Clinical Document Architecture
2.0.0-sd - release

Clinical Document Architecture, published by Health Level 7. This guide is not an authorized publication; it is the continuous build for version 2.0.0-sd built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-core-sd/ and changes regularly. See the Directory of published versions

Logical Model: ClinicalDocument - Detailed Descriptions

Active as of 2024-10-25

Definitions for the ClinicalDocument logical model.

Guidance on how to interpret the contents of this table can be found here

0. ClinicalDocument
Control1..1
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. ClinicalDocument.classCode
Control0..1
BindingFor example codes, see CDAActClass
(example to http://hl7.org/cda/stds/core/ValueSet/CDAActClass)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDOCCLIN
4. ClinicalDocument.moodCode
Control0..1
BindingThe codes SHALL be taken from CDAActMood
(required to http://hl7.org/cda/stds/core/ValueSet/CDAActMood)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN
6. ClinicalDocument.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
8. ClinicalDocument.typeId
Definition

ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
10. ClinicalDocument.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
XML FormatIn the XML format, this property is represented as an attribute.
Fixed Value2.16.840.1.113883.1.3
12. ClinicalDocument.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePOCD_HD000040
14. ClinicalDocument.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
16. ClinicalDocument.id
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
18. ClinicalDocument.sdtcCategory
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namecategory.
20. ClinicalDocument.code
Control1..1
BindingFor example codes, see FHIRDocumentTypeCodes
(example to http://hl7.org/fhir/ValueSet/doc-typecodes)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
22. ClinicalDocument.title
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
24. ClinicalDocument.sdtcStatusCode
Definition

The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient.

Control0..1
BindingThe codes SHALL be taken from ActStatus
(required to http://terminology.hl7.org/ValueSet/v3-ActStatus)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namestatusCode.
26. ClinicalDocument.effectiveTime
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
28. ClinicalDocument.confidentialityCode
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
30. ClinicalDocument.languageCode
Control0..1
BindingThe codes SHALL be taken from AllLanguages
(required to http://hl7.org/fhir/ValueSet/all-languages)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
32. ClinicalDocument.setId
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
34. ClinicalDocument.versionNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
36. ClinicalDocument.copyTime
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
38. ClinicalDocument.recordTarget
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
40. ClinicalDocument.author
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
42. ClinicalDocument.dataEnterer
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
44. ClinicalDocument.informant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
46. ClinicalDocument.custodian
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Custodian
48. ClinicalDocument.informationRecipient
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
50. ClinicalDocument.legalAuthenticator
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
52. ClinicalDocument.authenticator
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
54. ClinicalDocument.participant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
56. ClinicalDocument.inFulfillmentOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
58. ClinicalDocument.documentationOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
60. ClinicalDocument.relatedDocument
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
62. ClinicalDocument.authorization
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authorization
64. ClinicalDocument.componentOf
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
66. ClinicalDocument.component
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Component

Guidance on how to interpret the contents of this table can be found here

0. ClinicalDocument
Definition

Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.


Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Control10..1*
Is Modifierfalse
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. ClinicalDocument.classCode
Control0..1
BindingFor example codes, see CDAActClass
(example to http://hl7.org/cda/stds/core/ValueSet/CDAActClass)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDOCCLIN
4. ClinicalDocument.moodCode
Control0..1
BindingThe codes SHALL be taken from CDAActMood
(required to http://hl7.org/cda/stds/core/ValueSet/CDAActMood)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN
6. ClinicalDocument.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
8. ClinicalDocument.typeId
Definition

ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
10. ClinicalDocument.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Fixed Value2.16.840.1.113883.1.3
12. ClinicalDocument.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Fixed ValuePOCD_HD000040
14. ClinicalDocument.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
16. ClinicalDocument.id
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
18. ClinicalDocument.sdtcCategory
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namecategory.
20. ClinicalDocument.code
Control1..1
BindingFor example codes, see FHIRDocumentTypeCodes
(example to http://hl7.org/fhir/ValueSet/doc-typecodes)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
22. ClinicalDocument.title
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
24. ClinicalDocument.sdtcStatusCode
Definition

The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient.

Control0..1
BindingThe codes SHALL be taken from ActStatus
(required to http://terminology.hl7.org/ValueSet/v3-ActStatus)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namestatusCode.
26. ClinicalDocument.effectiveTime
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
28. ClinicalDocument.confidentialityCode
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
30. ClinicalDocument.languageCode
Control0..1
BindingThe codes SHALL be taken from AllLanguages
(required to http://hl7.org/fhir/ValueSet/all-languages)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
32. ClinicalDocument.setId
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
34. ClinicalDocument.versionNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
36. ClinicalDocument.copyTime
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
38. ClinicalDocument.recordTarget
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
40. ClinicalDocument.author
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
42. ClinicalDocument.dataEnterer
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
44. ClinicalDocument.informant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
46. ClinicalDocument.custodian
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Custodian
48. ClinicalDocument.informationRecipient
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
50. ClinicalDocument.legalAuthenticator
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
52. ClinicalDocument.authenticator
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
54. ClinicalDocument.participant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
56. ClinicalDocument.inFulfillmentOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
58. ClinicalDocument.documentationOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
60. ClinicalDocument.relatedDocument
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
62. ClinicalDocument.authorization
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authorization
64. ClinicalDocument.componentOf
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
66. ClinicalDocument.component
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Component

Guidance on how to interpret the contents of this table can be found here

0. ClinicalDocument
Definition

Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.

ShortBase for all types and resources
Control1..1
Is Modifierfalse
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. ClinicalDocument.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
4. ClinicalDocument.classCode
Control0..1
BindingFor example codes, see CDAActClass
(example to http://hl7.org/cda/stds/core/ValueSet/CDAActClass)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDOCCLIN
6. ClinicalDocument.moodCode
Control0..1
BindingThe codes SHALL be taken from CDAActMood
(required to http://hl7.org/cda/stds/core/ValueSet/CDAActMood)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN
8. ClinicalDocument.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
10. ClinicalDocument.typeId
Definition

ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
12. ClinicalDocument.typeId.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
14. ClinicalDocument.typeId.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
16. ClinicalDocument.typeId.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
18. ClinicalDocument.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Fixed Value2.16.840.1.113883.1.3
20. ClinicalDocument.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Fixed ValuePOCD_HD000040
22. ClinicalDocument.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
24. ClinicalDocument.id
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
26. ClinicalDocument.sdtcCategory
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namecategory.
28. ClinicalDocument.code
Control1..1
BindingFor example codes, see FHIRDocumentTypeCodes
(example to http://hl7.org/fhir/ValueSet/doc-typecodes)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
30. ClinicalDocument.title
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
32. ClinicalDocument.sdtcStatusCode
Definition

The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient.

Control0..1
BindingThe codes SHALL be taken from ActStatus
(required to http://terminology.hl7.org/ValueSet/v3-ActStatus)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namestatusCode.
34. ClinicalDocument.effectiveTime
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
36. ClinicalDocument.confidentialityCode
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
38. ClinicalDocument.languageCode
Control0..1
BindingThe codes SHALL be taken from AllLanguages
(required to http://hl7.org/fhir/ValueSet/all-languages)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
40. ClinicalDocument.setId
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
42. ClinicalDocument.versionNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
44. ClinicalDocument.copyTime
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
46. ClinicalDocument.recordTarget
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
48. ClinicalDocument.author
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
50. ClinicalDocument.dataEnterer
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
52. ClinicalDocument.informant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
54. ClinicalDocument.custodian
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Custodian
56. ClinicalDocument.informationRecipient
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
58. ClinicalDocument.legalAuthenticator
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
60. ClinicalDocument.authenticator
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
62. ClinicalDocument.participant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
64. ClinicalDocument.inFulfillmentOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
66. ClinicalDocument.documentationOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
68. ClinicalDocument.relatedDocument
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
70. ClinicalDocument.authorization
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authorization
72. ClinicalDocument.componentOf
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
74. ClinicalDocument.component
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Component