Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 3.0.0 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

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON

Logical Model: Instruction

The Instruction template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The template’s moodCode can only be INT. If an instruction was already given, the Procedure Activity Procedure template (instead of this template) should be used to represent the already occurred instruction. The act/code defines the type of instruction. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through act/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode.

Usage:

• Use this Logical Model: Immunization Activity, Instructions Section, Intervention Act, Medication Activity... Show 9 more, Medication Supply Order, Non-Medicinal Supply Activity, Planned Immunization Activity, Planned Intervention Act, Planned Medication Activity, Planned Procedure, Planned Supply, Plan of Treatment Section and Procedure Activity Procedure

Formal Views of Template Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Act

Name	Flags	Card.	Type	Description & Constraints
Act	C	1..1	Act	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root, value:extension
templateId:instruction		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.20
@extension		1..1	st	Required Pattern: 2014-06-09
@classCode		1..1	cs	Fixed Value: ACT
@moodCode		1..1	cs	Fixed Value: INT
code		1..1	CD	Binding: Patient Education (preferred)
text		0..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry
reference	C	0..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
statusCode		1..1	CS
@code		1..1	cs	Fixed Value: completed
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Act.code	preferred	PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 from https://vsac.nlm.nih.gov

Constraints

Id	Grade	Path(s)	Details	Requirements
should-text-ref-value	warning	Act	SHOULD contain text/reference/@value : text.reference.value.exists()
value-starts-octothorpe	error	Act.text.reference	If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#')

Name	Flags	Card.	Type	Description & Constraints
Act	C	1..1	Act	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root, value:extension
templateId:instruction		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.20
@extension		1..1	st	Required Pattern: 2014-06-09
@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: INT
code		1..1	CD	Binding: Patient Education (preferred)
text		0..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry
reference	C	0..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
statusCode		1..1	CS	Binding: ActStatus (required)
@code		1..1	cs	Fixed Value: completed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Act.classCode	required	Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCode	required	Fixed Value: INT http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.code	preferred	PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 from https://vsac.nlm.nih.gov
Act.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
should-text-ref-value	warning	Act	SHOULD contain text/reference/@value : text.reference.value.exists()
value-starts-octothorpe	error	Act.text.reference	If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#')

Name	Flags	Card.	Type	Description & Constraints
Act	C	1..1	Act	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root, value:extension
templateId:instruction		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: 2.16.840.1.113883.10.20.22.4.20
@extension		1..1	st	Required Pattern: 2014-06-09
@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: INT
@negationInd		0..1	bl
id		0..*	II
code		1..1	CD	Binding: Patient Education (preferred)
text		0..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@compression		0..1	cs	Binding: CDACompressionAlgorithm (required)
@integrityCheck		0..1	bin
@integrityCheckAlgorithm		0..1	cs	Binding: IntegrityCheckAlgorithm (2.0.0) (required)
@language		0..1	cs
@mediaType		0..1	cs	Binding: MediaType (example)
@representation		0..1	cs	Binding: CDABinaryDataEncoding (required)
xmlText		0..1	st	Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
reference	C	0..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
thumbnail		0..1	ED
statusCode		1..1	CS	Binding: ActStatus (required)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@code		1..1	cs	Fixed Value: completed
@sdtcValueSet		0..1	oid	XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion		0..1	st	XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime		0..1	IVL_TS
priorityCode		0..1	CE	Binding: ActPriority (example)
languageCode		0..1	CS	Binding: AllLanguages (required)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	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)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Act.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:instruction.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCode	required	Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCode	required	Fixed Value: INT http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.code	preferred	PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 from https://vsac.nlm.nih.gov
Act.text.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compression	required	CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithm	required	IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaType	example	MediaType http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representation	required	BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.statusCode.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
should-text-ref-value	warning	Act	SHOULD contain text/reference/@value : text.reference.value.exists()
value-starts-octothorpe	error	Act.text.reference	If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#')

This structure is derived from Act

Summary

Mandatory: 6 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

• The element 2 is sliced based on the values of Act.templateId

Differential View

This structure is derived from Act

Name	Flags	Card.	Type	Description & Constraints
Act	C	1..1	Act	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root, value:extension
templateId:instruction		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.20
@extension		1..1	st	Required Pattern: 2014-06-09
@classCode		1..1	cs	Fixed Value: ACT
@moodCode		1..1	cs	Fixed Value: INT
code		1..1	CD	Binding: Patient Education (preferred)
text		0..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry
reference	C	0..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
statusCode		1..1	CS
@code		1..1	cs	Fixed Value: completed
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Act.code	preferred	PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 from https://vsac.nlm.nih.gov

Constraints

Id	Grade	Path(s)	Details	Requirements
should-text-ref-value	warning	Act	SHOULD contain text/reference/@value : text.reference.value.exists()
value-starts-octothorpe	error	Act.text.reference	If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#')

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Act	C	1..1	Act	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root, value:extension
templateId:instruction		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.20
@extension		1..1	st	Required Pattern: 2014-06-09
@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: INT
code		1..1	CD	Binding: Patient Education (preferred)
text		0..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry
reference	C	0..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
statusCode		1..1	CS	Binding: ActStatus (required)
@code		1..1	cs	Fixed Value: completed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Act.classCode	required	Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCode	required	Fixed Value: INT http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.code	preferred	PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 from https://vsac.nlm.nih.gov
Act.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
should-text-ref-value	warning	Act	SHOULD contain text/reference/@value : text.reference.value.exists()
value-starts-octothorpe	error	Act.text.reference	If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#')

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Act	C	1..1	Act	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root, value:extension
templateId:instruction		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: 2.16.840.1.113883.10.20.22.4.20
@extension		1..1	st	Required Pattern: 2014-06-09
@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: INT
@negationInd		0..1	bl
id		0..*	II
code		1..1	CD	Binding: Patient Education (preferred)
text		0..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@compression		0..1	cs	Binding: CDACompressionAlgorithm (required)
@integrityCheck		0..1	bin
@integrityCheckAlgorithm		0..1	cs	Binding: IntegrityCheckAlgorithm (2.0.0) (required)
@language		0..1	cs
@mediaType		0..1	cs	Binding: MediaType (example)
@representation		0..1	cs	Binding: CDABinaryDataEncoding (required)
xmlText		0..1	st	Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
reference	C	0..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
thumbnail		0..1	ED
statusCode		1..1	CS	Binding: ActStatus (required)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@code		1..1	cs	Fixed Value: completed
@sdtcValueSet		0..1	oid	XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion		0..1	st	XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime		0..1	IVL_TS
priorityCode		0..1	CE	Binding: ActPriority (example)
languageCode		0..1	CS	Binding: AllLanguages (required)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	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)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Act.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:instruction.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCode	required	Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCode	required	Fixed Value: INT http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.code	preferred	PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 from https://vsac.nlm.nih.gov
Act.text.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compression	required	CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithm	required	IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaType	example	MediaType http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representation	required	BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.statusCode.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
should-text-ref-value	warning	Act	SHOULD contain text/reference/@value : text.reference.value.exists()
value-starts-octothorpe	error	Act.text.reference	If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#')

This structure is derived from Act

Summary

Mandatory: 6 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

• The element 2 is sliced based on the values of Act.templateId

Other representations of profile: CSV, Excel