Clinical Document Architecture
2.0.2-sd - release

This page is part of the CDA: Clinical Document Architecture (v2.0.2-sd: CDA 2.0 - Informative) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Logical Model: ClinicalDocument (CDA Class)

Official URL: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument Version: 2.0.2-sd
Active as of 2025-12-12 Computable Name: ClinicalDocument

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

Usages:

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

You can also check for usages in the FHIR IG Statistics

Formal Views of Template Content

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

This structure is derived from ANY

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Base for all types and resources

Elements defined in Ancestors:@nullFlavor
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Kind of document
Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS Document creation time
... confidentialityCode 1..1 CE Controls the disclosure of information in this document
... languageCode 0..1 CS Human language of character data
Binding: AllLanguages (required)
... setId 0..1 II An identifier that is common across all document revisions
... versionNumber 0..1 INT An integer value used to version successive replacement documents
... copyTime 0..1 TS Deprecated - use is discouraged
... recordTarget 1..* RecordTarget Medical record that this document belongs to
... author 1..* Author Humans and/or machines that authored the document
... dataEnterer 0..1 DataEnterer Participant who has transformed a dictated note into text
... informant 0..* Informant Person that provides relevant information
... custodian 1..1 Custodian Organization that is in charge of maintaining the document
... informationRecipient 0..* InformationRecipient A recipient who should receive a copy of the document
... legalAuthenticator 0..1 LegalAuthenticator Participant who has legally authenticated the document
... authenticator 0..* Authenticator Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
... participant 0..* Participant1 Other participants not explicitly mentioned by other classes
... inFulfillmentOf 0..* InFulfillmentOf Orders that are fulfilled by this document
... documentationOf 0..* DocumentationOf The main Act being documented
... relatedDocument 0..* RelatedDocument Source of a document revision, addenda, or transformation
... authorization 0..* Authorization Consents associated with this document
... componentOf 0..1 ComponentOf Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
... component 1..1 Component Body of the document

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClinicalDocument.classCode Base example CDAActClass 📦2.0.2-sd This IG
ClinicalDocument.moodCode Base required CDAActMood 📦2.0.2-sd This IG
ClinicalDocument.code Base example FHIR Document Type Codes 📦5.0.0 FHIR Std.
ClinicalDocument.sdtcStatusCode Base required ActStatus 📦2.0.0 THO v5.2
ClinicalDocument.languageCode Base required All Languages 📦5.0.0 FHIR Std.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Base for all types and resources

Elements defined in Ancestors:@nullFlavor
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId C 0..1 II Constraints: II-1
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Kind of document
Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS Document creation time
... confidentialityCode 1..1 CE Controls the disclosure of information in this document
... languageCode 0..1 CS Human language of character data
Binding: AllLanguages (required)
... setId 0..1 II An identifier that is common across all document revisions
... versionNumber 0..1 INT An integer value used to version successive replacement documents
... copyTime 0..1 TS Deprecated - use is discouraged
... recordTarget 1..* RecordTarget Medical record that this document belongs to
... author 1..* Author Humans and/or machines that authored the document
... dataEnterer 0..1 DataEnterer Participant who has transformed a dictated note into text
... informant 0..* Informant Person that provides relevant information
... custodian 1..1 Custodian Organization that is in charge of maintaining the document
... informationRecipient 0..* InformationRecipient A recipient who should receive a copy of the document
... legalAuthenticator 0..1 LegalAuthenticator Participant who has legally authenticated the document
... authenticator 0..* Authenticator Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
... participant 0..* Participant1 Other participants not explicitly mentioned by other classes
... inFulfillmentOf 0..* InFulfillmentOf Orders that are fulfilled by this document
... documentationOf 0..* DocumentationOf The main Act being documented
... relatedDocument 0..* RelatedDocument Source of a document revision, addenda, or transformation
... authorization 0..* Authorization Consents associated with this document
... componentOf 0..1 ComponentOf Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
... component 1..1 Component Body of the document

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalDocument.nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.classCode Base example CDAActClass 📦2.0.2-sd This IG
ClinicalDocument.moodCode Base required CDAActMood 📦2.0.2-sd This IG
ClinicalDocument.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.code Base example FHIR Document Type Codes 📦5.0.0 FHIR Std.
ClinicalDocument.sdtcStatusCode Base required ActStatus 📦2.0.0 THO v5.2
ClinicalDocument.languageCode Base required All Languages 📦5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
II-1 error ClinicalDocument.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Base for all types and resources

Elements defined in Ancestors:@nullFlavor
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId C 0..1 II Constraints: II-1
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Kind of document
Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS Document creation time
... confidentialityCode 1..1 CE Controls the disclosure of information in this document
... languageCode 0..1 CS Human language of character data
Binding: AllLanguages (required)
... setId 0..1 II An identifier that is common across all document revisions
... versionNumber 0..1 INT An integer value used to version successive replacement documents
... copyTime 0..1 TS Deprecated - use is discouraged
... recordTarget 1..* RecordTarget Medical record that this document belongs to
... author 1..* Author Humans and/or machines that authored the document
... dataEnterer 0..1 DataEnterer Participant who has transformed a dictated note into text
... informant 0..* Informant Person that provides relevant information
... custodian 1..1 Custodian Organization that is in charge of maintaining the document
... informationRecipient 0..* InformationRecipient A recipient who should receive a copy of the document
... legalAuthenticator 0..1 LegalAuthenticator Participant who has legally authenticated the document
... authenticator 0..* Authenticator Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
... participant 0..* Participant1 Other participants not explicitly mentioned by other classes
... inFulfillmentOf 0..* InFulfillmentOf Orders that are fulfilled by this document
... documentationOf 0..* DocumentationOf The main Act being documented
... relatedDocument 0..* RelatedDocument Source of a document revision, addenda, or transformation
... authorization 0..* Authorization Consents associated with this document
... componentOf 0..1 ComponentOf Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
... component 1..1 Component Body of the document

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalDocument.nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.classCode Base example CDAActClass 📦2.0.2-sd This IG
ClinicalDocument.moodCode Base required CDAActMood 📦2.0.2-sd This IG
ClinicalDocument.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.code Base example FHIR Document Type Codes 📦5.0.0 FHIR Std.
ClinicalDocument.sdtcStatusCode Base required ActStatus 📦2.0.0 THO v5.2
ClinicalDocument.languageCode Base required All Languages 📦5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
II-1 error ClinicalDocument.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

This structure is derived from ANY

Summary

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

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from ANY

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Base for all types and resources

Elements defined in Ancestors:@nullFlavor
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId 0..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Kind of document
Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS Document creation time
... confidentialityCode 1..1 CE Controls the disclosure of information in this document
... languageCode 0..1 CS Human language of character data
Binding: AllLanguages (required)
... setId 0..1 II An identifier that is common across all document revisions
... versionNumber 0..1 INT An integer value used to version successive replacement documents
... copyTime 0..1 TS Deprecated - use is discouraged
... recordTarget 1..* RecordTarget Medical record that this document belongs to
... author 1..* Author Humans and/or machines that authored the document
... dataEnterer 0..1 DataEnterer Participant who has transformed a dictated note into text
... informant 0..* Informant Person that provides relevant information
... custodian 1..1 Custodian Organization that is in charge of maintaining the document
... informationRecipient 0..* InformationRecipient A recipient who should receive a copy of the document
... legalAuthenticator 0..1 LegalAuthenticator Participant who has legally authenticated the document
... authenticator 0..* Authenticator Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
... participant 0..* Participant1 Other participants not explicitly mentioned by other classes
... inFulfillmentOf 0..* InFulfillmentOf Orders that are fulfilled by this document
... documentationOf 0..* DocumentationOf The main Act being documented
... relatedDocument 0..* RelatedDocument Source of a document revision, addenda, or transformation
... authorization 0..* Authorization Consents associated with this document
... componentOf 0..1 ComponentOf Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
... component 1..1 Component Body of the document

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClinicalDocument.classCode Base example CDAActClass 📦2.0.2-sd This IG
ClinicalDocument.moodCode Base required CDAActMood 📦2.0.2-sd This IG
ClinicalDocument.code Base example FHIR Document Type Codes 📦5.0.0 FHIR Std.
ClinicalDocument.sdtcStatusCode Base required ActStatus 📦2.0.0 THO v5.2
ClinicalDocument.languageCode Base required All Languages 📦5.0.0 FHIR Std.

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Base for all types and resources

Elements defined in Ancestors:@nullFlavor
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId C 0..1 II Constraints: II-1
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Kind of document
Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS Document creation time
... confidentialityCode 1..1 CE Controls the disclosure of information in this document
... languageCode 0..1 CS Human language of character data
Binding: AllLanguages (required)
... setId 0..1 II An identifier that is common across all document revisions
... versionNumber 0..1 INT An integer value used to version successive replacement documents
... copyTime 0..1 TS Deprecated - use is discouraged
... recordTarget 1..* RecordTarget Medical record that this document belongs to
... author 1..* Author Humans and/or machines that authored the document
... dataEnterer 0..1 DataEnterer Participant who has transformed a dictated note into text
... informant 0..* Informant Person that provides relevant information
... custodian 1..1 Custodian Organization that is in charge of maintaining the document
... informationRecipient 0..* InformationRecipient A recipient who should receive a copy of the document
... legalAuthenticator 0..1 LegalAuthenticator Participant who has legally authenticated the document
... authenticator 0..* Authenticator Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
... participant 0..* Participant1 Other participants not explicitly mentioned by other classes
... inFulfillmentOf 0..* InFulfillmentOf Orders that are fulfilled by this document
... documentationOf 0..* DocumentationOf The main Act being documented
... relatedDocument 0..* RelatedDocument Source of a document revision, addenda, or transformation
... authorization 0..* Authorization Consents associated with this document
... componentOf 0..1 ComponentOf Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
... component 1..1 Component Body of the document

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalDocument.nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.classCode Base example CDAActClass 📦2.0.2-sd This IG
ClinicalDocument.moodCode Base required CDAActMood 📦2.0.2-sd This IG
ClinicalDocument.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.code Base example FHIR Document Type Codes 📦5.0.0 FHIR Std.
ClinicalDocument.sdtcStatusCode Base required ActStatus 📦2.0.0 THO v5.2
ClinicalDocument.languageCode Base required All Languages 📦5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
II-1 error ClinicalDocument.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalDocument 1..1 ANY XML Namespace: urn:hl7-org:v3
Base for all types and resources

Elements defined in Ancestors:@nullFlavor
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 0..* CS
... typeId C 0..1 II Constraints: II-1
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... templateId 0..* II
... id 1..1 II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 1..1 CE Kind of document
Binding: FHIRDocumentTypeCodes (example)
... title 0..1 ST
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1 TS Document creation time
... confidentialityCode 1..1 CE Controls the disclosure of information in this document
... languageCode 0..1 CS Human language of character data
Binding: AllLanguages (required)
... setId 0..1 II An identifier that is common across all document revisions
... versionNumber 0..1 INT An integer value used to version successive replacement documents
... copyTime 0..1 TS Deprecated - use is discouraged
... recordTarget 1..* RecordTarget Medical record that this document belongs to
... author 1..* Author Humans and/or machines that authored the document
... dataEnterer 0..1 DataEnterer Participant who has transformed a dictated note into text
... informant 0..* Informant Person that provides relevant information
... custodian 1..1 Custodian Organization that is in charge of maintaining the document
... informationRecipient 0..* InformationRecipient A recipient who should receive a copy of the document
... legalAuthenticator 0..1 LegalAuthenticator Participant who has legally authenticated the document
... authenticator 0..* Authenticator Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
... participant 0..* Participant1 Other participants not explicitly mentioned by other classes
... inFulfillmentOf 0..* InFulfillmentOf Orders that are fulfilled by this document
... documentationOf 0..* DocumentationOf The main Act being documented
... relatedDocument 0..* RelatedDocument Source of a document revision, addenda, or transformation
... authorization 0..* Authorization Consents associated with this document
... componentOf 0..1 ComponentOf Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
... component 1..1 Component Body of the document

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalDocument.nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.classCode Base example CDAActClass 📦2.0.2-sd This IG
ClinicalDocument.moodCode Base required CDAActMood 📦2.0.2-sd This IG
ClinicalDocument.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd This IG
ClinicalDocument.code Base example FHIR Document Type Codes 📦5.0.0 FHIR Std.
ClinicalDocument.sdtcStatusCode Base required ActStatus 📦2.0.0 THO v5.2
ClinicalDocument.languageCode Base required All Languages 📦5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
II-1 error ClinicalDocument.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

This structure is derived from ANY

Summary

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

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel