Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build United States of America

This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: Referral Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.14 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: ReferralNote
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.14:2015-08-01

A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.

Examples of referral situations are when a patient is referred from a family physician to a cardiologist for cardiac evaluation or when patient is sent by a cardiologist to an emergency department for angina or when a patient is referred by a nurse practitioner to an audiologist for hearing screening or when a patient is referred by a hospitalist to social services.

Usage:

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

Formal Views of Profile Content

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

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderBase for all types and resources
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary C1..1II1198-32943: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... informationRecipient 1..1InformationRecipientThe 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.
.... intendedRecipient 1..1IntendedRecipient
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... participant:participant1 0..*Participant1
..... typeCode 1..1codeRequired Pattern: IND
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:participant2 0..*Participant1The 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).
..... typeCode 1..1codeRequired Pattern: CALLBCK
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeRequired Pattern: ASSIGNED
...... id 1..*II
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*EN
...... scopingOrganization 0..1Organization
... component 1..1Component2Slice: Unordered, Open by value:section.code
.... component:All Slices Content/Rules for all slices
..... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
...... Slices for component 0..1ElementSlice: Unordered, Open by value:section.code
....... component:planOfTreatment 0..1Element
........ section 1..1PlanofTreatmentSectionBase for all types and resources
....... component:advanceDirectives 0..1Element
........ section 1..1AdvanceDirectivesSectionEntriesOptionalBase for all types and resources
....... component:historyOfPresentIllness 0..1Element
........ section 1..1HistoryofPresentIllnessSectionBase for all types and resources
....... component:familyHistory 0..1Element
........ section 1..1FamilyHistorySectionBase for all types and resources
....... component:immunizations 0..1Element
........ section 1..1ImmunizationsSectionEntriesRequiredBase for all types and resources
....... component:problem 1..1Element
........ section 1..1ProblemSectionEntriesRequiredBase for all types and resources
....... component:procedures 0..1Element
........ section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
....... component:results 0..1Element
........ section 1..1ResultsSectionEntriesRequiredBase for all types and resources
....... component:reviewOfSystems 0..1Element
........ section 1..1ReviewofSystemsSectionBase for all types and resources
....... component:socialHistory 0..1Element
........ section 1..1SocialHistorySectionBase for all types and resources
....... component:vitalSigns 0..1Element
........ section 1..1VitalSignsSectionEntriesRequiredBase for all types and resources
....... component:functionalStatus 0..1Element
........ section 1..1FunctionalStatusSectionBase for all types and resources
....... component:physicalExam 0..1Element
........ section 1..1PhysicalExamSectionBase for all types and resources
....... component:nutrition 0..1Element
........ section 1..1NutritionSectionBase for all types and resources
....... component:mentalStatus 0..1Element
........ section 1..1MentalStatusSectionBase for all types and resources
....... component:medicalEquip 0..1Element
........ section 1..1MedicalEquipmentSectionBase for all types and resources
....... component:allergiesAndIntolerances 1..1Element
........ section 1..1AllergiesAndIntolerancesSectionEntriesRequiredBase for all types and resources
....... component:assessment 0..1Element
........ section 1..1AssessmentSectionBase for all types and resources
....... component:assessmentAndPlan 0..1Element
........ section 1..1AssessmentandPlanSectionBase for all types and resources
....... component:medicalHistory 0..1Element
........ section 1..1PastMedicalHistoryBase for all types and resources
....... component:generalStatus 0..1Element
........ section 1..1GeneralStatusSectionBase for all types and resources
....... component:medications 1..1Element
........ section 1..1MedicationsSectionEntriesRequiredBase for all types and resources
....... component:reasonForReferral 1..1Element
........ section 1..1ReasonforReferralSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes

Constraints

IdGradePath(s)DetailsRequirements
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
1198-32943errorClinicalDocument.templateId:primaryWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderBase for all types and resources
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CSRequired Pattern: US
.... root 1..1stringRequired Pattern: 2.16.840.1.113883.1.3
.... extension 1..1stringRequired Pattern: POCD_HD000040
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary C1..1II1198-32943: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... extension 1..1stringRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... title 1..1EDThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... recordTarget 1..*RecordTargetThe 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
.... patientRole 1..1PatientRole
..... classCode 1..1codeBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..*II
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id C1..*IISlice: Unordered, Open by value:root
1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
...... id:id1 0..1II
....... root 1..1stringRequired Pattern: 2.16.840.1.113883.4.6
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
... Slices for informant 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
Slice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id C1..*II1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:informant2 0..*Informant
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe 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.
.... assignedCustodian 1..1AssignedCustodian
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1CustodianOrganization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
...... name 1..1ON
...... telecom 1..1TEL
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... informationRecipient 1..1InformationRecipientThe 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.
.... intendedRecipient 1..1IntendedRecipient
..... classCode 1..1code
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Slice: Unordered, Open by value:signatureCode, value:assignedEntity
.... authenticator:authenticator1 0..*Authenticator
..... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... code 1..1stringRequired Pattern: S
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant 0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
Slice: Unordered, Open by value:typeCode
.... participant:participant1 C0..*Participant1
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: IND
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:participant2 0..*Participant1The 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).
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CALLBCK
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: RoleClassAssociative (required)
Required Pattern: ASSIGNED
...... id 1..*II
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name 1..*EN
...... scopingOrganization 0..1Organization
... Slices for authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
Slice: Unordered, Open by value:consent
.... authorization:authorization1 0..*Authorization
..... consent 1..1Consent
...... classCode 1..1codeBinding: ActClass (required)
Fixed Value: CONS
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... statusCode 1..1CSBinding: ActStatus (required)
....... code 1..1codeFixed Value: completed
... component 1..1Component2Slice: Unordered, Open by value:section.code
.... component:All Slices Content/Rules for all slices
..... contextConductionInd 1..1boolean
..... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... Slices for component 0..1ElementSlice: Unordered, Open by value:section.code
....... component:All Slices Content/Rules for all slices
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1Section
....... component:planOfTreatment 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PlanofTreatmentSectionBase for all types and resources
....... component:advanceDirectives 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AdvanceDirectivesSectionEntriesOptionalBase for all types and resources
....... component:historyOfPresentIllness 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1HistoryofPresentIllnessSectionBase for all types and resources
....... component:familyHistory 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FamilyHistorySectionBase for all types and resources
....... component:immunizations 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ImmunizationsSectionEntriesRequiredBase for all types and resources
....... component:problem 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProblemSectionEntriesRequiredBase for all types and resources
....... component:procedures 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
....... component:results 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ResultsSectionEntriesRequiredBase for all types and resources
....... component:reviewOfSystems 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReviewofSystemsSectionBase for all types and resources
....... component:socialHistory 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1SocialHistorySectionBase for all types and resources
....... component:vitalSigns 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1VitalSignsSectionEntriesRequiredBase for all types and resources
....... component:functionalStatus 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FunctionalStatusSectionBase for all types and resources
....... component:physicalExam 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PhysicalExamSectionBase for all types and resources
....... component:nutrition 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1NutritionSectionBase for all types and resources
....... component:mentalStatus 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MentalStatusSectionBase for all types and resources
....... component:medicalEquip 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicalEquipmentSectionBase for all types and resources
....... component:allergiesAndIntolerances 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AllergiesAndIntolerancesSectionEntriesRequiredBase for all types and resources
....... component:assessment 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentSectionBase for all types and resources
....... component:assessmentAndPlan 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentandPlanSectionBase for all types and resources
....... component:medicalHistory 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PastMedicalHistoryBase for all types and resources
....... component:generalStatus 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1GeneralStatusSectionBase for all types and resources
....... component:medications 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicationsSectionEntriesRequiredBase for all types and resources
....... component:reasonForReferral 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReasonforReferralSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informant:informant1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant1.typeCoderequiredPattern: IND
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant2.typeCoderequiredPattern: CALLBCK
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredPattern: ASSIGNED
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authorization:authorization1.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.statusCoderequiredActStatus
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN

Constraints

IdGradePath(s)DetailsRequirements
1198-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:1198-5299).
:
1198-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:1198-5300).
:
1198-5449nullClinicalDocument.author.assignedAuthor.idIf this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
:
1198-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
:
1198-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:1198-9991).
:
1198-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992).
:
1198-10006errorClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
:
1198-10007warningClinicalDocument.participant:participant1When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
:
1198-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790).
:
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
1198-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:1198-32418). For cases where information about newborn's time of birth needs to be captured.
:
1198-32943errorClinicalDocument.templateId:primaryWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
:
1198-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderBase for all types and resources
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CSRequired Pattern: US
... typeId 1..1II
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... assigningAuthorityName 0..1string
.... displayable 0..1boolean
.... root 1..1stringRequired Pattern: 2.16.840.1.113883.1.3
.... extension 1..1stringRequired Pattern: POCD_HD000040
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary C1..1II1198-32943: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... extension 1..1stringRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... title 1..1EDThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId C0..1II
... versionNumber C0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTargetThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: RCT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... patientRole 1..1PatientRole
..... classCode 1..1codeBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... sdtcDeceasedInd 0..1BLXML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime 0..1TSXML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... sdtcRaceCode C0..*CENote: 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.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (extensible)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (extensible)
...... guardian 0..*Guardian
....... classCode 1..1codeBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... templateId 0..*II
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressADUSFIELDEDBase for all types and resources
....... telecom 0..*TEL
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ value 0..1uri
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ use 0..1codeBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... classCode 1..1codeBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... templateId 0..*II
....... place 1..1Place
........ classCode 1..1codeBinding: EntityClassPlace (required)
Fixed Value: PLC
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name 0..1EN
........ addr C1..1AD
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... isNotOrdered 0..1boolean
......... use 0..*code
......... delimiter 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DEL
......... country 0..1ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CNT
......... state 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STA
......... county 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CPA
......... city 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CTY
......... postalCode 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: ZIP
......... streetAddressLine 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: SAL
......... houseNumber 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: BNR
......... houseNumberNumeric 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: BNN
......... direction 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DIR
......... streetName 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STR
......... streetNameBase 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STB
......... streetNameType 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STTYP
......... additionalLocator 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: ADL
......... unitID 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: UNID
......... unitType 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: UNIT
......... careOf 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CAR
......... censusTract 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CEN
......... deliveryAddressLine 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DAL
......... deliveryInstallationType 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DINST
......... deliveryInstallationArea 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DINSTA
......... deliveryInstallationQualifier 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DINSTQ
......... deliveryMode 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DMOD
......... deliveryModeIdentifier 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DMODID
......... buildingNumberSuffix 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: BNS
......... postBox 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: POB
......... precinct 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: PRE
......... other 0..1string
......... useablePeriod[x] 0..*
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TSIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TSEIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TSPIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TSSXPR_TS
...... languageCommunication 0..*LanguageCommunication
....... templateId 0..*II
....... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..*ON
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CE
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... Slices for id C1..*IISlice: Unordered, Open by value:root
1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
...... id:id1 0..1II
....... nullFlavor 0..1codeIf id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then
Binding: NullFlavor (required)
Required Pattern: UNK
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 1..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEOnly if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: v3 Code System RoleCode (extensible)
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringBinding: Healthcare Provider Taxonomy (preferred)
...... codeSystem 0..1string
...... codeSystemName 0..1string
...... codeSystemVersion 0..1string
...... displayName 0..1string
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 0..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... assignedAuthoringDevice 0..1AuthoringDevice
...... classCode 1..1codeBinding: EntityClassDevice (required)
Fixed Value: DEV
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... code 0..1CEBinding: EntityCode (extensible)
...... manufacturerModelName 1..1SC
...... softwareName 1..1SC
...... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time 1..1TS
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... Slices for informant 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
Slice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id C1..*II1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 0..*TEL
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... representedOrganization 0..1Organization
..... relatedEntity 0..1RelatedEntity
.... informant:informant2 0..*Informant
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 0..1AssignedEntity
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... assignedCustodian 1..1AssignedCustodian
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... representedCustodianOrganization 1..1CustodianOrganization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..1ON
...... telecom 1..1TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... informationRecipient 1..1InformationRecipientThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... intendedRecipient 1..1IntendedRecipient
..... classCode 1..1code
..... templateId 0..*II
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... receivedOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: LA
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... signatureCode 1..1CS
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... code 1..1stringRequired Pattern: S
..... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
..... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... Slices for authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Slice: Unordered, Open by value:signatureCode, value:assignedEntity
.... authenticator:authenticator1 0..*Authenticator
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUTHEN
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringRequired Pattern: S
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
..... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Healthcare Provider Taxonomy (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... representedOrganization 0..1Organization
... Slices for participant 0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
Slice: Unordered, Open by value:typeCode
.... participant:participant1 C0..*Participant1
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: IND
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... functionCode 0..1CE
..... time 0..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: INDRoleclassCodes (required)
...... templateId 0..*II
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... scopingOrganization 0..1Organization
.... participant:participant2 0..*Participant1The 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).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CALLBCK
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... functionCode 0..1CE
..... time 0..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: RoleClassAssociative (required)
Required Pattern: ASSIGNED
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name 1..*EN
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: FLFS
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... order 1..1Order
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMoodIntent (required)
Fixed Value: RQO
..... templateId 0..*II
..... id 1..*II
..... code 0..1CEBinding: v3 Code System ActCode (extensible)
..... priorityCode 0..1CEBinding: ActPriority (extensible)
... documentationOf 0..*DocumentationOf
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... serviceEvent 1..1ServiceEventA 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.
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 0..*II
..... code 0..1CE
..... effectiveTime 1..1IVL_TS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1dateTime
...... inclusive 0..1boolean
...... operator 0..1code
...... low 1..1TS
...... high 0..1TS
...... width 0..1PQ
...... center 0..1TS
..... performer 0..*Performer1The 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..1codeBinding: NullFlavor (required)
...... typeCode 1..1codeBinding: x_ServiceEventPerformer (required)
Fixed Value: DOC
...... realmCode 0..*CS
...... typeId 0..1II
...... templateId 0..*II
...... functionCode 0..1CE
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Care Team Member Function (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... time 0..1IVL_TS
...... assignedEntity 1..1AssignedEntity
....... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... templateId 0..*II
....... id 1..*II
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ assigningAuthorityName 0..1string
........ displayable 0..1boolean
........ root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
........ extension 0..1string
....... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
....... addr 0..*AD
....... telecom 0..*TEL
....... assignedPerson 0..1Person
....... representedOrganization 0..1Organization
... relatedDocument 0..*RelatedDocument
... Slices for authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
Slice: Unordered, Open by value:consent
.... authorization:authorization1 0..*Authorization
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... consent 1..1Consent
...... classCode 1..1codeBinding: ActClass (required)
Fixed Value: CONS
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..*II
...... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (extensible)
...... statusCode 1..1CSBinding: ActStatus (required)
....... code 1..1codeFixed Value: completed
... componentOf 0..1ComponentOfThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... encompassingEncounter 1..1EncompassingEncounter
..... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 1..*II
..... code 0..1CEBinding: ActEncounterCode (extensible)
..... effectiveTime 1..1IVL_TS
..... sdtcAdmissionReferralSourceCode 0..1CEXML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (extensible)
..... responsibleParty 0..1Element
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... typeCode 1..1codeBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity 1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1Element
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... typeCode 1..1codeBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component2Slice: Unordered, Open by value:section.code
.... component:All Slices Content/Rules for all slices
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
..... contextConductionInd 1..1boolean
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... nonXMLBody 0..1NonXMLBody
..... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... Slices for component 0..1ElementSlice: Unordered, Open by value:section.code
....... component:All Slices Content/Rules for all slices
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1Section
....... component:planOfTreatment 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PlanofTreatmentSectionBase for all types and resources
....... component:advanceDirectives 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AdvanceDirectivesSectionEntriesOptionalBase for all types and resources
....... component:historyOfPresentIllness 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1HistoryofPresentIllnessSectionBase for all types and resources
....... component:familyHistory 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FamilyHistorySectionBase for all types and resources
....... component:immunizations 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ImmunizationsSectionEntriesRequiredBase for all types and resources
....... component:problem 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProblemSectionEntriesRequiredBase for all types and resources
....... component:procedures 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
....... component:results 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ResultsSectionEntriesRequiredBase for all types and resources
....... component:reviewOfSystems 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReviewofSystemsSectionBase for all types and resources
....... component:socialHistory 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1SocialHistorySectionBase for all types and resources
....... component:vitalSigns 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1VitalSignsSectionEntriesRequiredBase for all types and resources
....... component:functionalStatus 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FunctionalStatusSectionBase for all types and resources
....... component:physicalExam 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PhysicalExamSectionBase for all types and resources
....... component:nutrition 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1NutritionSectionBase for all types and resources
....... component:mentalStatus 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MentalStatusSectionBase for all types and resources
....... component:medicalEquip 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicalEquipmentSectionBase for all types and resources
....... component:allergiesAndIntolerances 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AllergiesAndIntolerancesSectionEntriesRequiredBase for all types and resources
....... component:assessment 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentSectionBase for all types and resources
....... component:assessmentAndPlan 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentandPlanSectionBase for all types and resources
....... component:medicalHistory 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PastMedicalHistoryBase for all types and resources
....... component:generalStatus 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1GeneralStatusSectionBase for all types and resources
....... component:medications 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicationsSectionEntriesRequiredBase for all types and resources
....... component:reasonForReferral 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReasonforReferralSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.typeId.nullFlavorrequiredNullFlavor
ClinicalDocument.templateId:primary.nullFlavorrequiredNullFlavor
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMarital Status
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeextensibleRace Value Set
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCodeextensibleDetailed Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.delimiter.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.country.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.state.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.county.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.city.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postalCode.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetAddressLine.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumber.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumberNumeric.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.direction.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetName.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameBase.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameType.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.additionalLocator.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitID.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitType.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.careOf.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.censusTract.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryAddressLine.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationType.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationArea.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationQualifier.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryMode.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryModeIdentifier.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.buildingNumberSuffix.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postBox.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.precinct.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredNullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavorrequiredPattern: UNK
ClinicalDocument.author.assignedAuthor.codeextensibleRoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeextensibleEntityCode
ClinicalDocument.dataEnterer.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant1.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant2.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.custodian.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavorrequiredNullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.typeCoderequiredFixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.codeextensibleRoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant1.nullFlavorrequiredNullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredPattern: IND
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:participant1.associatedEntity.codeextensibleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant2.nullFlavorrequiredNullFlavor
ClinicalDocument.participant:participant2.typeCoderequiredPattern: CALLBCK
ClinicalDocument.participant:participant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredPattern: ASSIGNED
ClinicalDocument.participant:participant2.associatedEntity.codeextensibleRoleCode
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeextensibleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeextensibleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authorization:authorization1.nullFlavorrequiredNullFlavor
ClinicalDocument.authorization:authorization1.typeCoderequiredFixed Value: AUT
ClinicalDocument.authorization:authorization1.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.codeextensibleActCode
ClinicalDocument.authorization:authorization1.consent.statusCoderequiredActStatus
ClinicalDocument.componentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: AUT
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.codeextensibleActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeextensibleUSEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
ClinicalDocument.component.nullFlavorrequiredNullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: AUT
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
ClinicalDocument.component.structuredBody.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)

Constraints

IdGradePath(s)DetailsRequirements
1198-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:1198-5299).
:
1198-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:1198-5300).
:
1198-5402warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:1198-5402). Note: A nullFlavor of ' UNK' may be used if the state is unknown.
:
1198-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf 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:1198-5403).
:
1198-5449nullClinicalDocument.author.assignedAuthor.idIf this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
:
1198-6380errorClinicalDocument.setIdIf setId is present versionNumber **SHALL** be present (CONF:1198-6380).
:
1198-6387errorClinicalDocument.versionNumberIf versionNumber is present setId **SHALL** be present (CONF:1198-6387).
:
1198-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
:
1198-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:1198-9991).
:
1198-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992).
:
1198-10006errorClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
:
1198-10007warningClinicalDocument.participant:participant1When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
:
1198-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790).
:
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
1198-31347errorClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeIf sdtc:raceCode is present, then the patient SHALL contain [1..1] raceCode (CONF:1198-31347).
:
1198-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:1198-32418). For cases where information about newborn's time of birth needs to be captured.
:
1198-32943errorClinicalDocument.templateId:primaryWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
:
1198-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from USRealmHeader

Summary

Mandatory: 18 elements (31 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension
  • The element ClinicalDocument.participant is sliced based on the value of value:typeCode
  • The element ClinicalDocument.component is sliced based on the value of value:section.code
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:section.code

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderBase for all types and resources
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary C1..1II1198-32943: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... informationRecipient 1..1InformationRecipientThe 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.
.... intendedRecipient 1..1IntendedRecipient
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... participant:participant1 0..*Participant1
..... typeCode 1..1codeRequired Pattern: IND
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:participant2 0..*Participant1The 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).
..... typeCode 1..1codeRequired Pattern: CALLBCK
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeRequired Pattern: ASSIGNED
...... id 1..*II
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*EN
...... scopingOrganization 0..1Organization
... component 1..1Component2Slice: Unordered, Open by value:section.code
.... component:All Slices Content/Rules for all slices
..... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
...... Slices for component 0..1ElementSlice: Unordered, Open by value:section.code
....... component:planOfTreatment 0..1Element
........ section 1..1PlanofTreatmentSectionBase for all types and resources
....... component:advanceDirectives 0..1Element
........ section 1..1AdvanceDirectivesSectionEntriesOptionalBase for all types and resources
....... component:historyOfPresentIllness 0..1Element
........ section 1..1HistoryofPresentIllnessSectionBase for all types and resources
....... component:familyHistory 0..1Element
........ section 1..1FamilyHistorySectionBase for all types and resources
....... component:immunizations 0..1Element
........ section 1..1ImmunizationsSectionEntriesRequiredBase for all types and resources
....... component:problem 1..1Element
........ section 1..1ProblemSectionEntriesRequiredBase for all types and resources
....... component:procedures 0..1Element
........ section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
....... component:results 0..1Element
........ section 1..1ResultsSectionEntriesRequiredBase for all types and resources
....... component:reviewOfSystems 0..1Element
........ section 1..1ReviewofSystemsSectionBase for all types and resources
....... component:socialHistory 0..1Element
........ section 1..1SocialHistorySectionBase for all types and resources
....... component:vitalSigns 0..1Element
........ section 1..1VitalSignsSectionEntriesRequiredBase for all types and resources
....... component:functionalStatus 0..1Element
........ section 1..1FunctionalStatusSectionBase for all types and resources
....... component:physicalExam 0..1Element
........ section 1..1PhysicalExamSectionBase for all types and resources
....... component:nutrition 0..1Element
........ section 1..1NutritionSectionBase for all types and resources
....... component:mentalStatus 0..1Element
........ section 1..1MentalStatusSectionBase for all types and resources
....... component:medicalEquip 0..1Element
........ section 1..1MedicalEquipmentSectionBase for all types and resources
....... component:allergiesAndIntolerances 1..1Element
........ section 1..1AllergiesAndIntolerancesSectionEntriesRequiredBase for all types and resources
....... component:assessment 0..1Element
........ section 1..1AssessmentSectionBase for all types and resources
....... component:assessmentAndPlan 0..1Element
........ section 1..1AssessmentandPlanSectionBase for all types and resources
....... component:medicalHistory 0..1Element
........ section 1..1PastMedicalHistoryBase for all types and resources
....... component:generalStatus 0..1Element
........ section 1..1GeneralStatusSectionBase for all types and resources
....... component:medications 1..1Element
........ section 1..1MedicationsSectionEntriesRequiredBase for all types and resources
....... component:reasonForReferral 1..1Element
........ section 1..1ReasonforReferralSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes

Constraints

IdGradePath(s)DetailsRequirements
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
1198-32943errorClinicalDocument.templateId:primaryWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
:

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderBase for all types and resources
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CSRequired Pattern: US
.... root 1..1stringRequired Pattern: 2.16.840.1.113883.1.3
.... extension 1..1stringRequired Pattern: POCD_HD000040
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary C1..1II1198-32943: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... extension 1..1stringRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... title 1..1EDThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... recordTarget 1..*RecordTargetThe 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
.... patientRole 1..1PatientRole
..... classCode 1..1codeBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..*II
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id C1..*IISlice: Unordered, Open by value:root
1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
...... id:id1 0..1II
....... root 1..1stringRequired Pattern: 2.16.840.1.113883.4.6
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
... Slices for informant 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
Slice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id C1..*II1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:informant2 0..*Informant
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe 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.
.... assignedCustodian 1..1AssignedCustodian
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1CustodianOrganization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
...... name 1..1ON
...... telecom 1..1TEL
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... informationRecipient 1..1InformationRecipientThe 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.
.... intendedRecipient 1..1IntendedRecipient
..... classCode 1..1code
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Slice: Unordered, Open by value:signatureCode, value:assignedEntity
.... authenticator:authenticator1 0..*Authenticator
..... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... code 1..1stringRequired Pattern: S
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant 0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
Slice: Unordered, Open by value:typeCode
.... participant:participant1 C0..*Participant1
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: IND
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:participant2 0..*Participant1The 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).
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CALLBCK
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: RoleClassAssociative (required)
Required Pattern: ASSIGNED
...... id 1..*II
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name 1..*EN
...... scopingOrganization 0..1Organization
... Slices for authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
Slice: Unordered, Open by value:consent
.... authorization:authorization1 0..*Authorization
..... consent 1..1Consent
...... classCode 1..1codeBinding: ActClass (required)
Fixed Value: CONS
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... statusCode 1..1CSBinding: ActStatus (required)
....... code 1..1codeFixed Value: completed
... component 1..1Component2Slice: Unordered, Open by value:section.code
.... component:All Slices Content/Rules for all slices
..... contextConductionInd 1..1boolean
..... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... Slices for component 0..1ElementSlice: Unordered, Open by value:section.code
....... component:All Slices Content/Rules for all slices
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1Section
....... component:planOfTreatment 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PlanofTreatmentSectionBase for all types and resources
....... component:advanceDirectives 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AdvanceDirectivesSectionEntriesOptionalBase for all types and resources
....... component:historyOfPresentIllness 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1HistoryofPresentIllnessSectionBase for all types and resources
....... component:familyHistory 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FamilyHistorySectionBase for all types and resources
....... component:immunizations 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ImmunizationsSectionEntriesRequiredBase for all types and resources
....... component:problem 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProblemSectionEntriesRequiredBase for all types and resources
....... component:procedures 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
....... component:results 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ResultsSectionEntriesRequiredBase for all types and resources
....... component:reviewOfSystems 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReviewofSystemsSectionBase for all types and resources
....... component:socialHistory 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1SocialHistorySectionBase for all types and resources
....... component:vitalSigns 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1VitalSignsSectionEntriesRequiredBase for all types and resources
....... component:functionalStatus 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FunctionalStatusSectionBase for all types and resources
....... component:physicalExam 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PhysicalExamSectionBase for all types and resources
....... component:nutrition 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1NutritionSectionBase for all types and resources
....... component:mentalStatus 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MentalStatusSectionBase for all types and resources
....... component:medicalEquip 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicalEquipmentSectionBase for all types and resources
....... component:allergiesAndIntolerances 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AllergiesAndIntolerancesSectionEntriesRequiredBase for all types and resources
....... component:assessment 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentSectionBase for all types and resources
....... component:assessmentAndPlan 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentandPlanSectionBase for all types and resources
....... component:medicalHistory 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PastMedicalHistoryBase for all types and resources
....... component:generalStatus 0..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1GeneralStatusSectionBase for all types and resources
....... component:medications 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicationsSectionEntriesRequiredBase for all types and resources
....... component:reasonForReferral 1..1Element
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReasonforReferralSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informant:informant1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant1.typeCoderequiredPattern: IND
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant2.typeCoderequiredPattern: CALLBCK
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredPattern: ASSIGNED
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authorization:authorization1.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.statusCoderequiredActStatus
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN

Constraints

IdGradePath(s)DetailsRequirements
1198-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:1198-5299).
:
1198-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:1198-5300).
:
1198-5449nullClinicalDocument.author.assignedAuthor.idIf this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
:
1198-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
:
1198-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:1198-9991).
:
1198-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992).
:
1198-10006errorClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
:
1198-10007warningClinicalDocument.participant:participant1When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
:
1198-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790).
:
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
1198-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:1198-32418). For cases where information about newborn's time of birth needs to be captured.
:
1198-32943errorClinicalDocument.templateId:primaryWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
:
1198-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderBase for all types and resources
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CSRequired Pattern: US
... typeId 1..1II
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... assigningAuthorityName 0..1string
.... displayable 0..1boolean
.... root 1..1stringRequired Pattern: 2.16.840.1.113883.1.3
.... extension 1..1stringRequired Pattern: POCD_HD000040
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary C1..1II1198-32943: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... extension 1..1stringRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... title 1..1EDThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId C0..1II
... versionNumber C0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTargetThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: RCT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... patientRole 1..1PatientRole
..... classCode 1..1codeBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... sdtcDeceasedInd 0..1BLXML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime 0..1TSXML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... sdtcRaceCode C0..*CENote: 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.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (extensible)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (extensible)
...... guardian 0..*Guardian
....... classCode 1..1codeBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... templateId 0..*II
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressADUSFIELDEDBase for all types and resources
....... telecom 0..*TEL
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ value 0..1uri
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ use 0..1codeBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... classCode 1..1codeBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... templateId 0..*II
....... place 1..1Place
........ classCode 1..1codeBinding: EntityClassPlace (required)
Fixed Value: PLC
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name 0..1EN
........ addr C1..1AD
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... isNotOrdered 0..1boolean
......... use 0..*code
......... delimiter 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DEL
......... country 0..1ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CNT
......... state 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STA
......... county 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CPA
......... city 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CTY
......... postalCode 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: ZIP
......... streetAddressLine 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: SAL
......... houseNumber 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: BNR
......... houseNumberNumeric 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: BNN
......... direction 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DIR
......... streetName 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STR
......... streetNameBase 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STB
......... streetNameType 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: STTYP
......... additionalLocator 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: ADL
......... unitID 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: UNID
......... unitType 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: UNIT
......... careOf 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CAR
......... censusTract 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: CEN
......... deliveryAddressLine 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DAL
......... deliveryInstallationType 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DINST
......... deliveryInstallationArea 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DINSTA
......... deliveryInstallationQualifier 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DINSTQ
......... deliveryMode 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DMOD
......... deliveryModeIdentifier 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: DMODID
......... buildingNumberSuffix 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: BNS
......... postBox 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: POB
......... precinct 0..*ADXP
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... charset 0..1code
.......... language 0..1code
.......... mediaType 0..1codeFixed Value: text/plain
.......... representation 0..1codeFixed Value: TXT
.......... data[x] 0..1string
.......... partType 0..1code
.......... partType 0..1codeFixed Value: PRE
......... other 0..1string
......... useablePeriod[x] 0..*
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TSIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TSEIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TSPIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TSSXPR_TS
...... languageCommunication 0..*LanguageCommunication
....... templateId 0..*II
....... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..*ON
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CE
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... Slices for id C1..*IISlice: Unordered, Open by value:root
1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
...... id:id1 0..1II
....... nullFlavor 0..1codeIf id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then
Binding: NullFlavor (required)
Required Pattern: UNK
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 1..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEOnly if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: v3 Code System RoleCode (extensible)
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringBinding: Healthcare Provider Taxonomy (preferred)
...... codeSystem 0..1string
...... codeSystemName 0..1string
...... codeSystemVersion 0..1string
...... displayName 0..1string
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 0..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... assignedAuthoringDevice 0..1AuthoringDevice
...... classCode 1..1codeBinding: EntityClassDevice (required)
Fixed Value: DEV
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... code 0..1CEBinding: EntityCode (extensible)
...... manufacturerModelName 1..1SC
...... softwareName 1..1SC
...... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time 1..1TS
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... Slices for informant 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
Slice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id C1..*II1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 0..*TEL
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... representedOrganization 0..1Organization
..... relatedEntity 0..1RelatedEntity
.... informant:informant2 0..*Informant
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 0..1AssignedEntity
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... assignedCustodian 1..1AssignedCustodian
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... representedCustodianOrganization 1..1CustodianOrganization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..1ON
...... telecom 1..1TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... informationRecipient 1..1InformationRecipientThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... intendedRecipient 1..1IntendedRecipient
..... classCode 1..1code
..... templateId 0..*II
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... receivedOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: LA
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... signatureCode 1..1CS
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... code 1..1stringRequired Pattern: S
..... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
..... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... Slices for authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Slice: Unordered, Open by value:signatureCode, value:assignedEntity
.... authenticator:authenticator1 0..*Authenticator
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUTHEN
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringRequired Pattern: S
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
..... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Healthcare Provider Taxonomy (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... representedOrganization 0..1Organization
... Slices for participant 0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
Slice: Unordered, Open by value:typeCode
.... participant:participant1 C0..*Participant1
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: IND
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... functionCode 0..1CE
..... time 0..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: INDRoleclassCodes (required)
...... templateId 0..*II
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... scopingOrganization 0..1Organization
.... participant:participant2 0..*Participant1The 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).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CALLBCK
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... functionCode 0..1CE
..... time 0..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: RoleClassAssociative (required)
Required Pattern: ASSIGNED
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name 1..*EN
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: FLFS
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... order 1..1Order
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMoodIntent (required)
Fixed Value: RQO
..... templateId 0..*II
..... id 1..*II
..... code 0..1CEBinding: v3 Code System ActCode (extensible)
..... priorityCode 0..1CEBinding: ActPriority (extensible)
... documentationOf 0..*DocumentationOf
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... serviceEvent 1..1ServiceEventA 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.
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 0..*II
..... code 0..1CE
..... effectiveTime 1..1IVL_TS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1dateTime
...... inclusive 0..1boolean
...... operator 0..1code
...... low 1..1TS
...... high 0..1TS
...... width 0..1PQ
...... center 0..1TS
..... performer 0..*Performer1The 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..1codeBinding: NullFlavor (required)
...... typeCode 1..1codeBinding: x_ServiceEventPerformer (required)
Fixed Value: DOC
...... realmCode 0..*CS
...... typeId 0..1II
...... templateId 0..*II
...... functionCode 0..1CE
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Care Team Member Function (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... time 0..1IVL_TS
...... assignedEntity 1..1AssignedEntity
....... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... templateId 0..*II
....... id 1..*II
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ assigningAuthorityName 0..1string
........ displayable 0..1boolean
........ root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
........ extension 0..1string
....... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
....... addr 0..*AD
....... telecom 0..*TEL
....... assignedPerson 0..1Person
....... representedOrganization 0..1Organization
... relatedDocument 0..*RelatedDocument
... Slices for authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
Slice: Unordered, Open by value:consent
.... authorization:authorization1 0..*Authorization
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... consent 1..1Consent
...... classCode 1..1codeBinding: ActClass (required)
Fixed Value: CONS
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..*II
...... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (extensible)
...... statusCode 1..1CSBinding: ActStatus (required)
....... code 1..1codeFixed Value: completed
... componentOf 0..1ComponentOfThe 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..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... encompassingEncounter 1..1EncompassingEncounter
..... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 1..*II
..... code 0..1CEBinding: ActEncounterCode (extensible)
..... effectiveTime 1..1IVL_TS
..... sdtcAdmissionReferralSourceCode 0..1CEXML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (extensible)
..... responsibleParty 0..1Element
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... typeCode 1..1codeBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity 1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1Element
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... typeCode 1..1codeBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component2Slice: Unordered, Open by value:section.code
.... component:All Slices Content/Rules for all slices
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
..... contextConductionInd 1..1boolean
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... nonXMLBody 0..1NonXMLBody
..... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... Slices for component 0..1ElementSlice: Unordered, Open by value:section.code
....... component:All Slices Content/Rules for all slices
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1Section
....... component:planOfTreatment 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PlanofTreatmentSectionBase for all types and resources
....... component:advanceDirectives 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AdvanceDirectivesSectionEntriesOptionalBase for all types and resources
....... component:historyOfPresentIllness 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1HistoryofPresentIllnessSectionBase for all types and resources
....... component:familyHistory 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FamilyHistorySectionBase for all types and resources
....... component:immunizations 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ImmunizationsSectionEntriesRequiredBase for all types and resources
....... component:problem 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProblemSectionEntriesRequiredBase for all types and resources
....... component:procedures 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
....... component:results 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ResultsSectionEntriesRequiredBase for all types and resources
....... component:reviewOfSystems 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReviewofSystemsSectionBase for all types and resources
....... component:socialHistory 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1SocialHistorySectionBase for all types and resources
....... component:vitalSigns 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1VitalSignsSectionEntriesRequiredBase for all types and resources
....... component:functionalStatus 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1FunctionalStatusSectionBase for all types and resources
....... component:physicalExam 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PhysicalExamSectionBase for all types and resources
....... component:nutrition 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1NutritionSectionBase for all types and resources
....... component:mentalStatus 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MentalStatusSectionBase for all types and resources
....... component:medicalEquip 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicalEquipmentSectionBase for all types and resources
....... component:allergiesAndIntolerances 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AllergiesAndIntolerancesSectionEntriesRequiredBase for all types and resources
....... component:assessment 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentSectionBase for all types and resources
....... component:assessmentAndPlan 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1AssessmentandPlanSectionBase for all types and resources
....... component:medicalHistory 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1PastMedicalHistoryBase for all types and resources
....... component:generalStatus 0..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1GeneralStatusSectionBase for all types and resources
....... component:medications 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1MedicationsSectionEntriesRequiredBase for all types and resources
....... component:reasonForReferral 1..1Element
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
........ typeCode 1..1codeFixed Value: COMP
........ contextConductionInd 1..1boolean
........ section 1..1ReasonforReferralSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.typeId.nullFlavorrequiredNullFlavor
ClinicalDocument.templateId:primary.nullFlavorrequiredNullFlavor
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMarital Status
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeextensibleRace Value Set
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCodeextensibleDetailed Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.delimiter.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.country.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.state.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.county.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.city.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postalCode.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetAddressLine.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumber.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumberNumeric.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.direction.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetName.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameBase.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameType.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.additionalLocator.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitID.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitType.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.careOf.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.censusTract.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryAddressLine.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationType.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationArea.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationQualifier.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryMode.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryModeIdentifier.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.buildingNumberSuffix.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postBox.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.precinct.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredNullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavorrequiredPattern: UNK
ClinicalDocument.author.assignedAuthor.codeextensibleRoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeextensibleEntityCode
ClinicalDocument.dataEnterer.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant1.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant2.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.custodian.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavorrequiredNullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.typeCoderequiredFixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.codeextensibleRoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant1.nullFlavorrequiredNullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredPattern: IND
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:participant1.associatedEntity.codeextensibleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant2.nullFlavorrequiredNullFlavor
ClinicalDocument.participant:participant2.typeCoderequiredPattern: CALLBCK
ClinicalDocument.participant:participant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredPattern: ASSIGNED
ClinicalDocument.participant:participant2.associatedEntity.codeextensibleRoleCode
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeextensibleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeextensibleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authorization:authorization1.nullFlavorrequiredNullFlavor
ClinicalDocument.authorization:authorization1.typeCoderequiredFixed Value: AUT
ClinicalDocument.authorization:authorization1.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.codeextensibleActCode
ClinicalDocument.authorization:authorization1.consent.statusCoderequiredActStatus
ClinicalDocument.componentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: AUT
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.codeextensibleActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeextensibleUSEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
ClinicalDocument.component.nullFlavorrequiredNullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: AUT
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
ClinicalDocument.component.structuredBody.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)

Constraints

IdGradePath(s)DetailsRequirements
1198-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:1198-5299).
:
1198-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:1198-5300).
:
1198-5402warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:1198-5402). Note: A nullFlavor of ' UNK' may be used if the state is unknown.
:
1198-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf 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:1198-5403).
:
1198-5449nullClinicalDocument.author.assignedAuthor.idIf this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
:
1198-6380errorClinicalDocument.setIdIf setId is present versionNumber **SHALL** be present (CONF:1198-6380).
:
1198-6387errorClinicalDocument.versionNumberIf versionNumber is present setId **SHALL** be present (CONF:1198-6387).
:
1198-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
:
1198-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:1198-9991).
:
1198-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992).
:
1198-10006errorClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
:
1198-10007warningClinicalDocument.participant:participant1When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
:
1198-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790).
:
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
1198-31347errorClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeIf sdtc:raceCode is present, then the patient SHALL contain [1..1] raceCode (CONF:1198-31347).
:
1198-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:1198-32418). For cases where information about newborn's time of birth needs to be captured.
:
1198-32943errorClinicalDocument.templateId:primaryWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32943).
:
1198-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from USRealmHeader

Summary

Mandatory: 18 elements (31 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension
  • The element ClinicalDocument.participant is sliced based on the value of value:typeCode
  • The element ClinicalDocument.component is sliced based on the value of value:section.code
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:section.code

 

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