Clinical Document Architecture V2.0.1
2.1.0 - CI Build

Clinical Document Architecture V2.0.1, published by Health Level 7. This is not an authorized publication; it is the continuous build for version 2.1.0). This version is based on the current content of https://github.com/HL7/cda-core-2.0/ and changes regularly. See the Directory of published versions

Logical Model: CDAR2.ClinicalDocument - JSON Profile

JSON representation of the ClinicalDocument logical model.

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{
  "resourceType" : "StructureDefinition",
  "id" : "ClinicalDocument",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n      <p>The ClinicalDocument class is the entry point into the CDA R-MIM, and corresponds to the &lt;ClinicalDocument&gt; XML element that is the root element of a CDA document.</p>\n      <p>A CDA document is logically broken up into a CDA Header and a CDA Body. The CDA Header is comprised of ClinicalDocument attributes, participants, and act relationships. The CDA Body is the target of the ClinicalDocument component act relationship.</p>\n      <p>The ClinicalDocument class inherits various attributes from the InfrastructureRoot class of the RIM, including ClinicalDocument.templateId and ClinicalDocument.typeId. When ClinicalDocument.templateId is valued in an instance, it signals the imposition of a set of template-defined constraints. In addition, the templateId attribute is available in all other CDA classes, thus enabling the imposition of a set of template-defined constraints at any level of granularity. The value of this attribute provides a unique identifier for the template(s) in question.</p>\n      <p>ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = &quot;2.16.840.1.113883.1.3&quot; (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = &quot;POCD_HD000040&quot; (which is the unique identifier for the CDA, Release Two Hierarchical Description).</p>\n    </div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-namespace",
      "valueUri" : "urn:hl7-org:v3"
    }
  ],
  "url" : "http://hl7.org/fhir/cda/StructureDefinition/ClinicalDocument",
  "version" : "2.1.0",
  "name" : "CDAR2.ClinicalDocument",
  "title" : "ClinicalDocument (CDA Class)",
  "status" : "active",
  "experimental" : false,
  "date" : "2021-04-15T20:51:17+00:00",
  "publisher" : "Health Level 7",
  "description" : "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",
  "fhirVersion" : "4.0.1",
  "kind" : "logical",
  "abstract" : false,
  "type" : "ClinicalDocument",
  "baseDefinition" : "http://hl7.org/fhir/StructureDefinition/Base",
  "derivation" : "specialization",
  "snapshot" : {
    "element" : [
      {
        "id" : "ClinicalDocument",
        "path" : "ClinicalDocument",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "Base",
          "min" : 0,
          "max" : "*"
        },
        "isModifier" : false
      },
      {
        "id" : "ClinicalDocument.classCode",
        "path" : "ClinicalDocument.classCode",
        "representation" : [
          "xmlAttr"
        ],
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.classCode",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "code"
          }
        ],
        "defaultValueCode" : "DOCCLIN",
        "fixedCode" : "DOCCLIN",
        "binding" : {
          "strength" : "extensible",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-ActClass"
        }
      },
      {
        "id" : "ClinicalDocument.moodCode",
        "path" : "ClinicalDocument.moodCode",
        "representation" : [
          "xmlAttr"
        ],
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.moodCode",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "code"
          }
        ],
        "defaultValueCode" : "EVN",
        "fixedCode" : "EVN",
        "binding" : {
          "strength" : "required",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-ActMood"
        }
      },
      {
        "id" : "ClinicalDocument.realmCode",
        "path" : "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",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.realmCode",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CS"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.typeId",
        "path" : "ClinicalDocument.typeId",
        "definition" : "When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.typeId",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.templateId",
        "path" : "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",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.templateId",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.id",
        "path" : "ClinicalDocument.id",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.id",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.code",
        "path" : "ClinicalDocument.code",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.code",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CE"
          }
        ],
        "binding" : {
          "strength" : "extensible",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-DocumentType"
        }
      },
      {
        "id" : "ClinicalDocument.title",
        "path" : "ClinicalDocument.title",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.title",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/ST"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.effectiveTime",
        "path" : "ClinicalDocument.effectiveTime",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.effectiveTime",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/TS"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.confidentialityCode",
        "path" : "ClinicalDocument.confidentialityCode",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.confidentialityCode",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CE"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.languageCode",
        "path" : "ClinicalDocument.languageCode",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.languageCode",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CS"
          }
        ],
        "binding" : {
          "strength" : "required",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-HumanLanguage"
        }
      },
      {
        "id" : "ClinicalDocument.setId",
        "path" : "ClinicalDocument.setId",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.setId",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.versionNumber",
        "path" : "ClinicalDocument.versionNumber",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.versionNumber",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/INT"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.copyTime",
        "path" : "ClinicalDocument.copyTime",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.copyTime",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/TS"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.recordTarget",
        "path" : "ClinicalDocument.recordTarget",
        "min" : 1,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.recordTarget",
          "min" : 1,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/RecordTarget"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.author",
        "path" : "ClinicalDocument.author",
        "min" : 1,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.author",
          "min" : 1,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Author"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.dataEnterer",
        "path" : "ClinicalDocument.dataEnterer",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.dataEnterer",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/DataEnterer"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.informant",
        "path" : "ClinicalDocument.informant",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.informant",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Informant"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.custodian",
        "path" : "ClinicalDocument.custodian",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.custodian",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Custodian"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.informationRecipient",
        "path" : "ClinicalDocument.informationRecipient",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.informationRecipient",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/InformationRecipient"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.legalAuthenticator",
        "path" : "ClinicalDocument.legalAuthenticator",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.legalAuthenticator",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/LegalAuthenticator"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.authenticator",
        "path" : "ClinicalDocument.authenticator",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.authenticator",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Authenticator"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.participant",
        "path" : "ClinicalDocument.participant",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.participant",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Participant"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.inFulfillmentOf",
        "path" : "ClinicalDocument.inFulfillmentOf",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.inFulfillmentOf",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/InFulfillmentOf"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.documentationOf",
        "path" : "ClinicalDocument.documentationOf",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.documentationOf",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/DocumentationOf"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.relatedDocument",
        "path" : "ClinicalDocument.relatedDocument",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.relatedDocument",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/RelatedDocument"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.authorization",
        "path" : "ClinicalDocument.authorization",
        "min" : 0,
        "max" : "*",
        "base" : {
          "path" : "ClinicalDocument.authorization",
          "min" : 0,
          "max" : "*"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Authorization"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.componentOf",
        "path" : "ClinicalDocument.componentOf",
        "min" : 0,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.componentOf",
          "min" : 0,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/ComponentOf"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.component",
        "path" : "ClinicalDocument.component",
        "min" : 1,
        "max" : "1",
        "base" : {
          "path" : "ClinicalDocument.component",
          "min" : 1,
          "max" : "1"
        },
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Component2"
          }
        ]
      }
    ]
  },
  "differential" : {
    "element" : [
      {
        "id" : "ClinicalDocument",
        "path" : "ClinicalDocument",
        "min" : 1,
        "max" : "1"
      },
      {
        "id" : "ClinicalDocument.classCode",
        "path" : "ClinicalDocument.classCode",
        "representation" : [
          "xmlAttr"
        ],
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "code"
          }
        ],
        "defaultValueCode" : "DOCCLIN",
        "fixedCode" : "DOCCLIN",
        "binding" : {
          "strength" : "extensible",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-ActClass"
        }
      },
      {
        "id" : "ClinicalDocument.moodCode",
        "path" : "ClinicalDocument.moodCode",
        "representation" : [
          "xmlAttr"
        ],
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "code"
          }
        ],
        "defaultValueCode" : "EVN",
        "fixedCode" : "EVN",
        "binding" : {
          "strength" : "required",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-ActMood"
        }
      },
      {
        "id" : "ClinicalDocument.realmCode",
        "path" : "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",
        "min" : 0,
        "max" : "*",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CS"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.typeId",
        "path" : "ClinicalDocument.typeId",
        "definition" : "When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.",
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.templateId",
        "path" : "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",
        "min" : 0,
        "max" : "*",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.id",
        "path" : "ClinicalDocument.id",
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.code",
        "path" : "ClinicalDocument.code",
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CE"
          }
        ],
        "binding" : {
          "strength" : "extensible",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-DocumentType"
        }
      },
      {
        "id" : "ClinicalDocument.title",
        "path" : "ClinicalDocument.title",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/ST"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.effectiveTime",
        "path" : "ClinicalDocument.effectiveTime",
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/TS"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.confidentialityCode",
        "path" : "ClinicalDocument.confidentialityCode",
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CE"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.languageCode",
        "path" : "ClinicalDocument.languageCode",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/CS"
          }
        ],
        "binding" : {
          "strength" : "required",
          "valueSet" : "http://terminology.hl7.org/ValueSet/v3-HumanLanguage"
        }
      },
      {
        "id" : "ClinicalDocument.setId",
        "path" : "ClinicalDocument.setId",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.versionNumber",
        "path" : "ClinicalDocument.versionNumber",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/INT"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.copyTime",
        "path" : "ClinicalDocument.copyTime",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/TS"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.recordTarget",
        "path" : "ClinicalDocument.recordTarget",
        "min" : 1,
        "max" : "*",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/RecordTarget"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.author",
        "path" : "ClinicalDocument.author",
        "min" : 1,
        "max" : "*",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Author"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.dataEnterer",
        "path" : "ClinicalDocument.dataEnterer",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/DataEnterer"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.informant",
        "path" : "ClinicalDocument.informant",
        "min" : 0,
        "max" : "*",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Informant"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.custodian",
        "path" : "ClinicalDocument.custodian",
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/fhir/cda/StructureDefinition/Custodian"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.informationRecipient",
        "path" : "ClinicalDocument.informationRecipient",
        "min" : 0,
        "max" : "*",
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