This is the set of resources that conform to both Operative Note (http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote) and Operative Note (http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote).
| Name | Flags | Card. | Type | Description & Constraints |
|---|
  ClinicalDocument | C | 1..1 | | Base 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..1 | CS | |
 nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| code | | 1..1 | ??, ?? | |
| sdtcValueSet | | 0..1 | ??, ?? | |
 sdtcValueSetVersion | | 0..1 | ??, ?? | |
| typeId | | 1..1 | II | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| assigningAuthorityName | | 0..1 | ??, ?? | |
| displayable | | 0..1 | ??, ?? | |
| root | | 1..1 | ??, ??, ??, ?? | |
| extension | | 1..1 | ??, ?? | |
| templateId | | 2..* | II | |
| code | | 1..1 | CE | left: The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these 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.; right: The Operative Note recommends use of a single document type code, 11504-8 "Surgical operation note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these 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..1 | ED | |
| translation | | 0..* | CD | |
| title | | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code |
| sdtcStatusCode | | 0..1 | CS | Binding: ?? (required) |
| effectiveTime | C | 1..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..1 | CE | |
| 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..1 | ED | |
| translation | | 0..* | CD | |
| languageCode | | 1..1 | CS | Binding: ?? (required) |
| setId | | 0..1 | II | |
| versionNumber | | 0..1 | INT | |
| copyTime | | 0..1 | TS | |
| recordTarget | | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | PatientRole | |
 nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | 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 | C | 1..* | TEL | left: (USCDI) Phone Number / Email; right: 𝗨𝗦𝗖𝗗𝗜: Phone Number / Email
should-use: SHOULD contain @use
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
 useablePeriod | | 0..* | | |
 useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| patient | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159).
shall-given: SHALL contain at least one [1..*] given (CONF:81-7157).
shall-max-suffix: There may be at most one suffix
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278).
|
| sdtcDesc | | 0..1 | ED | |
| administrativeGenderCode | | 1..1 | CE | Binding: ?? (required) |
| birthTime | C | 1..1 | TS | left: (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..1 | BL | sdtc:deceasedInd |
| sdtcDeceasedTime | C | 0..1 | TS | left: (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..1 | BL | |
| sdtcMultipleBirthOrderNumber | | 0..1 | INT_POS | |
| maritalStatusCode | | 0..1 | CE | Binding: ?? (required) |
| religiousAffiliationCode | | 0..1 | CE | Binding: ?? (required) |
| raceCode | | 1..1 | CE | left: (USCDI) Race; right: 𝗨𝗦𝗖𝗗𝗜: Race
Binding: ?? (required) |
| sdtcRaceCode | | 0..* | CE | left: (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..1 | CE | left: (USCDI) Ethnicity; right: 𝗨𝗦𝗖𝗗𝗜: Ethnicity
Binding: ?? (required) |
| sdtcEthnicGroupCode | | 0..* | CE | left: (USCDI) Ethnicity; right: 𝗨𝗦𝗖𝗗𝗜: Ethnicity
Binding: ?? (required)
|
| guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (required) |
| addr | C | 0..* | ??, ?? | Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
|
| telecom | C | 0..* | TEL | should-use: SHOULD contain @use
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
| useablePeriod | | 0..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| guardianPerson | | 1..1 | Person | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
|
| sdtcDesc | | 0..1 | ED | |
| sdtcAsPatientRelationship | | 0..* | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| guardianOrganization | | 0..1 | Organization | |
| birthplace | | 0..1 | Birthplace | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | Place | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | EN | |
| addr | C | 1..1 | AD | 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| isNotOrdered | | 0..1 | ??, ?? | |
| use | | 0..* | ??, ?? | Binding: ?? (required)
|
| item | C | 0..* | Base | AD-1: Can only have only one of the possible item elements in each choice
|
| (Choice of one) | | 1..1 | | |
 delimiter | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
 (Choice of one) | | 1..1 | | |
 nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
 xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| country | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| state | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| county | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| city | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| postalCode | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| streetAddressLine | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| houseNumber | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| houseNumberNumeric | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| direction | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| streetName | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| streetNameBase | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| streetNameType | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| additionalLocator | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| unitID | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| unitType | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| careOf | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| censusTract | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| deliveryAddressLine | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| deliveryInstallationType | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| deliveryInstallationArea | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| deliveryInstallationQualifier | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| deliveryMode | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| deliveryModeIdentifier | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| buildingNumberSuffix | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| postBox | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| xmlText | | 0..1 | ??, ?? | Allows for mixed text content |
| representation | | 0..1 | ??, ?? | |
| mediaType | | 0..1 | ??, ?? | |
| language | | 0..1 | ??, ?? | |
| partType | | 0..1 | ??, ?? | |
| precinct | C | 0..1 | ADXP | text-null: xmlText and nullFlavor are mutually exclusive (one must be present) |
| (Choice of one) | | 1..1 | | |
| nullFlavor | | 0..1 | ??, ?? | 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..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| languageCommunication | C | 0..* | LanguageCommunication | left: (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..1 | II | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| assigningAuthorityName | | 0..1 | ??, ?? | |
| displayable | | 0..1 | ??, ?? | |
| root | | 1..1 | ??, ??, ??, ?? | |
| extension | | 1..1 | ??, ?? | |
| templateId | | 0..* | II | |
| languageCode | | 1..1 | CS | Binding: ?? (required) |
| modeCode | | 0..1 | CE | Binding: ?? (required) |
| proficiencyLevelCode | | 0..1 | CE | Binding: ?? (required) |
| preferenceInd | | 0..1 | BL | |
| providerOrganization | | 0..1 | Organization | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | TEL | should-use: SHOULD contain @use
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
| useablePeriod | | 0..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| addr | C | 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
|
| standardIndustryClassCode | | 0..1 | CE | Binding: ?? (example) |
| asOrganizationPartOf | | 0..1 | OrganizationPartOf | |
| author | | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person.
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| time | C | 1..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 | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Only 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..1 | ED | |
| translation | | 0..* | CD | |
| addr | C | 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
|
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
| useablePeriod | | 0..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| (Choice of one) | | 1..1 | | |
| assignedPerson | | 0..1 | Person | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
|
| sdtcDesc | | 0..1 | ED | |
| sdtcAsPatientRelationship | | 0..* | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
 assignedAuthoringDevice | | 0..1 | AuthoringDevice | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (example) |
| manufacturerModelName | | 1..1 | SC | Binding: ?? (example) |
| softwareName | | 1..1 | SC | Binding: ?? (example) |
| asMaintainedEntity | | 0..* | MaintainedEntity | |
| representedOrganization | | 0..1 | Organization | |
| dataEnterer | | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 0..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..1 | AssignedEntity | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (preferred) |
| addr | C | 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
|
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
| useablePeriod | | 0..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| assignedPerson | | 1..1 | Person | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
|
| sdtcDesc | | 0..1 | ED | |
| sdtcAsPatientRelationship | | 0..* | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| representedOrganization | | 0..1 | Organization | |
| sdtcPatient | | 0..1 | Base | |
| informant | | 0..* | Informant | |
| custodian | | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.
There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | AssignedCustodian | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CustodianOrganization | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | ON | |
| telecom | C | 1..1 | TEL | should-use: SHOULD contain @use |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
| useablePeriod | | 0..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| sdtcTelecom | | 0..* | TEL | The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
|
| addr | C | 1..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..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | IntendedRecipient | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | Person | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
|
| sdtcDesc | | 0..1 | ED | |
| sdtcAsPatientRelationship | | 0..* | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| receivedOrganization | | 0..1 | Organization | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | ON | |
| telecom | | 0..* | TEL | |
| addr | | 0..* | AD | |
| standardIndustryClassCode | | 0..1 | CE | Binding: ?? (example) |
| asOrganizationPartOf | | 0..1 | OrganizationPartOf | |
| legalAuthenticator | | 0..1 | LegalAuthenticator | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..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 | C | 1..1 | CS | Binding: ?? (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..1 | ED | 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. |
| assignedEntity | | 1..1 | AssignedEntity | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (preferred) |
| addr | C | 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
|
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
| useablePeriod | | 0..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| assignedPerson | | 1..1 | Person | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
|
| sdtcDesc | | 0..1 | ED | |
| sdtcAsPatientRelationship | | 0..* | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| representedOrganization | | 0..1 | Organization | |
| sdtcPatient | | 0..1 | Base | |
| authenticator | | 0..* | Authenticator | The 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..1 | II | |
| 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 | C | 1..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 | C | 1..1 | CS | Binding: ?? (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..1 | ED | 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. |
| assignedEntity | | 1..1 | AssignedEntity | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (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..1 | ED | |
| translation | | 0..* | CD | |
| addr | C | 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
|
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| value | | 0..1 | ??, ?? | |
| useablePeriod | | 0..* | | |
| useablePeriod | | | IVL_TS | |
| useablePeriod | | | EIVL_TS | |
| useablePeriod | | | PIVL_TS | |
| useablePeriod | | | SXPR_TS | |
| use | | 0..1 | ??, ?? | Binding: ?? (required) |
| assignedPerson | | 1..1 | Person | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..* | ??, ?? | Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
|
| sdtcDesc | | 0..1 | ED | |
| sdtcAsPatientRelationship | | 0..* | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| representedOrganization | | 0..1 | Organization | |
| sdtcPatient | | 0..1 | Base | |
| participant | C | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others 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).
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).
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| time | C | 0..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..1 | AssociatedEntity | |
| inFulfillmentOf | | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | Order | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (example) |
| priorityCode | | 0..1 | CE | Binding: ?? (example) |
| documentationOf | | 1..* | DocumentationOf | A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..1 | CE | Binding Description (No ValueSet): (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
1198-8487: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487). |
| effectiveTime | C | 1..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.
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high. |
| 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 | C | 1..1 | IVXB_TS | Low is required
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..1 | TS | |
| (Choice of one) | | 1..1 | | |
| width | | 0..1 | PQ | Represents the duration |
| high | C | 0..1 | IVXB_TS | Equals low if only the date is known
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 | | 1..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
|
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 0..1 | CE | should-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..1 | ED | |
| translation | | 0..* | CD | |
| time | C | 0..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 | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (preferred) |
| addr | | 0..* | AD | |
| telecom | | 0..* | TEL | |
| assignedPerson | | 0..1 | Person | |
| representedOrganization | | 0..1 | Organization | |
| sdtcPatient | | 0..1 | Base | |
| relatedDocument | | 0..* | RelatedDocument | |
| authorization | | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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) |
| consent | | 1..1 | Consent | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| assigningAuthorityName | | 0..1 | ??, ?? | |
| displayable | | 0..1 | ??, ?? | |
| root | | 1..1 | ??, ??, ??, ?? | |
| extension | | 1..1 | ??, ?? | |
| templateId | | 0..* | II | |
| classCode | | 1..1 | ??, ?? | Binding: ?? (required) |
| moodCode | | 1..1 | ??, ?? | Binding: ?? (required) |
| code | | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: ?? (example) |
| statusCode | | 1..1 | CS | Binding: ?? (required) |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| code | | 1..1 | ??, ?? | |
| sdtcValueSet | | 0..1 | ??, ?? | |
| sdtcValueSetVersion | | 0..1 | ??, ?? | |
| componentOf | | 0..1 | ComponentOf | 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. |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | Binding: ?? (preferred) |
| effectiveTime | C | 1..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. |
| sdtcAdmissionReferralSourceCode | | 0..1 | CE | |
| dischargeDispositionCode | | 0..1 | CE | Binding: ?? (example) |
| responsibleParty | | 0..1 | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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 | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | | 0..* | EncounterParticipant | |
| location | | 0..1 | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | HealthCareFacility | |
| component | | 1..1 | Component | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | NonXMLBody | |
| structuredBody | | 1..1 | StructuredBody | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | CE | |
| languageCode | | 0..1 | CS | Binding: ?? (required) |
| component | | 8..* | InfrastructureRoot | |
| nullFlavor | | 0..1 | ??, ?? | Binding: ?? (required) |
| realmCode | | 0..* | CS | |
| typeId | | 0..1 | II | |
| 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..1 | Section | |
Documentation for this format |