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 (CDA Class)

Official URL: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument Version: 2.0.0-sd
Active as of 2024-10-25 Computable Name: ClinicalDocument

This is a generated StructureDefinition that describes CDA - that is, CDA as it actually is for R2. The intent of this StructureDefinition is to enable CDA to be a FHIR resource. That enables the FHIR infrastructure - API, conformance, query - to be used directly against CDA

Usage:

  • This Logical Model Profile is not used by any profiles in this Implementation Guide

Formal Views of Template Content

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

This structure is derived from ANY

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS
... confidentialityCode 1..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget
... author 1..* Author
... dataEnterer 0..1 DataEnterer
... informant 0..* Informant
... custodian 1..1 Custodian
... informationRecipient 0..* InformationRecipient
... legalAuthenticator 0..1 LegalAuthenticator
... authenticator 0..* Authenticator
... participant 0..* Participant1
... inFulfillmentOf 0..* InFulfillmentOf
... documentationOf 0..* DocumentationOf
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization
... componentOf 0..1 ComponentOf
... component 1..1 Component

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
from this IG
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
from this IG
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS
... confidentialityCode 1..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget
... author 1..* Author
... dataEnterer 0..1 DataEnterer
... informant 0..* Informant
... custodian 1..1 Custodian
... informationRecipient 0..* InformationRecipient
... legalAuthenticator 0..1 LegalAuthenticator
... authenticator 0..* Authenticator
... participant 0..* Participant1
... inFulfillmentOf 0..* InFulfillmentOf
... documentationOf 0..* DocumentationOf
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization
... componentOf 0..1 ComponentOf
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
from this IG
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
from this IG
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS
... confidentialityCode 1..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget
... author 1..* Author
... dataEnterer 0..1 DataEnterer
... informant 0..* Informant
... custodian 1..1 Custodian
... informationRecipient 0..* InformationRecipient
... legalAuthenticator 0..1 LegalAuthenticator
... authenticator 0..* Authenticator
... participant 0..* Participant1
... inFulfillmentOf 0..* InFulfillmentOf
... documentationOf 0..* DocumentationOf
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization
... componentOf 0..1 ComponentOf
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
from this IG
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
from this IG
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

This structure is derived from ANY

Summary

Mandatory: 0 element(10 nested mandatory elements)
Fixed: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from ANY

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS
... confidentialityCode 1..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget
... author 1..* Author
... dataEnterer 0..1 DataEnterer
... informant 0..* Informant
... custodian 1..1 Custodian
... informationRecipient 0..* InformationRecipient
... legalAuthenticator 0..1 LegalAuthenticator
... authenticator 0..* Authenticator
... participant 0..* Participant1
... inFulfillmentOf 0..* InFulfillmentOf
... documentationOf 0..* DocumentationOf
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization
... componentOf 0..1 ComponentOf
... component 1..1 Component

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
from this IG
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
from this IG
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS
... confidentialityCode 1..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget
... author 1..* Author
... dataEnterer 0..1 DataEnterer
... informant 0..* Informant
... custodian 1..1 Custodian
... informationRecipient 0..* InformationRecipient
... legalAuthenticator 0..1 LegalAuthenticator
... authenticator 0..* Authenticator
... participant 0..* Participant1
... inFulfillmentOf 0..* InFulfillmentOf
... documentationOf 0..* DocumentationOf
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization
... componentOf 0..1 ComponentOf
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
from this IG
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
from this IG
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS
... confidentialityCode 1..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget
... author 1..* Author
... dataEnterer 0..1 DataEnterer
... informant 0..* Informant
... custodian 1..1 Custodian
... informationRecipient 0..* InformationRecipient
... legalAuthenticator 0..1 LegalAuthenticator
... authenticator 0..* Authenticator
... participant 0..* Participant1
... inFulfillmentOf 0..* InFulfillmentOf
... documentationOf 0..* DocumentationOf
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization
... componentOf 0..1 ComponentOf
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
from this IG
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
from this IG
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

This structure is derived from ANY

Summary

Mandatory: 0 element(10 nested mandatory elements)
Fixed: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel