ClinicalDocument
type: StructureDefinition
node role: treeRoot
id:
  v: ClinicalDocument
text:
  status:
    v: generated
  div:
    v: The ClinicalDocument class is the entry point into the CDA R-MIM, and corresponds to the <ClinicalDocument> XML element that is the root element of a CDA document. A CDA document is logically broken up into a CDA Header and a CDA Body. The CDA Header is comprised of ClinicalDocument attributes, participants, and act relationships. The CDA Body is the target of the ClinicalDocument component act relationship. The ClinicalDocument class inherits various attributes from the InfrastructureRoot class of the RIM, including ClinicalDocument.templateId and ClinicalDocument.typeId. When ClinicalDocument.templateId is valued in an instance, it signals the imposition of a set of template-defined constraints. In addition, the templateId attribute is available in all other CDA classes, thus enabling the imposition of a set of template-defined constraints at any level of granularity. The value of this attribute provides a unique identifier for the template(s) in question. ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/logical-target
    l: logical-target
  value: Boolean
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/data-absent-reason
        l: data-absent-reason
      value: Code
        v: not-applicable
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-namespace
    l: xml-namespace
  value: Uri
    v: urn:hl7-org:v3
    l: v3
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-name
    l: xml-name
  value: String
    v: ClinicalDocument
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/type-profile-style
    l: type-profile-style
  value: Code
    v: cda
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/logical-container
    l: logical-container
  value: Uri
    v: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument
    l: ClinicalDocument
url:
  v: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument
  l: ClinicalDocument
version:
  v: 2.0.3-sd
name:
  v: ClinicalDocument
title:
  v: ClinicalDocument (CDA Class)
status:
  v: active
experimental:
  v: false
date:
  v: 2026-06-12T07:06:38+10:00
publisher:
  v: Health Level 7
contact:
  name:
    v: HL7 International - Structured Documents
  telecom:
    system:
      v: url
    value:
      v: http://www.hl7.org/Special/committees/structure
  telecom:
    system:
      v: email
description:
  v: 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
fhir version:
  v: 5.0.0
mapping:
  identity:
    v: rim
  uri:
    v: http://hl7.org/v3
    l: v3
  name:
    v: RIM Mapping
kind:
  v: logical
abstract:
  v: false
type:
  v: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument
  l: ClinicalDocument
base definition:
  v: http://hl7.org/cda/stds/core/StructureDefinition/ANY
  l: ANY
derivation:
  v: specialization
snapshot:
  extension:
    url:
      v: http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version
      l: snapshot-base-version
    value: String
      v: 2.0.3-sd
  element:
    id:
      v: ClinicalDocument
    path:
      v: ClinicalDocument
    short:
      v: Base for all types and resources
    definition:
      v: 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:
      v: 1
    max:
      v: 1
    base:
      path:
        v: Base
      min:
        v: 0
      max:
        v: *
    is modifier:
      v: false
    mapping:
      identity:
        v: rim
      map:
        v: n/a
  element:
    id:
      v: ClinicalDocument.nullFlavor
    path:
      v: ClinicalDocument.nullFlavor
    representation:
      v: xmlAttr
    label:
      v: Exceptional Value Detail
    definition:
      v: If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
    min:
      v: 0
    max:
      v: 1
    base:
      path:
        v: ANY.nullFlavor
      min:
        v: 0
      max:
        v: 1
    type:
      code:
        v: code
        l: code
      profile:
        v: http://hl7.org/cda/stds/core/StructureDefinition/cs-simple
        l: cs-simple
    binding:
      strength:
        v: required
      value set:
        v: http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
        l: CDANullFlavor
  element:
    id:
      v: ClinicalDocument.classCode
    path:
      v: ClinicalDocument.classCode
    representation:
      v: xmlAttr
    min:
      v: 0
    max:
      v: 1
    base:
      path:
        v: ClinicalDocument.classCode
      min:
        v: 0
      max:
        v: 1
    type:
      code:
        v: code
        l: code
      profile:
        v: http://hl7.org/cda/stds/core/StructureDefinition/cs-simple
        l: cs-simple
    fixed: Code
      v: DOCCLIN
    binding:
      strength:
        v: example
      value set:
        v: http://hl7.org/cda/stds/core/ValueSet/CDAActClass
        l: CDAActClass
  element:
    id:
      v: ClinicalDocument.moodCode
    fixed: Code

v: ClinicalDocument.moodCode

v: xmlAttr

v: 0

v: 1

path:
  v: ClinicalDocument.moodCode
min:
  v: 0
max:
  v: 1

code:
  v: code
  l: code
profile:
  v: http://hl7.org/cda/stds/core/StructureDefinition/cs-simple
  l: cs-simple

Code
v: EVN

strength:
  v: required
value set:
  v: http://hl7.org/cda/stds/core/ValueSet/CDAActMood
  l: CDAActMood

id:
  v: ClinicalDocument.realmCode
path:
  v: ClinicalDocument.realmCode
definition:
  v: 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:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.realmCode
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CS
    l: CS

id:
  v: ClinicalDocument.typeId
path:
  v: ClinicalDocument.typeId
definition:
  v: ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.typeId
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/II
    l: II
constraint:
  key:
    v: II-1
  severity:
    v: error
  human:
    v: An II instance must have either a root or an nullFlavor.
  expression:
    v: root.exists() or nullFlavor.exists()

id:
  v: ClinicalDocument.typeId.nullFlavor
path:
  v: ClinicalDocument.typeId.nullFlavor
representation:
  v: xmlAttr
label:
  v: Exceptional Value Detail
definition:
  v: If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ANY.nullFlavor
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: code
    l: code
  profile:
    v: http://hl7.org/cda/stds/core/StructureDefinition/cs-simple
    l: cs-simple
binding:
  strength:
    v: required
  value set:
    v: http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    l: CDANullFlavor

id:
  v: ClinicalDocument.typeId.assigningAuthorityName
path:
  v: ClinicalDocument.typeId.assigningAuthorityName
representation:
  v: xmlAttr
label:
  v: Assigning Authority Name
definition:
  v: 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:
  v: 0
max:
  v: 1
base:
  path:
    v: II.assigningAuthorityName
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: string
    l: string
  profile:
    v: http://hl7.org/cda/stds/core/StructureDefinition/st-simple
    l: st-simple

id:
  v: ClinicalDocument.typeId.displayable
path:
  v: ClinicalDocument.typeId.displayable
representation:
  v: xmlAttr
label:
  v: Displayable
definition:
  v: Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
min:
  v: 0
max:
  v: 1
base:
  path:
    v: II.displayable
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: boolean
    l: boolean
  profile:
    v: http://hl7.org/cda/stds/core/StructureDefinition/bl-simple
    l: bl-simple

id:
  v: ClinicalDocument.typeId.root
path:
  v: ClinicalDocument.typeId.root
representation:
  v: xmlAttr
label:
  v: Root
definition:
  v: Identifies the type as an HL7 Registered model
min:
  v: 1
max:
  v: 1
base:
  path:
    v: II.root
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: string
    l: string
  profile:
    v: http://hl7.org/cda/stds/core/StructureDefinition/oid
    l: oid
  profile:
    v: http://hl7.org/cda/stds/core/StructureDefinition/uuid
    l: uuid
  profile:
    v: http://hl7.org/cda/stds/core/StructureDefinition/ruid
    l: ruid
fixed: String
  v: 2.16.840.1.113883.1.3

id:
  v: ClinicalDocument.typeId.extension
path:
  v: ClinicalDocument.typeId.extension
representation:
  v: xmlAttr
label:
  v: Extension
definition:
  v: A character string as a unique identifier within the scope of the identifier root.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: II.extension
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: string
    l: string
  profile:
    v: http://hl7.org/cda/stds/core/StructureDefinition/st-simple
    l: st-simple
fixed: String
  v: POCD_HD000040

id:
  v: ClinicalDocument.templateId
path:
  v: ClinicalDocument.templateId
definition:
  v: 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:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.templateId
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/II
    l: II

id:
  v: ClinicalDocument.id
path:
  v: ClinicalDocument.id
definition:
  v: Represents the unique instance identifier of a clinical document.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: ClinicalDocument.id
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/II
    l: II

id:
  v: ClinicalDocument.sdtcCategory
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-namespace
    l: xml-namespace
  value: Uri
    v: urn:hl7-org:sdtc
    l: sdtc
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-name
    l: xml-name
  value: String
    v: category
path:
  v: ClinicalDocument.sdtcCategory
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.sdtcCategory
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CD
    l: CD

id:
  v: ClinicalDocument.code
path:
  v: ClinicalDocument.code
short:
  v: Kind of document
definition:
  v: The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note).
min:
  v: 1
max:
  v: 1
base:
  path:
    v: ClinicalDocument.code
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CE
    l: CE
binding:
  strength:
    v: example
  value set:
    v: http://hl7.org/fhir/ValueSet/doc-typecodes
    l: doc-typecodes

id:
  v: ClinicalDocument.title
path:
  v: ClinicalDocument.title
comment:
  v: It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of ClinicalDocument.code (e.g. a 'consultation' or 'progress note'). Where these display names are rendered to the clinician, or where the document has a unique title, the ClinicalDocument.title component should be used.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.title
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/ST
    l: ST

id:
  v: ClinicalDocument.sdtcStatusCode
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-namespace
    l: xml-namespace
  value: Uri
    v: urn:hl7-org:sdtc
    l: sdtc
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-name
    l: xml-name
  value: String
    v: statusCode
path:
  v: ClinicalDocument.sdtcStatusCode
definition:
  v: The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.sdtcStatusCode
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CS
    l: CS
binding:
  strength:
    v: required
  value set:
    v: http://terminology.hl7.org/ValueSet/v3-ActStatus
    l: v3-ActStatus

id:
  v: ClinicalDocument.effectiveTime
path:
  v: ClinicalDocument.effectiveTime
short:
  v: Document creation time
definition:
  v: Signifies the document creation time, when the document first came into being.
comment:
  v: Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: ClinicalDocument.effectiveTime
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/TS
    l: TS

id:
  v: ClinicalDocument.confidentialityCode
path:
  v: ClinicalDocument.confidentialityCode
short:
  v: Controls the disclosure of information in this document
comment:
  v: Confidentiality is a required contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: ClinicalDocument.confidentialityCode
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CE
    l: CE

id:
  v: ClinicalDocument.languageCode
path:
  v: ClinicalDocument.languageCode
short:
  v: Human language of character data
definition:
  v: Specifies the human language of character data (whether they be in contents or attribute values).
comment:
  v: Language is a contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.languageCode
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CS
    l: CS
binding:
  strength:
    v: required
  value set:
    v: http://hl7.org/fhir/ValueSet/all-languages
    l: all-languages

id:
  v: ClinicalDocument.setId
path:
  v: ClinicalDocument.setId
short:
  v: An identifier that is common across all document revisions
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.setId
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/II
    l: II

id:
  v: ClinicalDocument.versionNumber
path:
  v: ClinicalDocument.versionNumber
short:
  v: An integer value used to version successive replacement documents
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.versionNumber
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/INT
    l: INT

id:
  v: ClinicalDocument.copyTime
path:
  v: ClinicalDocument.copyTime
short:
  v: Deprecated - use is discouraged
definition:
  v: Represents the time a document is released (i.e. copied or sent to a display device) from a document management system that maintains revision control over the document. Once valued, it cannot be changed. The intent is to give the viewer of the document some notion as to how long the document has been out of the safe context of its document management system.
requirements:
  v: Included for backwards compatibility with CDA, Release One. ClinicalDocument.copyTime has been deprecated because it is not part of the document at the time it is authenticated, but instead represents metadata about the document, applied at some variable time after authentication. Further use is discouraged.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.copyTime
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/TS
    l: TS

id:
  v: ClinicalDocument.recordTarget
path:
  v: ClinicalDocument.recordTarget
short:
  v: Medical record that this document belongs to
comment:
  v: A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated.
requirements:
  v: The recordTarget(s) of a document are stated in the header and propagate to nested content, where they cannot be overridden.
min:
  v: 1
max:
  v: *
base:
  path:
    v: ClinicalDocument.recordTarget
  min:
    v: 1
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
    l: RecordTarget

id:
  v: ClinicalDocument.author
path:
  v: ClinicalDocument.author
short:
  v: Humans and/or machines that authored the document
comment:
  v: In some cases, the role or function of the author is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is 'Medical Student Progress Note'. The role of the author can also be recorded in the Author.functionCode or AssignedAuthor.code attribute. If either of these attributes is included, they should be equivalent to or further specialize the role inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply 'Physician Progress Note' and the value of Author.functionCode is 'rounding physician'), and shall not conflict with the role inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.
min:
  v: 1
max:
  v: *
base:
  path:
    v: ClinicalDocument.author
  min:
    v: 1
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Author
    l: Author

id:
  v: ClinicalDocument.dataEnterer
path:
  v: ClinicalDocument.dataEnterer
short:
  v: Participant who has transformed a dictated note into text
alias:
  v: Transcriptionist
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.dataEnterer
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
    l: DataEnterer

id:
  v: ClinicalDocument.informant
path:
  v: ClinicalDocument.informant
short:
  v: Person that provides relevant information
definition:
  v: An informant (or source of information) is a person that provides relevant information, such as the parent of a comatose patient who describes the patient's behavior prior to the onset of coma.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.informant
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Informant
    l: Informant

id:
  v: ClinicalDocument.custodian
path:
  v: ClinicalDocument.custodian
short:
  v: Organization that is in charge of maintaining the document
definition:
  v: Represents the organization that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian.
requirements:
  v: The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document, the custodian represents the steward of the original source document.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: ClinicalDocument.custodian
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Custodian
    l: Custodian

id:
  v: ClinicalDocument.informationRecipient
path:
  v: ClinicalDocument.informationRecipient
short:
  v: A recipient who should receive a copy of the document
comment:
  v: The information recipient is an entity to whom a copy of a document is directed, at the time of document authorship. It is not the same as the cumulative set of persons to whom the document has subsequently been disclosed, over the life-time of the patient. Such a disclosure list would not be contained within the document, and it outside the scope of CDA.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.informationRecipient
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
    l: InformationRecipient

id:
  v: ClinicalDocument.legalAuthenticator
path:
  v: ClinicalDocument.legalAuthenticator
short:
  v: Participant who has legally authenticated the document
comment:
  v: The CDA is a standard that specifies the structure of exchanged clinical documents. In the case where a local document is transformed into a CDA document for exchange, authentication occurs on the local document, and that fact is reflected in the exchanged CDA document. A CDA document can reflect the unauthenticated, authenticated, or legally authenticated state. The unauthenticated state exists when no authentication information has been recorded (i.e., it is the absence of being either authenticated or legally authenticated).
requirements:
  v: While electronic signatures are not captured in a CDA document, both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual. A legalAuthenticator has a required legalAuthenticator.time indicating the time of authentication, and a required legalAuthenticator.signatureCode, indicating that a signature has been obtained and is on file.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.legalAuthenticator
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
    l: LegalAuthenticator

id:
  v: ClinicalDocument.authenticator
path:
  v: ClinicalDocument.authenticator
short:
  v: Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
definition:
  v: Represents a participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document. An example would be a resident physician who sees a patient and dictates a note, then later signs it.
comment:
  v: A clinical document can have zero to many authenticators. While electronic signatures are not captured in a CDA document, both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual. An authenticator has a required authenticator.time indicating the time of authentication, and a required authenticator.signatureCode, indicating that a signature has been obtained and is on file.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.authenticator
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Authenticator
    l: Authenticator

id:
  v: ClinicalDocument.participant
path:
  v: ClinicalDocument.participant
short:
  v: Other participants not explicitly mentioned by other classes
definition:
  v: Used to represent other participants not explicitly mentioned by other classes, that were somehow involved in the documented acts.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.participant
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Participant1
    l: Participant1

id:
  v: ClinicalDocument.inFulfillmentOf
path:
  v: ClinicalDocument.inFulfillmentOf
short:
  v: Orders that are fulfilled by this document
comment:
  v: For instance, a provider orders an X-Ray. The X-Ray is performed. A radiologist reads the X-Ray and generates a report. The X-Ray order identifier is transmitted in the Order class, the performed X-Ray procedure is transmitted in the ServiceEvent class, and the ClinicalDocument.code would be valued with 'Diagnostic Imaging Report'.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.inFulfillmentOf
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
    l: InFulfillmentOf

id:
  v: ClinicalDocument.documentationOf
path:
  v: ClinicalDocument.documentationOf
short:
  v: The main Act being documented
comment:
  v: In some cases, the ServiceEvent is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is 'History and Physical Report' and the procedure being documented is a 'History and Physical' act. A ServiceEvent can further specialize the act inherent in the ClinicalDocument.code, such as where the ClinicalDocument.code is simply 'Procedure Report' and the procedure was a 'colonoscopy'. If ServiceEvent is included, it must be equivalent to or further specialize the value inherent in the ClinicalDocument.code, and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.documentationOf
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
    l: DocumentationOf

id:
  v: ClinicalDocument.relatedDocument
path:
  v: ClinicalDocument.relatedDocument
short:
  v: Source of a document revision, addenda, or transformation
requirements:
  v: A conformant CDA document can have a single relatedDocument with typeCode 'APND'; a single relatedDocument with typeCode 'RPLC'; a single relatedDocument with typeCode 'XFRM'; a combination of two relatedDocuments with typeCodes 'XFRM' and 'RPLC'; or a combination of two relatedDocuments with typeCodes 'XFRM' and 'APND'. No other combinations are allowed.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.relatedDocument
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
    l: RelatedDocument

id:
  v: ClinicalDocument.authorization
path:
  v: ClinicalDocument.authorization
short:
  v: Consents associated with this document
comment:
  v: The type of consent (e.g. a consent to perform the related ServiceEvent, a consent for the information contained in the document to be released to a third party) is conveyed in Consent.code. Consents referenced in the CDA Header have been finalized (Consent.statusCode must equal 'completed') and should be on file.
min:
  v: 0
max:
  v: *
base:
  path:
    v: ClinicalDocument.authorization
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Authorization
    l: Authorization

id:
  v: ClinicalDocument.componentOf
path:
  v: ClinicalDocument.componentOf
short:
  v: Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
definition:
  v: This optional class represents the setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note.
comment:
  v: In some cases, the setting of the encounter is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is 'Diabetes Clinic Progress Note'. The setting of an encounter can also be transmitted in the HealthCareFacility.code attribute. If HealthCareFacility.code is sent, it should be equivalent to or further specialize the value inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply 'Clinic Progress Note' and the value of HealthCareFacility.code is 'cardiology clinic'), and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: ClinicalDocument.componentOf
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
    l: ComponentOf

id:
  v: ClinicalDocument.component
path:
  v: ClinicalDocument.component
short:
  v: Body of the document
min:
  v: 1
max:
  v: 1
base:
  path:
    v: ClinicalDocument.component
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Component
    l: Component

element:
  id:
    v: ClinicalDocument
  path:
    v: ClinicalDocument
  min:
    v: 1
  max:
    v: 1
element:
  id:
    v: ClinicalDocument.classCode
  path:
    v: ClinicalDocument.classCode
  representation:
    v: xmlAttr
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: code
      l: code
    profile:
      v: http://hl7.org/cda/stds/core/StructureDefinition/cs-simple
      l: cs-simple
  fixed: Code
    v: DOCCLIN
  binding:
    strength:
      v: example
    value set:
      v: http://hl7.org/cda/stds/core/ValueSet/CDAActClass
      l: CDAActClass
element:
  id:
    v: ClinicalDocument.moodCode
  path:
    v: ClinicalDocument.moodCode
  representation:
    v: xmlAttr
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: code
      l: code
    profile:
      v: http://hl7.org/cda/stds/core/StructureDefinition/cs-simple
      l: cs-simple
  fixed: Code
    v: EVN
  binding:
    strength:
      v: required
    value set:
      v: http://hl7.org/cda/stds/core/ValueSet/CDAActMood
      l: CDAActMood
element:
  id:
    v: ClinicalDocument.realmCode
  path:
    v: ClinicalDocument.realmCode
  definition:
    v: 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:
    v: 0
  max:
    v: *
  type:
    code:
      v: http://hl7.org/cda/stds/core/StructureDefinition/CS
      l: CS
element:
  id:
    v: ClinicalDocument.typeId
  path:
    v: ClinicalDocument.typeId
  definition:
    v: ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: http://hl7.org/cda/stds/core/StructureDefinition/II
      l: II
element:
  id:
    v: ClinicalDocument.typeId.root
  path:
    v: ClinicalDocument.typeId.root
  representation:
    v: xmlAttr
  definition:
    v: Identifies the type as an HL7 Registered model
  min:
    v: 1
  max:
    v: 1
  fixed: String
    v: 2.16.840.1.113883.1.3
element:
  id:
    v: ClinicalDocument.typeId.extension
  path:
    v: ClinicalDocument.typeId.extension
  representation:
    v: xmlAttr
  definition:
    v: A character string as a unique identifier within the scope of the identifier root.
  min:
    v: 1
  max:
    v: 1
  type:
    code:
      v: string
      l: string
    profile:
      v: http://hl7.org/cda/stds/core/StructureDefinition/st-simple
      l: st-simple
  fixed: String
    v: POCD_HD000040
element:
  id:
    v: ClinicalDocument.templateId
  path:
    v: ClinicalDocument.templateId
  definition:
    v: 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:
    v: 0
  max:
    v: *
  type:
    code:
      v: http://hl7.org/cda/stds/core/StructureDefinition/II
      l: II
element:
  id:
    v: ClinicalDocument.id
  path:
    v: ClinicalDocument.id
  definition:
    v: Represents the unique instance identifier of a clinical document.
  min:
    v: 1
  max:
    v: 1
  type:
    code:
      v: http://hl7.org/cda/stds/core/StructureDefinition/II
      l: II
element:
  id:
    v: ClinicalDocument.sdtcCategory
  extension:
    url:
      v: http://hl7.org/fhir/tools/StructureDefinition/xml-namespace
      l: xml-namespace
    value: Uri
      v: urn:hl7-org:sdtc
      l: sdtc
  extension:
    url:
      v: http://hl7.org/fhir/tools/StructureDefinition/xml-name
      l: xml-name
    value: String
      v: category
  path:
    v: ClinicalDocument.sdtcCategory
  min:
    v: 0
  max:
    v: *
  type:
    code:
      v: http://hl7.org/cda/stds/core/StructureDefinition/CD
      l: CD
element:
  id:
    v: ClinicalDocument.code
  path:
    v: ClinicalDocument.code
  short:
    v: Kind of document
  definition:
    v: The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note).
  min:
    v: 1
  max:
    v: 1
  type:
    code:
      v: http://hl7.org/cda/stds/core/StructureDefinition/CE
      l: CE

strength:
  v: example
value set:
  v: http://hl7.org/fhir/ValueSet/doc-typecodes
  l: doc-typecodes

id:
  v: ClinicalDocument.title
path:
  v: ClinicalDocument.title
comment:
  v: It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of ClinicalDocument.code (e.g. a 'consultation' or 'progress note'). Where these display names are rendered to the clinician, or where the document has a unique title, the ClinicalDocument.title component should be used.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/ST
    l: ST

id:
  v: ClinicalDocument.sdtcStatusCode
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-namespace
    l: xml-namespace
  value: Uri
    v: urn:hl7-org:sdtc
    l: sdtc
extension:
  url:
    v: http://hl7.org/fhir/tools/StructureDefinition/xml-name
    l: xml-name
  value: String
    v: statusCode
path:
  v: ClinicalDocument.sdtcStatusCode
definition:
  v: The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CS
    l: CS
binding:
  strength:
    v: required
  value set:
    v: http://terminology.hl7.org/ValueSet/v3-ActStatus
    l: v3-ActStatus

id:
  v: ClinicalDocument.effectiveTime
path:
  v: ClinicalDocument.effectiveTime
short:
  v: Document creation time
definition:
  v: Signifies the document creation time, when the document first came into being.
comment:
  v: Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA.
min:
  v: 1
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/TS
    l: TS

id:
  v: ClinicalDocument.confidentialityCode
path:
  v: ClinicalDocument.confidentialityCode
short:
  v: Controls the disclosure of information in this document
comment:
  v: Confidentiality is a required contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value.
min:
  v: 1
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CE
    l: CE

id:
  v: ClinicalDocument.languageCode
path:
  v: ClinicalDocument.languageCode
short:
  v: Human language of character data
definition:
  v: Specifies the human language of character data (whether they be in contents or attribute values).
comment:
  v: Language is a contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/CS
    l: CS
binding:
  strength:
    v: required
  value set:
    v: http://hl7.org/fhir/ValueSet/all-languages
    l: all-languages

id:
  v: ClinicalDocument.setId
path:
  v: ClinicalDocument.setId
short:
  v: An identifier that is common across all document revisions
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/II
    l: II

id:
  v: ClinicalDocument.versionNumber
path:
  v: ClinicalDocument.versionNumber
short:
  v: An integer value used to version successive replacement documents
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/INT
    l: INT

id:
  v: ClinicalDocument.copyTime
path:
  v: ClinicalDocument.copyTime
short:
  v: Deprecated - use is discouraged
definition:
  v: Represents the time a document is released (i.e. copied or sent to a display device) from a document management system that maintains revision control over the document. Once valued, it cannot be changed. The intent is to give the viewer of the document some notion as to how long the document has been out of the safe context of its document management system.
requirements:
  v: Included for backwards compatibility with CDA, Release One. ClinicalDocument.copyTime has been deprecated because it is not part of the document at the time it is authenticated, but instead represents metadata about the document, applied at some variable time after authentication. Further use is discouraged.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/TS
    l: TS

id:
  v: ClinicalDocument.recordTarget
path:
  v: ClinicalDocument.recordTarget
short:
  v: Medical record that this document belongs to
comment:
  v: A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated.
requirements:
  v: The recordTarget(s) of a document are stated in the header and propagate to nested content, where they cannot be overridden.
min:
  v: 1
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
    l: RecordTarget

id:
  v: ClinicalDocument.author
path:
  v: ClinicalDocument.author
short:
  v: Humans and/or machines that authored the document
comment:
  v: In some cases, the role or function of the author is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is 'Medical Student Progress Note'. The role of the author can also be recorded in the Author.functionCode or AssignedAuthor.code attribute. If either of these attributes is included, they should be equivalent to or further specialize the role inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply 'Physician Progress Note' and the value of Author.functionCode is 'rounding physician'), and shall not conflict with the role inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.
min:
  v: 1
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Author
    l: Author

id:
  v: ClinicalDocument.dataEnterer
path:
  v: ClinicalDocument.dataEnterer
short:
  v: Participant who has transformed a dictated note into text
alias:
  v: Transcriptionist
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/DataEnterer
    l: DataEnterer

id:
  v: ClinicalDocument.informant
path:
  v: ClinicalDocument.informant
short:
  v: Person that provides relevant information
definition:
  v: An informant (or source of information) is a person that provides relevant information, such as the parent of a comatose patient who describes the patient's behavior prior to the onset of coma.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Informant
    l: Informant

id:
  v: ClinicalDocument.custodian
path:
  v: ClinicalDocument.custodian
short:
  v: Organization that is in charge of maintaining the document
definition:
  v: Represents the organization that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian.
requirements:
  v: The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document, the custodian represents the steward of the original source document.
min:
  v: 1
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Custodian
    l: Custodian

id:
  v: ClinicalDocument.informationRecipient
path:
  v: ClinicalDocument.informationRecipient
short:
  v: A recipient who should receive a copy of the document
comment:
  v: The information recipient is an entity to whom a copy of a document is directed, at the time of document authorship. It is not the same as the cumulative set of persons to whom the document has subsequently been disclosed, over the life-time of the patient. Such a disclosure list would not be contained within the document, and it outside the scope of CDA.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient
    l: InformationRecipient

id:
  v: ClinicalDocument.legalAuthenticator
path:
  v: ClinicalDocument.legalAuthenticator
short:
  v: Participant who has legally authenticated the document
comment:
  v: The CDA is a standard that specifies the structure of exchanged clinical documents. In the case where a local document is transformed into a CDA document for exchange, authentication occurs on the local document, and that fact is reflected in the exchanged CDA document. A CDA document can reflect the unauthenticated, authenticated, or legally authenticated state. The unauthenticated state exists when no authentication information has been recorded (i.e., it is the absence of being either authenticated or legally authenticated).
requirements:
  v: While electronic signatures are not captured in a CDA document, both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual. A legalAuthenticator has a required legalAuthenticator.time indicating the time of authentication, and a required legalAuthenticator.signatureCode, indicating that a signature has been obtained and is on file.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator
    l: LegalAuthenticator

id:
  v: ClinicalDocument.authenticator
path:
  v: ClinicalDocument.authenticator
short:
  v: Participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document
definition:
  v: Represents a participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document. An example would be a resident physician who sees a patient and dictates a note, then later signs it.
comment:
  v: A clinical document can have zero to many authenticators. While electronic signatures are not captured in a CDA document, both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual. An authenticator has a required authenticator.time indicating the time of authentication, and a required authenticator.signatureCode, indicating that a signature has been obtained and is on file.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Authenticator
    l: Authenticator

id:
  v: ClinicalDocument.participant
path:
  v: ClinicalDocument.participant
short:
  v: Other participants not explicitly mentioned by other classes
definition:
  v: Used to represent other participants not explicitly mentioned by other classes, that were somehow involved in the documented acts.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Participant1
    l: Participant1

id:
  v: ClinicalDocument.inFulfillmentOf
path:
  v: ClinicalDocument.inFulfillmentOf
short:
  v: Orders that are fulfilled by this document
comment:
  v: For instance, a provider orders an X-Ray. The X-Ray is performed. A radiologist reads the X-Ray and generates a report. The X-Ray order identifier is transmitted in the Order class, the performed X-Ray procedure is transmitted in the ServiceEvent class, and the ClinicalDocument.code would be valued with 'Diagnostic Imaging Report'.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf
    l: InFulfillmentOf

id:
  v: ClinicalDocument.documentationOf
path:
  v: ClinicalDocument.documentationOf
short:
  v: The main Act being documented
comment:
  v: In some cases, the ServiceEvent is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is 'History and Physical Report' and the procedure being documented is a 'History and Physical' act. A ServiceEvent can further specialize the act inherent in the ClinicalDocument.code, such as where the ClinicalDocument.code is simply 'Procedure Report' and the procedure was a 'colonoscopy'. If ServiceEvent is included, it must be equivalent to or further specialize the value inherent in the ClinicalDocument.code, and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
    l: DocumentationOf

id:
  v: ClinicalDocument.relatedDocument
path:
  v: ClinicalDocument.relatedDocument
short:
  v: Source of a document revision, addenda, or transformation
requirements:
  v: A conformant CDA document can have a single relatedDocument with typeCode 'APND'; a single relatedDocument with typeCode 'RPLC'; a single relatedDocument with typeCode 'XFRM'; a combination of two relatedDocuments with typeCodes 'XFRM' and 'RPLC'; or a combination of two relatedDocuments with typeCodes 'XFRM' and 'APND'. No other combinations are allowed.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument
    l: RelatedDocument

id:
  v: ClinicalDocument.authorization
path:
  v: ClinicalDocument.authorization
short:
  v: Consents associated with this document
comment:
  v: The type of consent (e.g. a consent to perform the related ServiceEvent, a consent for the information contained in the document to be released to a third party) is conveyed in Consent.code. Consents referenced in the CDA Header have been finalized (Consent.statusCode must equal 'completed') and should be on file.
min:
  v: 0
max:
  v: *
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Authorization
    l: Authorization

id:
  v: ClinicalDocument.componentOf
path:
  v: ClinicalDocument.componentOf
short:
  v: Setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred.
definition:
  v: This optional class represents the setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note.
comment:
  v: In some cases, the setting of the encounter is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is 'Diabetes Clinic Progress Note'. The setting of an encounter can also be transmitted in the HealthCareFacility.code attribute. If HealthCareFacility.code is sent, it should be equivalent to or further specialize the value inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply 'Clinic Progress Note' and the value of HealthCareFacility.code is 'cardiology clinic'), and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
    l: ComponentOf

id:
  v: ClinicalDocument.component
path:
  v: ClinicalDocument.component
short:
  v: Body of the document
min:
  v: 1
max:
  v: 1
type:
  code:
    v: http://hl7.org/cda/stds/core/StructureDefinition/Component
    l: Component