Clinical Document Architecture
2.0.2-sd - release
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
| Active as of 2025-12-12 |
XML representation of the RelatedDocument logical model.
<StructureDefinition xmlns="http://hl7.org/fhir">
<id value="RelatedDocument"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p><b>Document Identification, Revisions, and Addenda</b></p>
<p>A clinical document can be replaced by a new document and/or appended with an addendum.</p>
<p>A replacement document is a new version of the parent document. The parent document is considered superseded, but a system may retain it for historical or auditing purposes. The parent document being replaced is referenced via act relationship relatedDocument, where relatedDocument.typeCode is set to equal "RPLC" (for "replaces"). An example is a report found to contain an error that is subsequently replaced by the corrected report.</p>
<p>An addendum is a separate document that references the parent document, and may extend or alter the observations in the prior document. The parent document remains a current component of the patient record, and the addendum and its parent are both read by report recipients. The parent report (represented by the ParentDocument class) being appended is referenced via act relationship relatedDocument, where relatedDocument.typeCode is set to equal "APND" (for "appends").</p>
<p>Every CDA document must have a unique ClinicalDocument.id, and thus the replacement or addendum documents each have ClinicalDocument.id that is different from that of the parent document.</p>
<p>CDA documents may also contain a ClinicalDocument.setId and a ClinicalDocument.versionNumber, which together support a document identification and versioning scheme used in some document management systems. In this scheme, all documents in a chain of replacements have the same ClinicalDocument.setId and are distinguished by an incrementing ClinicalDocument.versionNumber. The initial version of a document gets, in addition to a new unique value for ClinicalDocument.id, a new value for ClinicalDocument.setId, and has the value of ClinicalDocument.versionNumber set to equal "1". A replacement document gets a new globally unique ClinicalDocument.id value, and uses the same value for ClinicalDocument.setId as the parent report being replaced, and increments the value of ClinicalDocument.versionNumber by 1. (Note that version number must be incremented by one when a report is replaced, but can also be incremented more often to meet local requirements.)</p>
<p><b>Document transformations</b></p>
<p>A CDA document can be a transformation from some other format, meaning that it has undergone a machine translation from some other format (such as DICOM SR). In this case, relatedDocument.typeCode should be set to "XFRM".</p>
<p>A proper transformation must ensure that the human readable clinical content of the report is not impacted. Local business rules determine whether or not a transformed report replaces the source, but typically this would not be the case. If it is, an additional relationship of type "RPLC" is to be used. The "XFRM" relationship can also be used when translating a document in a local format into CDA for the purpose of exchange. In this case, the target of the "XFRM" relationship is the local document identifier.</p>
</div>
</text>
<extension
url="http://hl7.org/fhir/tools/StructureDefinition/logical-target">
<valueBoolean>
<extension
url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
<valueCode value="not-applicable"/>
</extension>
</valueBoolean>
</extension>
<extension
url="http://hl7.org/fhir/tools/StructureDefinition/xml-namespace">
<valueUri value="urn:hl7-org:v3"/>
</extension>
<extension url="http://hl7.org/fhir/tools/StructureDefinition/xml-name">
<valueString value="relatedDocument"/>
</extension>
<extension
url="http://hl7.org/fhir/tools/StructureDefinition/logical-container">
<valueUri
value="http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument"/>
</extension>
<extension
url="http://hl7.org/fhir/tools/StructureDefinition/type-profile-style">
<valueCode value="cda"/>
</extension>
<url
value="http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument"/>
<version value="2.0.2-sd"/>
<name value="RelatedDocument"/>
<title value="RelatedDocument (CDA Class)"/>
<status value="active"/>
<experimental value="false"/>
<date value="2025-12-12T15:26:32+11:00"/>
<publisher value="Health Level 7"/>
<contact>
<name value="HL7 International - Structured Documents"/>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/structure"/>
</telecom>
<telecom>
<system value="email"/>
<value value="structdog@lists.HL7.org"/>
</telecom>
</contact>
<description
value="**Document Identification, Revisions, and Addenda**
A clinical document can be replaced by a new document and/or appended with an addendum.
A replacement document is a new version of the parent document. The parent document is considered superseded, but a system may retain it for historical or auditing purposes. The parent document being replaced is referenced via act relationship relatedDocument, where relatedDocument.typeCode is set to equal "RPLC" (for "replaces"). An example is a report found to contain an error that is subsequently replaced by the corrected report.
An addendum is a separate document that references the parent document, and may extend or alter the observations in the prior document. The parent document remains a current component of the patient record, and the addendum and its parent are both read by report recipients. The parent report (represented by the ParentDocument class) being appended is referenced via act relationship relatedDocument, where relatedDocument.typeCode is set to equal "APND" (for "appends").
Every CDA document must have a unique ClinicalDocument.id, and thus the replacement or addendum documents each have ClinicalDocument.id that is different from that of the parent document.
CDA documents may also contain a ClinicalDocument.setId and a ClinicalDocument.versionNumber, which together support a document identification and versioning scheme used in some document management systems. In this scheme, all documents in a chain of replacements have the same ClinicalDocument.setId and are distinguished by an incrementing ClinicalDocument.versionNumber. The initial version of a document gets, in addition to a new unique value for ClinicalDocument.id, a new value for ClinicalDocument.setId, and has the value of ClinicalDocument.versionNumber set to equal "1". A replacement document gets a new globally unique ClinicalDocument.id value, and uses the same value for ClinicalDocument.setId as the parent report being replaced, and increments the value of ClinicalDocument.versionNumber by 1. (Note that version number must be incremented by one when a report is replaced, but can also be incremented more often to meet local requirements.)
**Document transformations**
A CDA document can be a transformation from some other format, meaning that it has undergone a machine translation from some other format (such as DICOM SR). In this case, relatedDocument.typeCode should be set to "XFRM".
A proper transformation must ensure that the human readable clinical content of the report is not impacted. Local business rules determine whether or not a transformed report replaces the source, but typically this would not be the case. If it is, an additional relationship of type "RPLC" is to be used. The "XFRM" relationship can also be used when translating a document in a local format into CDA for the purpose of exchange. In this case, the target of the "XFRM" relationship is the local document identifier.
"/>
<fhirVersion value="5.0.0"/>
<mapping>
<identity value="rim"/>
<uri value="http://hl7.org/v3"/>
<name value="RIM Mapping"/>
</mapping>
<kind value="logical"/>
<abstract value="false"/>
<type
value="http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument"/>
<baseDefinition
value="http://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot"/>
<derivation value="specialization"/>
<snapshot>
<extension
url="http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version">
<valueString value="2.0.2-sd"/>
</extension>
<element id="RelatedDocument">
<path value="RelatedDocument"/>
<short value="Base for all types and resources"/>
<definition
value="Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type."/>
<min value="1"/>
<max value="1"/>
<base>
<path value="Base"/>
<min value="0"/>
<max value="*"/>
</base>
<isModifier value="false"/>
<mapping>
<identity value="rim"/>
<map value="n/a"/>
</mapping>
</element>
<element id="RelatedDocument.nullFlavor">
<path value="RelatedDocument.nullFlavor"/>
<representation value="xmlAttr"/>
<label value="Exceptional Value Detail"/>
<definition
value="If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="ANY.nullFlavor"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="code"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"/>
</type>
<binding>
<strength value="required"/>
<valueSet
value="http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor"/>
</binding>
</element>
<element id="RelatedDocument.realmCode">
<path value="RelatedDocument.realmCode"/>
<definition
value="When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="InfrastructureRoot.realmCode"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="http://hl7.org/cda/stds/core/StructureDefinition/CS"/>
</type>
</element>
<element id="RelatedDocument.typeId">
<path value="RelatedDocument.typeId"/>
<definition
value="When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="InfrastructureRoot.typeId"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="http://hl7.org/cda/stds/core/StructureDefinition/II"/>
</type>
<constraint>
<key value="II-1"/>
<severity value="error"/>
<human
value="An II instance must have either a root or an nullFlavor."/>
<expression value="root.exists() or nullFlavor.exists()"/>
<source
value="http://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot"/>
</constraint>
</element>
<element id="RelatedDocument.typeId.nullFlavor">
<path value="RelatedDocument.typeId.nullFlavor"/>
<representation value="xmlAttr"/>
<label value="Exceptional Value Detail"/>
<definition
value="If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="ANY.nullFlavor"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="code"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"/>
</type>
<binding>
<strength value="required"/>
<valueSet
value="http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor"/>
</binding>
</element>
<element id="RelatedDocument.typeId.assigningAuthorityName">
<path value="RelatedDocument.typeId.assigningAuthorityName"/>
<representation value="xmlAttr"/>
<label value="Assigning Authority Name"/>
<definition
value="A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="II.assigningAuthorityName"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="string"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/st-simple"/>
</type>
</element>
<element id="RelatedDocument.typeId.displayable">
<path value="RelatedDocument.typeId.displayable"/>
<representation value="xmlAttr"/>
<label value="Displayable"/>
<definition
value="Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false)."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="II.displayable"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="boolean"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/bl-simple"/>
</type>
</element>
<element id="RelatedDocument.typeId.root">
<path value="RelatedDocument.typeId.root"/>
<representation value="xmlAttr"/>
<label value="Root"/>
<definition value="Identifies the type as an HL7 Registered model"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="II.root"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="string"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/oid"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/uuid"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/ruid"/>
</type>
<fixedString value="2.16.840.1.113883.1.3"/>
</element>
<element id="RelatedDocument.typeId.extension">
<path value="RelatedDocument.typeId.extension"/>
<representation value="xmlAttr"/>
<label value="Extension"/>
<definition
value="A character string as a unique identifier within the scope of the identifier root."/>
<min value="1"/>
<max value="1"/>
<base>
<path value="II.extension"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="string"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/st-simple"/>
</type>
</element>
<element id="RelatedDocument.templateId">
<path value="RelatedDocument.templateId"/>
<definition
value="When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="InfrastructureRoot.templateId"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="http://hl7.org/cda/stds/core/StructureDefinition/II"/>
</type>
</element>
<element id="RelatedDocument.typeCode">
<path value="RelatedDocument.typeCode"/>
<representation value="xmlAttr"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="RelatedDocument.typeCode"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="code"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"/>
</type>
<binding>
<strength value="required"/>
<valueSet
value="http://terminology.hl7.org/ValueSet/v3-xActRelationshipDocument"/>
</binding>
</element>
<element id="RelatedDocument.parentDocument">
<path value="RelatedDocument.parentDocument"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="RelatedDocument.parentDocument"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code
value="http://hl7.org/cda/stds/core/StructureDefinition/ParentDocument"/>
</type>
</element>
</snapshot>
<differential>
<element id="RelatedDocument">
<path value="RelatedDocument"/>
<min value="1"/>
<max value="1"/>
</element>
<element id="RelatedDocument.typeCode">
<path value="RelatedDocument.typeCode"/>
<representation value="xmlAttr"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="code"/>
<profile
value="http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"/>
</type>
<binding>
<strength value="required"/>
<valueSet
value="http://terminology.hl7.org/ValueSet/v3-xActRelationshipDocument"/>
</binding>
</element>
<element id="RelatedDocument.parentDocument">
<path value="RelatedDocument.parentDocument"/>
<min value="1"/>
<max value="1"/>
<type>
<code
value="http://hl7.org/cda/stds/core/StructureDefinition/ParentDocument"/>
</type>
</element>
</differential>
</StructureDefinition>
IG © 2019+ Health Level 7. Package hl7.cda.uv.core#2.0.2-sd based on FHIR 5.0.0. Generated 2025-12-12
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