Generated Narrative: StructureDefinition USRealmHeaderforPatientGeneratedDocument Name Flags Card. Type Description & Constraints ClinicalDocument 1..1 USRealmHeader 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) #xD; templateId 2..* II #xD; Slices for templateId Content/Rules for all slices #xD; templateId:us-patient-gen-doc 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.29.1 #xD; @extension 1..1 st Required Pattern: 2024-05-01 #xD; recordTarget 1..1 RecordTarget The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. #xD; patientRole 1..1 PatientRole #xD; id 1..* II #xD; patient <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-languageCommunication )">C 1..1 Patient Constraints: should-languageCommunication #xD; guardian <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-id, should-code )">C 0..* Guardian Constraints: should-id, should-code #xD; id 0..* II #xD; code 0..1 CE #xD; languageCommunication 0..* LanguageCommunication 헨?헦?헖?헗?헜?: Preferred Language #xD; languageCode 1..1 CS Binding: AllLanguages (required) #xD; preferenceInd 0..1 BL Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. #xD; providerOrganization 0..1 Organization If present, this organization represents the provider organization where the person is claiming to be a patient. #xD; author 1..* Author The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate. #xD; assignedAuthor C 1..1 AssignedAuthor Constraints: should-code #xD; id 1..* II #xD; code 0..1 CE When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. #xD; @code 1..1 cs Binding: Personal And Legal Relationship Role Type (preferred) #xD; dataEnterer 0..1 DataEnterer The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. #xD; assignedEntity 1..1 AssignedEntity #xD; code 0..1 CE Binding: Personal And Legal Relationship Role Type (preferred) #xD; Slices for informant Content/Rules for all slices #xD; informant:non-provider 0..* Informant The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. #xD; relatedEntity 1..1 RelatedEntity #xD; code <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-us-code-attr )">C 0..1 CE Constraints: should-us-code-attr #xD; @code 0..1 cs Binding: Personal And Legal Relationship Role Type (preferred) #xD; custodian 1..1 Custodian The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. #xD; assignedCustodian 1..1 AssignedCustodian #xD; representedCustodianOrganization 1..1 CustodianOrganization The representedCustodianOrganization may be the person when the document is not maintained by an organization. #xD; id 1..* II The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way. #xD; informationRecipient 0..* InformationRecipient The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. #xD; intendedRecipient C 1..1 IntendedRecipient Constraints: should-id #xD; id C 0..* II The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. Constraints: should-root #xD; @root 0..1 oid, uuid, ruid For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. #xD; legalAuthenticator 0..1 LegalAuthenticator In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. #xD; assignedEntity 1..1 AssignedEntity #xD; id 1..* II The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. #xD; code 0..1 CE #xD; @code 0..1 cs Binding: Personal And Legal Relationship Role Type (preferred) #xD; authenticator 0..* Authenticator The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. #xD; assignedEntity C 1..1 AssignedEntity Constraints: should-code #xD; id 1..* II The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way. #xD; code 0..1 CE Binding: Personal And Legal Relationship Role Type (preferred) #xD; participant 0..* Participant1 The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin) #xD; @typeCode 1..1 cs Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 #xD; associatedEntity C 1..1 AssociatedEntity Constraints: should-code #xD; code 0..1 CE Binding: Personal And Legal Relationship Role Type (preferred) #xD; inFulfillmentOf 0..* InFulfillmentOf The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. #xD; order 1..1 Order #xD; id 1..* II A scheduled appointment or service event in a practice management system may be represented using this id element. #xD; documentationOf 0..* DocumentationOf #xD; serviceEvent <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-code, should-performer )">C 1..1 ServiceEvent A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. Constraints: should-code, should-performer #xD; code 0..1 CE The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. #xD; performer 0..* Performer1 The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. #xD; functionCode 0..1 CE When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode #xD; @code 0..1 cs Binding: ParticipationFunction (required) #xD; assignedEntity 1..1 AssignedEntity #xD; id 1..* II The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way. #xD; code 0..1 CE If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) #xD; Documentation for this format
US Realm Header for Patient Generated Document
HL7 International - Structured Documents
This template focuses on the patient or related person in the roles of author and other participants and is designed to be used in conjunction with the US Realm Header. It includes additional conformances which further constrain the US Realm Header. The Patient Generated Document Header template is not a separate document type. The document body may contain any structured or unstructured content from C-CDA.
Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.
If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
setId.exists() implies versionNumber.exists()
If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
versionNumber.exists() implies setId.exists()
Documents SHOULD contain a RelatedPerson participant
If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question
SHALL contain exactly one [1..1] realmCode="US" (CONF:4537-16791).
The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.
Specifies the code system that defines the code.
If applicable, a version descriptor defined specifically for the given code system.
A name or title for the code, under which the sending system shows the code value to its users.
The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.
The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.
The text or phrase used as the basis for the coding.
Specifies additional codes that increase the specificity of the the primary code.
A set of other concept descriptors that translate this concept descriptor into other code systems.
ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
SHALL contain exactly one [1..1] typeId (CONF:4537-5361).
An II instance must have either a root or an nullFlavor.
A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.
Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
Identifies the type as an HL7 Registered model
A character string as a unique identifier within the scope of the identifier root.
This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:4537-5251).
When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.
**SHALL** be a globally unique identifier for the document (CONF:4537-9991).
SHALL contain exactly one [1..1] id (CONF:4537-5363).
**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
SHALL contain exactly one [1..1] code (CONF:4537-5253).
The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
SHALL contain exactly one [1..1] title (CONF:4537-5254).
The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient.
SHALL contain exactly one [1..1] US Realm Date and Time (Point in Time) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5256).
SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet AllLanguages https://www.hl7.org/fhir/valueset-all-languages.html (OID 2.16.840.1.113883.4.642.3.21) DYNAMIC.
MAY contain zero or one [0..1] setId (CONF:4537-5261).
MAY contain zero or one [0..1] versionNumber (CONF:4537-5264).
The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.
SHALL contain exactly one [1..1] recordTarget (CONF:1198-28460).
When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.
This recordTarget SHALL contain exactly one [1..1] patientRole (CONF:1198-28461).
This patientRole SHALL contain at least one [1..*] id (CONF:1198-28462).
This patientRole SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5271).
Specifies the periods of time during which the telecommunication address can be used. For a telephone number, this can indicate the time of day in which the party can be reached on that telephone. For a web address, it may specify a time range in which the web content is promised to be available under the given address.
One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.
Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-5375).
This patientRole SHALL contain exactly one [1..1] patient (CONF:1198-28465).
If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists()
If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true')
This patient SHALL contain at least one [1..*] US Realm Patient Name (PTN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1) (CONF:4537-5284).
The desc extension allows multimedia depictions of patients, healthcare providers, or other individuals to be included in a CDA document.
𝗨𝗦𝗖𝗗𝗜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
This patient SHALL contain exactly one [1..1] birthTime (CONF:4537-5298).
**SHALL** be precise to at least the year
nullFlavor.exists() or value.toString().length() >= 4
**SHOULD** be precise to at least the day
nullFlavor.exists() or value.toString().length() >= 10
This patient MAY contain zero or one [0..1] sdtc:deceasedInd (CONF:4537-32990).
This patient MAY contain zero or one [0..1] sdtc:deceasedTime (CONF:4537-32988).
This patient SHOULD contain zero or one [0..1] maritalStatusCode, which SHALL be selected from ValueSet Marital Status urn:oid:2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:4537-5303).
This patient MAY contain zero or one [0..1] religiousAffiliationCode, which SHALL be selected from ValueSet Religious Affiliation urn:oid:2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:4537-5317).
𝗨𝗦𝗖𝗗𝗜: Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
This patient MAY contain zero or more [0..*] guardian (CONF:1198-28469).
The guardian, if present, SHOULD contain zero or more [0..*] id (CONF:1198-28470).
The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-28473).
The guardian, if present, SHOULD contain zero or more [0..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5359).
The guardian, if present, SHOULD contain zero or more [0..*] telecom (CONF:4537-5382).
The telecom, if present, SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7993).
The guardian, if present, SHALL contain exactly one [1..1] guardianPerson (CONF:4537-5385).
This guardianPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-5386).
Each participant role other than an informant/relatedEntity may have zero or more relationship roles with the patient. Each of these roles can be expressed with an asPatientRelationship element which further describes the type of role using a code element.
This patient MAY contain zero or one [0..1] birthplace (CONF:4537-5395).
The birthplace, if present, SHALL contain exactly one [1..1] place (CONF:4537-5396).
This place SHALL contain exactly one [1..1] addr (CONF:4537-5397).
If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://terminology.hl7.org/ValueSet/USPS-State'))
If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.empty() or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
nullFlavor.exists() or item.country.exists()
A boolean value specifying whether the order of the address parts is known or not. While the address parts are always a Sequence, the order in which they are presented may or may not be known. Where this matters, the isNotOrdered property can be used to convey this information.
A set of codes advising a system or user which address in a set of like addresses to select for a given purpose.
A series of items that constitute the address.
Can only have only one of the possible item elements in each choice
(delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1
Delimiters are printed without framing white space. If no value component is provided, the delimiter appears as a line break.
xmlText and nullFlavor are mutually exclusive (one must be present)
Specifies the representation of the binary data that is the content of the binary data value
Identifies the type of the encapsulated data and identifies a method to interpret or render the data.
For character based information the language property specifies the human language of the text.
This element is represented in XML as textual content. The actual name "xmlText" will not appear in a CDA instance.
A sub-unit of a country with limited sovereignty in a federally organized country.
A sub-unit of a state or province. (49 of the United States of America use the term "county;" Louisiana uses the term "parish".)
The name of the city, town, village, or other community or delivery center
A postal code designating a region defined by the postal service.
The number of a building, house or lot alongside the street. Also known as "primary street number". This does not number the street but rather the building.
The numeric portion of a building number
Name of a roadway or artery recognized by a municipality (including street type and direction)
The base name of a roadway or artery recognized by a municipality (excluding street type and direction)
The designation given to the street. (e.g. Street, Avenue, Crescent, etc.)
This can be a unit designator, such as apartment number, suite number, or floor. There may be several unit designators in an address (e.g., "3rd floor, Appt. 342"). This can also be a designator pointing away from the location, rather than specifying a smaller location within some larger one (e.g., Dutch "t.o." means "opposite to" for house boats located across the street facing houses).
The number or name of a specific unit contained within a building or complex, as assigned by that building or complex.
Indicates the type of specific unit contained within a building or complex. E.g. Appartment, Floor
The name of the party who will take receipt at the specified address, and will take on responsibility for ensuring delivery to the target recipient
A geographic sub-unit delineated for demographic purposes.
A delivery address line is frequently used instead of breaking out delivery mode, delivery installation, etc. An address generally has only a delivery address line or a street address line, but not both.
Indicates the type of delivery installation (the facility to which the mail will be delivered prior to final shipping via the delivery mode.) Example: post office, letter carrier depot, community mail center, station, etc.
The location of the delivery installation, usually a town or city, and is only required if the area is different from the municipality. Area to which mail delivery service is provided from any postal facility or service such as an individual letter carrier, rural route, or postal route.
A number, letter or name identifying a delivery installation. E.g., for Station A, the delivery installation qualifier would be 'A'.
Indicates the type of service offered, method of delivery. For example: post office box, rural route, general delivery, etc.
Represents the routing information such as a letter carrier route number. It is the identifying number of the designator (the box number or rural route number).
Any alphabetic character, fraction or other text that may appear after the numeric portion of a building number
A numbered box located in a post station.
A General Timing Specification (GTS) specifying the periods of time during which the address can be used. This is used to specify different addresses for different times of the week or year.
This patient SHOULD contain zero or more [0..*] languageCommunication which SHALL be selected from ValueSet AllLanguages https://www.hl7.org/fhir/valueset-all-languages.html (OID 2.16.840.1.113883.4.642.3.21) DYNAMIC (CONF:XXX).
The languageCommunication, if present, MAY contain zero or one [0..1] modeCode, which SHALL be selected from ValueSet LanguageAbilityMode urn:oid:2.16.840.1.113883.1.11.12249 DYNAMIC (CONF:4537-5409).
The languageCommunication, if present, SHOULD contain zero or one [0..1] proficiencyLevelCode, which SHALL be selected from ValueSet LanguageAbilityProficiency urn:oid:2.16.840.1.113883.1.11.12199 DYNAMIC (CONF:4537-9965).
Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1.
The languageCommunication, if present, MAY contain zero or one [0..1] preferenceInd (CONF:1198-28475).
If present, this organization represents the provider organization where the person is claiming to be a patient.
This patientRole MAY contain zero or one [0..1] providerOrganization (CONF:1198-28476).
The providerOrganization, if present, SHALL contain at least one [1..*] id (CONF:4537-5417).
Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-16820).
The providerOrganization, if present, SHALL contain at least one [1..*] name (CONF:4537-5419).
The providerOrganization, if present, SHALL contain at least one [1..*] telecom (CONF:4537-5420).
Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7994).
The providerOrganization, if present, SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5422).
The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate.
SHALL contain at least one [1..*] author (CONF:1198-28477).
Such authors SHALL contain exactly one [1..1] US Realm Date and Time (Point in Time) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5445).
Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:1198-28478).
There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
(assignedPerson | assignedAuthoringDevice).count() = 1
SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
This assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-28479).
If NPI is unknown, set @nullFlavor to UNK
SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-32884).
SHOULD contain zero or one [0..1] @extension (CONF:4537-32885).
When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.
This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:1198-28481).
This assignedAuthor SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5452).
This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:4537-5428).
Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7995).
The assignedPerson, if present, SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-16789).
The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] manufacturerModelName (CONF:4537-16784).
The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] softwareName (CONF:4537-16785).
The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author.
MAY contain zero or one [0..1] dataEnterer (CONF:1198-28678).
The dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-28679).
This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-5443).
Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-16821).
This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-28680).
This assignedEntity SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5460).
This assignedEntity SHALL contain at least one [1..*] telecom (CONF:4537-5466).
Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7996).
This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:4537-5469).
This assignedPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-5470).
MAY contain zero or more [0..*] informant (CONF:4537-31355) such that it
The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
MAY contain zero or more [0..*] informant (CONF:4537-8001) such that it
SHALL contain exactly one [1..1] assignedEntity (CONF:4537-8002).
If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-9945).
This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:4537-32174).
This assignedEntity SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-8220).
This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:4537-8221).
This assignedPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-8222).
The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
SHALL contain exactly one [1..1] relatedEntity (CONF:1198-28682).
This relatedEntity MAY contain zero or one [0..1] code (CONF:1198-28683).
The code, if present, SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-28684).
The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.
SHALL contain exactly one [1..1] custodian (CONF:1198-28685).
This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:1198-28686).
The representedCustodianOrganization may be the person when the document is not maintained by an organization.
This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:1198-28687).
The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way.
This representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:1198-28688).
Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-16822).
This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:4537-5524).
This representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:4537-5525).
This telecom SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7998).
The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
This representedCustodianOrganization SHALL contain exactly one [1..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5559).
The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.
MAY contain zero or more [0..*] informationRecipient (CONF:1198-28690).
The informationRecipient, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:1198-28691).
The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
This intendedRecipient SHOULD contain zero or more [0..*] id (CONF:1198-28692).
For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.
The id, if present, SHOULD contain zero or one [0..1] @root (CONF:1198-28693).
This intendedRecipient MAY contain zero or one [0..1] informationRecipient (CONF:4537-5567).
The informationRecipient, if present, SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-5568).
This intendedRecipient MAY contain zero or one [0..1] receivedOrganization (CONF:4537-5577).
The receivedOrganization, if present, SHALL contain exactly one [1..1] name (CONF:4537-5578).
In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
MAY contain zero or one [0..1] legalAuthenticator (CONF:1198-28694).
The legalAuthenticator, if present, SHALL contain exactly one [1..1] US Realm Date and Time (Point in Time) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5580).
The legalAuthenticator, if present, SHALL contain exactly one [1..1] signatureCode (CONF:4537-5583).
CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: HL7ParticipationSignature urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:4537-5584).
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
A textual or multimedia depiction of the signature by which the participant endorses his or her participation in the Act as specified in the Participation.typeCode and that he or she agrees to assume the associated accountability.
The legalAuthenticator, if present, MAY contain zero or one [0..1] sdtc:signatureText (CONF:4537-30810).
The legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-28695).
This assignedEntity SHALL contain at least one [1..*] id (CONF:1198-28696).
Such ids MAY contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-16823).
This assignedEntity MAY contain zero or one [0..1] code (CONF:1198-28697).
The code, if present, MAY contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-28698).
This assignedEntity SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5589).
This assignedEntity SHALL contain at least one [1..*] telecom (CONF:4537-5595).
Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7999).
This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:4537-5597).
This assignedPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-5598).
The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
MAY contain zero or more [0..*] authenticator (CONF:1198-28699).
SHALL contain exactly one [1..1] US Realm Date and Time (Point in Time) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5608).
SHALL contain exactly one [1..1] signatureCode (CONF:4537-5610).
This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: HL7ParticipationSignature urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:4537-5611).
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
MAY contain zero or one [0..1] sdtc:signatureText (CONF:4537-30811).
The authenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-28700).
The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way.
This assignedEntity SHALL contain at least one [1..*] id (CONF:1198-28701).
Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-16824).
This assignedEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-28702).
The code, if present, MAY contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:4537-16826).
This assignedEntity SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5616).
This assignedEntity SHALL contain at least one [1..*] telecom (CONF:4537-5622).
Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-8000).
This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:4537-5624).
This assignedPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-5625).
The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)
MAY contain zero or more [0..*] participant (CONF:1198-28703).
**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33')
Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
The participant, if present, SHALL contain exactly one [1..1] @typeCode (CONF:1198-28704).
MAY contain zero or one [0..1] time (CONF:4537-10004).
The participant, if present, SHALL contain exactly one [1..1] associatedEntity (CONF:1198-28705).
This associatedEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-28706).
The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
MAY contain zero or more [0..*] inFulfillmentOf (CONF:1198-28707).
The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:1198-28708).
A scheduled appointment or service event in a practice management system may be represented using this id element.
This order SHALL contain at least one [1..*] id (CONF:1198-28709).
MAY contain zero or more [0..*] documentationOf (CONF:1198-28710).
A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:1198-28711).
The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.
This serviceEvent SHOULD contain zero or one [0..1] code (CONF:1198-28712).
This serviceEvent SHALL contain exactly one [1..1] US Realm Date and Time (Interval) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:4537-14837).
Either @value or low/high should be present, but not both
A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.
A code specifying whether the set component is included (union) or excluded (set-difference) from the set, or other set operations with the current set component and the set as constructed from the representation stream up to the current point.
**MAY** be precise to at least the second
This effectiveTime SHALL contain exactly one [1..1] low (CONF:4537-14838).
**SHALL** be precise to at least the day
**SHOULD** be precise to at least the minute
nullFlavor.exists() or value.toString().length() > 10
Specifies whether the limit is included in the interval (interval is closed) or excluded from the interval (interval is open).
The arithmetic mean of the interval (low plus high divided by 2). The purpose of distinguishing the center as a semantic property is for conversions of intervals from and to point values.
The difference between high and low boundary. The purpose of distinguishing a width property is to handle all cases of incomplete information symmetrically. In any interval representation only two of the three properties high, low, and width need to be stated and the third can be derived.
The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
This serviceEvent SHOULD contain zero or more [0..*] performer (CONF:1198-28713).
The performer, if present, SHALL contain exactly one [1..1] @typeCode, which SHALL be selected from ValueSet x_ServiceEventPerformer urn:oid:2.16.840.1.113883.1.11.19601 STATIC (CONF:4537-14840).
When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode
The performer, if present, MAY contain zero or one [0..1] functionCode (CONF:4537-16818).
The functionCode, if present, SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Care Team Member Function urn:oid:2.16.840.1.113762.1.4.1099.30 DYNAMIC (CONF:4537-32889).
The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-28715).
The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way.
This assignedEntity SHALL contain at least one [1..*] id (CONF:1198-28716).
Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-14847).
If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set
This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-28718).
The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
MAY contain zero or more [0..*] authorization (CONF:4537-16792) such that it
SHALL contain exactly one [1..1] consent (CONF:4537-16793).
This consent MAY contain zero or more [0..*] id (CONF:4537-16794).
The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
This consent MAY contain zero or one [0..1] code (CONF:4537-16795).
This consent SHALL contain exactly one [1..1] statusCode (CONF:4537-16797).
This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:4537-16798).
The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
MAY contain zero or one [0..1] componentOf (CONF:4537-9955).
The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:4537-9956).
This encompassingEncounter SHALL contain at least one [1..*] id (CONF:4537-9959).
This encompassingEncounter MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Act Encounter Codes urn:oid:2.16.840.1.113762.1.4.1240.5 (CONF:1198-30873).
This encompassingEncounter SHALL contain exactly one [1..1] US Realm Date and Time (Interval) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:4537-9958).
This element is a coded concept that represents the type of referral. Its RIM source class is PatientEncounter.
The responsibleParty participant represents the participant having primary legal responsibility for the encounter. This differs from the legalAuthenticator participant in that the legalAuthenticator may or may not be the responsible party, and is serving a medical records function by signing off on the document, moving it into a completed state.
This encompassingEncounter SHOULD contain zero or one [0..1] responsibleParty (CONF:1198-8391).
The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32904).
This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
assignedPerson.exists() or representedOrganization.exists()
The location participant (location class) relates a healthcare facility (HealthCareFacility class) to the encounter to indicate where the encounter took place. The entity playing the role of HealthCareFacility is a place (Place class). The entity scoping the HealthCareFacility role is an organization (Organization class). The setting of an encounter (e.g. cardiology clinic, primary care clinic, rehabilitation hospital, skilled nursing facility) can be expressed in HealthCareFacility.code. Note that setting and physical location are not the same. There is a many-to-many relationship between setting and the physical location where care is delivered. Thus, a particular room can provide the location for cardiology clinic one day, and for primary care clinic another day; and cardiology clinic today might be held in one physical location, but in another physical location tomorrow. When the location is an organization, this is indicated by the presence of a scoping Organization, without a playing Place.