXB_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
1..* | AuthorParticipation | Represents the person(s) who wrote the note. | |
| informant |
0..* | Informant | ||
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:legalAuthenticator |
0..* | Participant2 | Represents the person(s) legally responsible for the contents of the note. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) Fixed Value: LA | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
1..1 | USRealmDateTimeInterval | Indicates the time of signing the note. | |
| awarenessCode |
0..1 | CE | ||
| participantRole |
C | 1..1 | ParticipantRole | Constraints: 3250-16930 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDARoleClassRoot (required) | |
| id |
1..* | II | This may be the ID of the note author. If so, no additional information in this participant is required. | |
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: EntityClassRoot (required) | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
1..* | USRealmPersonNamePNUSFIELDED | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by exists:encounter | |
| entryRelationship:encounter |
0..* | EntryRelationship | Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter. | |
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
1..1 | Encounter | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | Binding: CDAActClass (required) Fixed Value: ENC | |
| @moodCode |
1..1 | cs | Binding: XDocumentEncounterMood (2.0.0) (required) | |
| id |
C | 1..* | II | Constraints: 3250-16914 |
| code |
0..1 | CD | Binding: ActEncounterCode (example) | |
| text |
0..1 | ED | ||
| statusCode |
0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime |
0..1 | IVL_TS | ||
| sdtcDischargeDispositionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| observation |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| Slices for reference |
0..* | Reference | Slice: Unordered, Open by exists:externalDocument | |
| reference:externalDocument |
0..* | Reference | Represents an unstructured C-CDA document containing the original contents of the note in the original format. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipExternalReference (required) | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocument | Constraints: should-code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: ActClassDocument (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
1..1 | II | ||
| code |
0..1 | CD | Binding: FHIRDocumentTypeCodes (example) | |
| text |
0..1 | ED | ||
| setId |
0..1 | II | ||
| versionNumber |
0..1 | INT | ||
| sdtcAuthor |
0..* | Author | XML Namespace: urn:hl7-org:sdtc XML: author (urn:hl7-org:sdtc) | |
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Act.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.templateId:note-activity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.classCode | Base | required | x_ActClassDocumentEntryAct | 📍2.0.0 | THO v5.2 |
| Act.moodCode | Base | required | x_DocumentActMood | 📍2.0.0 | THO v5.2 |
| Act.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Act.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.code.translation | Base | preferred |
Note Types
|
📦20240606 | VSAC v0.23 |
| Act.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Act.text.mediaType | Base | preferred |
SupportedFileFormats
|
📦20240606 | VSAC v0.23 |
| Act.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.reference.use | Base | required | TelecommunicationAddressUse | 📍2.0.0 | THO v5.2 |
| Act.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.effectiveTime.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.effectiveTime.operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Act.participant:legalAuthenticator.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.classCode | Base | required | CDAActClass | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.moodCode | Base | required | x_DocumentEncounterMood | 📍2.0.0 | THO v5.2 |
| Act.entryRelationship:encounter.​encounter.code | Base | example | ActEncounterCode | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeCode | Base | required | x_ActRelationshipExternalReference | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.classCode | Base | required | ActClassDocument | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.code | Base | example | FHIR Document Type Codes | 📦5.0.0 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 3250-16912 | error | Act.text | If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912). |
mediaType.exists() implies (representation = 'B64' and xmlText.exists())
|
| 3250-16914 | error | Act.entryRelationship:encounter.encounter.id | If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914). |
|
| 3250-16930 | error | Act.participant:legalAuthenticator.participantRole | If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930). |
|
| II-1 | error | Act.typeId, Act.participant:legalAuthenticator.typeId, Act.participant:legalAuthenticator.participantRole.typeId, Act.participant:legalAuthenticator.participantRole.playingEntity.typeId, Act.entryRelationship:encounter.typeId, Act.entryRelationship:encounter.encounter.typeId, Act.reference:externalDocument.typeId, Act.reference:externalDocument.externalDocument.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-code | warning | Act.reference:externalDocument.externalDocument | SHOULD contain code |
code.exists()
|
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Act.code | SHOULD contain translation |
translation.exists()
|
| should-value-att | warning | Act.effectiveTime | SHOULD contain @value |
value.exists()
|
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
value.exists() implies value.startsWith('#')
|
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:note-activity |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.202 | |
| @extension |
1..1 | st | Required Pattern: 2016-11-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
0..* | II | ||
| code |
C | 1..1 | CD | Binding: v3 Code System ActCode (example) Constraints: should-translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 34109-9 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). Binding: Note Types (preferred) | |
| text |
C | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry Constraints: 3250-16912 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative. Binding: SupportedFileFormats (preferred) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 1..1 | TEL | Constraints: value-starts-octothorpe |
| @value |
1..1 | url | ||
| useablePeriod |
0..* | |||
| useablePeriod |
IVL_TS | |||
| useablePeriod |
EIVL_TS | |||
| useablePeriod |
PIVL_TS | |||
| useablePeriod |
SXPR_TS | |||
| @use |
0..* | cs | Binding: TelecommunicationAddressUse (2.0.0) (required) | |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. Binding: ActStatus (required) | |
| effectiveTime |
C | 1..1 | IVL_TS | The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time. Constraints: should-value-att |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
0..1 | IVXB_TS | ||
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
0..1 | IVXB_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
1..* | AuthorParticipation | Represents the person(s) who wrote the note. | |
| informant |
0..* | Informant | ||
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:legalAuthenticator |
0..* | Participant2 | Represents the person(s) legally responsible for the contents of the note. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) Fixed Value: LA | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
1..1 | USRealmDateTimeInterval | Indicates the time of signing the note. | |
| awarenessCode |
0..1 | CE | ||
| participantRole |
C | 1..1 | ParticipantRole | Constraints: 3250-16930 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDARoleClassRoot (required) | |
| id |
1..* | II | This may be the ID of the note author. If so, no additional information in this participant is required. | |
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: EntityClassRoot (required) | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
1..* | USRealmPersonNamePNUSFIELDED | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by exists:encounter | |
| entryRelationship:encounter |
0..* | EntryRelationship | Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter. | |
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
1..1 | Encounter | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | Binding: CDAActClass (required) Fixed Value: ENC | |
| @moodCode |
1..1 | cs | Binding: XDocumentEncounterMood (2.0.0) (required) | |
| id |
C | 1..* | II | Constraints: 3250-16914 |
| code |
0..1 | CD | Binding: ActEncounterCode (example) | |
| text |
0..1 | ED | ||
| statusCode |
0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime |
0..1 | IVL_TS | ||
| sdtcDischargeDispositionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| observation |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| Slices for reference |
0..* | Reference | Slice: Unordered, Open by exists:externalDocument | |
| reference:externalDocument |
0..* | Reference | Represents an unstructured C-CDA document containing the original contents of the note in the original format. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipExternalReference (required) | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocument | Constraints: should-code |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: ActClassDocument (required) | |
| @moodCode |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
| id |
1..1 | II | ||
| code |
0..1 | CD | Binding: FHIRDocumentTypeCodes (example) | |
| text |
0..1 | ED | ||
| setId |
0..1 | II | ||
| versionNumber |
0..1 | INT | ||
| sdtcAuthor |
0..* | Author | XML Namespace: urn:hl7-org:sdtc XML: author (urn:hl7-org:sdtc) | |
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Act.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.templateId:note-activity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.classCode | Base | required | x_ActClassDocumentEntryAct | 📍2.0.0 | THO v5.2 |
| Act.moodCode | Base | required | x_DocumentActMood | 📍2.0.0 | THO v5.2 |
| Act.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Act.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.code.translation | Base | preferred |
Note Types
|
📦20240606 | VSAC v0.23 |
| Act.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Act.text.mediaType | Base | preferred |
SupportedFileFormats
|
📦20240606 | VSAC v0.23 |
| Act.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.text.reference.use | Base | required | TelecommunicationAddressUse | 📍2.0.0 | THO v5.2 |
| Act.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.effectiveTime.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.effectiveTime.operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Act.participant:legalAuthenticator.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Act.participant:legalAuthenticator.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.classCode | Base | required | CDAActClass | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.entryRelationship:encounter.​encounter.moodCode | Base | required | x_DocumentEncounterMood | 📍2.0.0 | THO v5.2 |
| Act.entryRelationship:encounter.​encounter.code | Base | example | ActEncounterCode | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Act.entryRelationship:encounter.​encounter.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​typeCode | Base | required | x_ActRelationshipExternalReference | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.classCode | Base | required | ActClassDocument | 📦3.0.0 | THO v6.5 |
| Act.reference:externalDocument.​externalDocument.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Act.reference:externalDocument.​externalDocument.code | Base | example | FHIR Document Type Codes | 📦5.0.0 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 3250-16912 | error | Act.text | If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912). |
mediaType.exists() implies (representation = 'B64' and xmlText.exists())
|
| 3250-16914 | error | Act.entryRelationship:encounter.encounter.id | If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914). |
|
| 3250-16930 | error | Act.participant:legalAuthenticator.participantRole | If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930). |
|
| II-1 | error | Act.typeId, Act.participant:legalAuthenticator.typeId, Act.participant:legalAuthenticator.participantRole.typeId, Act.participant:legalAuthenticator.participantRole.playingEntity.typeId, Act.entryRelationship:encounter.typeId, Act.entryRelationship:encounter.encounter.typeId, Act.reference:externalDocument.typeId, Act.reference:externalDocument.externalDocument.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-code | warning | Act.reference:externalDocument.externalDocument | SHOULD contain code |
code.exists()
|
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Act.code | SHOULD contain translation |
translation.exists()
|
| should-value-att | warning | Act.effectiveTime | SHOULD contain @value |
value.exists()
|
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
value.exists() implies value.startsWith('#')
|
This structure is derived from Act
Summary
Mandatory: 12 elements(8 nested mandatory elements)
Fixed: 5 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0 based on FHIR 5.0.0. Generated 2025-10-02
Links: Table of Contents |
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