Union of http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical and http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical

This is the set of resources that conform to either of the profiles History and Physical (http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical) and History and Physical (http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical). E.g. what you have to deal with if you get resources conforming to one of them

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1Base for all types and resources
4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
should-legalAuthenticator: SHOULD contain legalAuthenticator
should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant
... nullFlavor 0..1??Binding: ?? (required)
... classCode 0..1??Binding: ?? (example)
... moodCode 0..1??Binding: ?? (required)
... realmCode 1..1CS
.... nullFlavor 0..1??Binding: ?? (required)
.... code 1..1??
.... sdtcValueSet 0..1??
.... sdtcValueSetVersion 0..1??
... typeId 1..1II
.... nullFlavor 0..1??Binding: ?? (required)
.... assigningAuthorityName 0..1??
.... displayable 0..1??
.... root 1..1??, ??, ??
.... extension 1..1??
... templateId 2..*II
... code 1..1CEThe H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ?? (required)
.... code 1..1??
.... codeSystem 1..1??, ??, ??
.... codeSystemName 0..1??
.... codeSystemVersion 0..1??
.... displayName 0..1??
.... sdtcValueSet 0..1??
.... sdtcValueSetVersion 0..1??
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... sdtcStatusCode 0..1CSBinding: ?? (required)
... effectiveTime C1..1??Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
... confidentialityCode 1..1CE
.... code 1..1??Binding: ?? (preferred)
.... codeSystem 0..1??, ??, ??
.... codeSystemName 0..1??
.... codeSystemVersion 0..1??
.... displayName 0..1??
.... sdtcValueSet 0..1??
.... sdtcValueSetVersion 0..1??
.... originalText 0..1ED
.... translation 0..*CD
... languageCode 1..1CSBinding: ?? (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... contextControlCode 0..1??Binding: ?? (required)
.... patientRole 1..1PatientRole
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... sdtcIdentifiedBy 0..*IdentifiedBy
..... addr C1..*??left: (USCDI) Address; right: 𝗨𝗦𝗖𝗗𝗜: Address
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C1..*TELleft: (USCDI) Phone Number / Email; right: 𝗨𝗦𝗖𝗗𝗜: Phone Number / Email
should-use: SHOULD contain @use
...... nullFlavor 0..1??Binding: ?? (required)
...... value 0..1??
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1??Binding: ?? (required)
..... patient C1..1Patient4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name C1..*??Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159).
shall-given: SHALL contain at least one [1..*] given (CONF:81-7157).
shall-max-suffix: There may be at most one suffix
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278).
...... sdtcDesc 0..1ED
...... administrativeGenderCode 1..1CEBinding: ?? (required)
...... birthTime C1..1TSleft: (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); right: 𝗨𝗦𝗖𝗗𝗜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcDeceasedInd 0..1BLsdtc:deceasedInd
...... sdtcDeceasedTime C0..1TSleft: (USCDI) Date of Death; right: 𝗨𝗦𝗖𝗗𝗜: Date of Death
should-value-att: SHOULD contain @value
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcMultipleBirthInd 0..1BL
...... sdtcMultipleBirthOrderNumber 0..1INT_POS
...... maritalStatusCode 0..1CEBinding: ?? (required)
...... religiousAffiliationCode 0..1CEBinding: ?? (required)
...... raceCode 1..1CEleft: (USCDI) Race; right: 𝗨𝗦𝗖𝗗𝗜: Race
Binding: ?? (required)
...... sdtcRaceCode 0..*CEleft: (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.; right: 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.
Binding: ?? (required)
...... ethnicGroupCode 1..1CEleft: (USCDI) Ethnicity; right: 𝗨𝗦𝗖𝗗𝗜: Ethnicity
Binding: ?? (required)
...... sdtcEthnicGroupCode 0..*CEleft: (USCDI) Ethnicity; right: 𝗨𝗦𝗖𝗗𝗜: Ethnicity
Binding: ?? (required)
...... guardian C0..*Guardianshould-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 0..1??Binding: ?? (required)
....... sdtcIdentifiedBy 0..*IdentifiedBy
....... code 0..1CEBinding: ?? (required)
....... addr C0..*??Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
....... telecom C0..*TELshould-use: SHOULD contain @use
........ nullFlavor 0..1??Binding: ?? (required)
........ value 0..1??
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ use 0..1??Binding: ?? (required)
....... guardianPerson 1..1Person
........ nullFlavor 0..1??Binding: ?? (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... nullFlavor 0..1??Binding: ?? (required)
......... assigningAuthorityName 0..1??
......... displayable 0..1??
......... root 1..1??, ??, ??
......... extension 1..1??
........ templateId 0..*II
........ classCode 0..1??Binding: ?? (required)
........ determinerCode 0..1??Binding: ?? (required)
........ name C1..*??Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
........ sdtcDesc 0..1ED
........ sdtcAsPatientRelationship 0..*InfrastructureRoot
......... nullFlavor 0..1??Binding: ?? (required)
......... realmCode 0..*CS
......... typeId 0..1II
.......... nullFlavor 0..1??Binding: ?? (required)
.......... assigningAuthorityName 0..1??
.......... displayable 0..1??
.......... root 1..1??, ??, ??
.......... extension 1..1??
......... templateId 0..*II
......... classCode 1..1??
......... determinerCode 0..1??
......... code 1..1CE
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 0..1??Binding: ?? (required)
....... place 1..1Place
........ nullFlavor 0..1??Binding: ?? (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... nullFlavor 0..1??Binding: ?? (required)
......... assigningAuthorityName 0..1??
......... displayable 0..1??
......... root 1..1??, ??, ??
......... extension 1..1??
........ templateId 0..*II
........ classCode 0..1??Binding: ?? (required)
........ determinerCode 0..1??Binding: ?? (required)
........ name 0..1EN
........ addr C1..1AD4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country
......... nullFlavor 0..1??Binding: ?? (required)
......... isNotOrdered 0..1??
......... use 0..*??Binding: ?? (required)
......... item C0..*BaseAD-1: Can only have only one of the possible item elements in each choice
.......... (Choice of one) 1..1
........... delimiter C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... country C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... state C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... county C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... city C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... postalCode C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... streetAddressLine C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... houseNumber C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... houseNumberNumeric C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... direction C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... streetName C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... streetNameBase C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... streetNameType C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... additionalLocator C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... unitID C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... unitType C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... careOf C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... censusTract C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... deliveryAddressLine C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... deliveryInstallationType C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... deliveryInstallationArea C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... deliveryInstallationQualifier C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... deliveryMode C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... deliveryModeIdentifier C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... buildingNumberSuffix C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... postBox C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... precinct C0..1ADXPtext-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. nullFlavor 0..1??Binding: ?? (required)
............. xmlText 0..1??Allows for mixed text content
............ representation 0..1??
............ mediaType 0..1??
............ language 0..1??
............ partType 0..1??
........... xmlText 0..1??Allows for mixed text content
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication C0..*LanguageCommunicationleft: (USCDI) Preferred Language; right: 𝗨𝗦𝗖𝗗𝗜: Preferred Language
should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode
should-preferenceInd: SHOULD contain preferenceInd
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... languageCode 1..1CSBinding: ?? (required)
....... modeCode 0..1CEBinding: ?? (required)
....... proficiencyLevelCode 0..1CEBinding: ?? (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name 1..*ON
...... telecom C1..*TELshould-use: SHOULD contain @use
....... nullFlavor 0..1??Binding: ?? (required)
....... value 0..1??
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1??Binding: ?? (required)
...... addr C1..*??Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
...... standardIndustryClassCode 0..1CEBinding: ?? (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... contextControlCode 0..1??Binding: ?? (required)
.... functionCode 0..1CE
.... time C1..1??Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedAuthor C1..1AssignedAuthor4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... sdtcIdentifiedBy 0..*IdentifiedBy
..... code 0..1CEOnly if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: ?? (example)
...... code 1..1??Binding: ?? (preferred)
...... codeSystem 0..1??, ??, ??
...... codeSystemName 0..1??
...... codeSystemVersion 0..1??
...... displayName 0..1??
...... sdtcValueSet 0..1??
...... sdtcValueSetVersion 0..1??
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*??Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C1..*TELshould-use: SHOULD contain @use
...... nullFlavor 0..1??Binding: ?? (required)
...... value 0..1??
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1??Binding: ?? (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1Person
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 0..1??Binding: ?? (required)
....... determinerCode 0..1??Binding: ?? (required)
....... name C1..*??Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
....... sdtcDesc 0..1ED
....... sdtcAsPatientRelationship 0..*InfrastructureRoot
........ nullFlavor 0..1??Binding: ?? (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... nullFlavor 0..1??Binding: ?? (required)
......... assigningAuthorityName 0..1??
......... displayable 0..1??
......... root 1..1??, ??, ??
......... extension 1..1??
........ templateId 0..*II
........ classCode 1..1??
........ determinerCode 0..1??
........ code 1..1CE
...... assignedAuthoringDevice 0..1AuthoringDevice
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 0..1??Binding: ?? (required)
....... determinerCode 0..1??Binding: ?? (required)
....... code 0..1CEBinding: ?? (example)
....... manufacturerModelName 1..1SCBinding: ?? (example)
....... softwareName 1..1SCBinding: ?? (example)
....... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... contextControlCode 0..1??Binding: ?? (required)
.... time C0..1??Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedEntity 1..1AssignedEntity
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... sdtcIdentifiedBy 0..*IdentifiedBy
..... code 0..1CEBinding: ?? (preferred)
..... addr C1..*??Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C1..*TELshould-use: SHOULD contain @use
...... nullFlavor 0..1??Binding: ?? (required)
...... value 0..1??
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1??Binding: ?? (required)
..... assignedPerson 1..1Person
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name C1..*??Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1ED
...... sdtcAsPatientRelationship 0..*InfrastructureRoot
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 1..1??
....... determinerCode 0..1??
....... code 1..1CE
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1Base
... informant 0..*Informant
... custodian 1..1CustodianThe custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... assignedCustodian 1..1AssignedCustodian
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... representedCustodianOrganization 1..1CustodianOrganization
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name 1..1ON
...... telecom C1..1TELshould-use: SHOULD contain @use
....... nullFlavor 0..1??Binding: ?? (required)
....... value 0..1??
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1??Binding: ?? (required)
...... sdtcTelecom 0..*TELThe stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
...... addr C1..1??Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... intendedRecipient 1..1IntendedRecipient
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... sdtcIdentifiedBy 0..*IdentifiedBy
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name C1..*??Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1ED
...... sdtcAsPatientRelationship 0..*InfrastructureRoot
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 1..1??
....... determinerCode 0..1??
....... code 1..1CE
..... receivedOrganization 0..1Organization
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: ?? (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorThe legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... contextControlCode 0..1??Binding: ?? (required)
.... time C1..1??Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C1..1CSBinding: ?? (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... nullFlavor 0..1??Binding: ?? (required)
..... code 1..1??
..... sdtcValueSet 0..1??
..... sdtcValueSetVersion 0..1??
.... sdtcSignatureText 0..1EDThe 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.
.... assignedEntity 1..1AssignedEntity
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... sdtcIdentifiedBy 0..*IdentifiedBy
..... code 0..1CEBinding: ?? (preferred)
..... addr C1..*??Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C1..*TELshould-use: SHOULD contain @use
...... nullFlavor 0..1??Binding: ?? (required)
...... value 0..1??
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1??Binding: ?? (required)
..... assignedPerson 1..1Person
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name C1..*??Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1ED
...... sdtcAsPatientRelationship 0..*InfrastructureRoot
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 1..1??
....... determinerCode 0..1??
....... code 1..1CE
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1Base
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... time C1..1??Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C1..1CSBinding: ?? (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... nullFlavor 0..1??Binding: ?? (required)
..... code 1..1??
..... sdtcValueSet 0..1??
..... sdtcValueSetVersion 0..1??
.... sdtcSignatureText 0..1EDThe 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.
.... assignedEntity 1..1AssignedEntity
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... sdtcIdentifiedBy 0..*IdentifiedBy
..... code 0..1CEBinding: ?? (example)
...... nullFlavor 0..1??Binding: ?? (required)
...... code 0..1??Binding: ?? (preferred)
...... codeSystem 0..1??, ??, ??
...... codeSystemName 0..1??
...... codeSystemVersion 0..1??
...... displayName 0..1??
...... sdtcValueSet 0..1??
...... sdtcValueSetVersion 0..1??
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*??Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C1..*TELshould-use: SHOULD contain @use
...... nullFlavor 0..1??Binding: ?? (required)
...... value 0..1??
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1??Binding: ?? (required)
..... assignedPerson 1..1Person
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... classCode 0..1??Binding: ?? (required)
...... determinerCode 0..1??Binding: ?? (required)
...... name C1..*??Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1ED
...... sdtcAsPatientRelationship 0..*InfrastructureRoot
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 1..1??
....... determinerCode 0..1??
....... code 1..1CE
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1Base
... participant C0..*Participant1The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations.
4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 1..1??Binding: ?? (required)
.... contextControlCode 0..1??Binding: ?? (required)
.... functionCode 0..1CE
.... time C0..1??Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
.... associatedEntity 1..1AssociatedEntity
... inFulfillmentOf 0..*InFulfillmentOfinFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... order 1..1Order
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... moodCode 0..1??Binding: ?? (required)
..... code 0..1CEBinding: ?? (example)
..... priorityCode 0..1CEBinding: ?? (example)
... documentationOf 0..*DocumentationOf
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... moodCode 0..1??Binding: ?? (required)
..... code 0..1CE
..... effectiveTime C1..1??Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... nullFlavor 0..1??Binding: ?? (required)
...... value 0..1??Either @value or low/high should be present, but not both
...... operator 0..1??Binding: ?? (required)
...... low C1..1IVXB_TS**MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
....... nullFlavor 0..1??Binding: ?? (required)
....... value 0..1??
....... inclusive 0..1??
...... center 0..1TS
...... width 0..1PQ
...... high C0..1IVXB_TS**MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
....... nullFlavor 0..1??Binding: ?? (required)
....... value 0..1??
....... inclusive 0..1??
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... typeCode 1..1??Binding: ?? (required)
...... functionCode C0..1CEshould-code-attr: SHOULD contain @code
....... nullFlavor 0..1??Binding: ?? (required)
....... code 0..1??Binding: ?? (preferred)
....... codeSystem 0..1??, ??, ??
....... codeSystemName 0..1??
....... codeSystemVersion 0..1??
....... displayName 0..1??
....... sdtcValueSet 0..1??
....... sdtcValueSetVersion 0..1??
....... originalText 0..1ED
....... translation 0..*CD
...... time C0..1??Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... assignedEntity C1..1AssignedEntityshould-us-code: SHOULD contain code
....... nullFlavor 0..1??Binding: ?? (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ nullFlavor 0..1??Binding: ?? (required)
........ assigningAuthorityName 0..1??
........ displayable 0..1??
........ root 1..1??, ??, ??
........ extension 1..1??
....... templateId 0..*II
....... classCode 0..1??Binding: ?? (required)
....... sdtcIdentifiedBy 0..*IdentifiedBy
....... code 0..1CEBinding: ?? (preferred)
....... addr 0..*AD
....... telecom 0..*TEL
....... assignedPerson 0..1Person
....... representedOrganization 0..1Organization
....... sdtcPatient 0..1Base
... relatedDocument 0..*RelatedDocument
... authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... consent 1..1Consent
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... moodCode 0..1??Binding: ?? (required)
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: ?? (example)
..... statusCode 1..1CSBinding: ?? (required)
...... nullFlavor 0..1??Binding: ?? (required)
...... code 1..1??
...... sdtcValueSet 0..1??
...... sdtcValueSetVersion 0..1??
... componentOf 1..1ComponentOfThe H&P Note is always associated with an encounter.
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... encompassingEncounter C1..1EncompassingEncountershould-responsibleParty: SHOULD contain responsibleParty
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... moodCode 0..1??Binding: ?? (required)
..... code 0..1CEBinding: ?? (preferred)
..... effectiveTime C1..1??The effectiveTime represents the time interval or point in time in which the encounter took place.
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
..... sdtcAdmissionReferralSourceCode 0..1CE
..... dischargeDispositionCode 0..1CEBinding: ?? (example)
..... responsibleParty C0..1InfrastructureRootThe responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care.
1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348).
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... typeCode 0..1??Binding: ?? (required)
...... assignedEntity C1..1AssignedEntity1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
..... encounterParticipant C0..*EncounterParticipantThe encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care.
1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343).
..... location 0..1InfrastructureRoot
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... typeCode 0..1??Binding: ?? (required)
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component
.... nullFlavor 0..1??Binding: ?? (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... nullFlavor 0..1??Binding: ?? (required)
..... assigningAuthorityName 0..1??
..... displayable 0..1??
..... root 1..1??, ??, ??
..... extension 1..1??
.... templateId 0..*II
.... typeCode 0..1??Binding: ?? (required)
.... contextConductionInd 0..1??
.... nonXMLBody 0..1NonXMLBody
.... structuredBody C1..1StructuredBodyIn this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional.
ccrfv-or-cc-or-rfv: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12).
ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
should-section-hpi: SHOULD contain a History of Present Illness Section
..... nullFlavor 0..1??Binding: ?? (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... nullFlavor 0..1??Binding: ?? (required)
...... assigningAuthorityName 0..1??
...... displayable 0..1??
...... root 1..1??, ??, ??
...... extension 1..1??
..... templateId 0..*II
..... classCode 0..1??Binding: ?? (required)
..... moodCode 0..1??Binding: ?? (required)
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: ?? (required)
..... component 12..*InfrastructureRoot
...... nullFlavor 0..1??Binding: ?? (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... nullFlavor 0..1??Binding: ?? (required)
....... assigningAuthorityName 0..1??
....... displayable 0..1??
....... root 1..1??, ??, ??
....... extension 1..1??
...... templateId 0..*II
...... typeCode 0..1??
...... contextConductionInd 0..1??
...... section 1..1Section
... sdtcCategory 0..*CDUsed to categorize the document as a History and Physical. If present, there SHALL be a category of 34117-2 (History and physical note).
XML: category (urn:hl7-org:sdtc)

doco Documentation for this format