Clinical Document Architecture
2.0.0-sd-ballot - ballot

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-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/ahdis/cda-core-2.0/ and changes regularly. See the Directory of published versions

Logical Model: ClinicalDocument - Detailed Descriptions

Active as of 2024-03-04

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)
ValidationInstances 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 ActClass
(example to http://terminology.hl7.org/ValueSet/v3-ActClass
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 ActMood
(required to http://terminology.hl7.org/ValueSet/v3-ActMood
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.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
20. ClinicalDocument.title
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
22. 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.
24. ClinicalDocument.effectiveTime
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
26. ClinicalDocument.confidentialityCode
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
28. 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
30. ClinicalDocument.setId
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
32. ClinicalDocument.versionNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
34. ClinicalDocument.copyTime
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
36. ClinicalDocument.recordTarget
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
38. ClinicalDocument.author
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
40. ClinicalDocument.dataEnterer
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
42. ClinicalDocument.informant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
44. ClinicalDocument.custodian
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Custodian
46. ClinicalDocument.informationRecipient
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
48. ClinicalDocument.legalAuthenticator
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
50. ClinicalDocument.authenticator
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
52. ClinicalDocument.participant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
54. ClinicalDocument.inFulfillmentOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
56. ClinicalDocument.documentationOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
58. ClinicalDocument.relatedDocument
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
60. ClinicalDocument.authorization
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authorization
62. ClinicalDocument.componentOf
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
64. 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)
ValidationInstances 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 ActClass
(example to http://terminology.hl7.org/ValueSet/v3-ActClass
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 ActMood
(required to http://terminology.hl7.org/ValueSet/v3-ActMood
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.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
20. ClinicalDocument.title
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
22. 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.
24. ClinicalDocument.effectiveTime
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
26. ClinicalDocument.confidentialityCode
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
28. 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
30. ClinicalDocument.setId
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
32. ClinicalDocument.versionNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
34. ClinicalDocument.copyTime
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
36. ClinicalDocument.recordTarget
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
38. ClinicalDocument.author
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
40. ClinicalDocument.dataEnterer
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
42. ClinicalDocument.informant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
44. ClinicalDocument.custodian
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Custodian
46. ClinicalDocument.informationRecipient
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
48. ClinicalDocument.legalAuthenticator
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
50. ClinicalDocument.authenticator
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
52. ClinicalDocument.participant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
54. ClinicalDocument.inFulfillmentOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
56. ClinicalDocument.documentationOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
58. ClinicalDocument.relatedDocument
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
60. ClinicalDocument.authorization
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authorization
62. ClinicalDocument.componentOf
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
64. 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)
ValidationInstances 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 ActClass
(example to http://terminology.hl7.org/ValueSet/v3-ActClass
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 ActMood
(required to http://terminology.hl7.org/ValueSet/v3-ActMood
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.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
28. ClinicalDocument.title
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
30. 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.
32. ClinicalDocument.effectiveTime
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
34. ClinicalDocument.confidentialityCode
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
36. 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
38. ClinicalDocument.setId
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
40. ClinicalDocument.versionNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
42. ClinicalDocument.copyTime
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
44. ClinicalDocument.recordTarget
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
46. ClinicalDocument.author
Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
48. ClinicalDocument.dataEnterer
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
50. ClinicalDocument.informant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
52. ClinicalDocument.custodian
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Custodian
54. ClinicalDocument.informationRecipient
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
56. ClinicalDocument.legalAuthenticator
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
58. ClinicalDocument.authenticator
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
60. ClinicalDocument.participant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
62. ClinicalDocument.inFulfillmentOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
64. ClinicalDocument.documentationOf
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
66. ClinicalDocument.relatedDocument
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
68. ClinicalDocument.authorization
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authorization
70. ClinicalDocument.componentOf
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
72. ClinicalDocument.component
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Component