This page is part of the CDA: Clinical Document Architecture (v2.0.0-sd-ballot: CDA 2.0 Ballot 1) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions
Active as of 2023-10-27 |
Definitions for the ClinicalDocument logical model.
Guidance on how to interpret the contents of this table can be found here
0. ClinicalDocument | |
Control | 1..1 |
Validation | Instances of this type are validated by templateId |
XML Format | In the XML format, this property has the namespace urn:hl7-org:v3 . |
2. ClinicalDocument.classCode | |
Control | 0..1 |
Binding | For example codes, see ActClass |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | DOCCLIN |
4. ClinicalDocument.moodCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from ActMood |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | EVN |
6. ClinicalDocument.realmCode | |
Definition | When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
8. ClinicalDocument.typeId | |
Definition | ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
10. ClinicalDocument.typeId.root | |
Definition | Identifies the type as an HL7 Registered model |
Control | 1..1 |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | 2.16.840.1.113883.1.3 |
12. ClinicalDocument.typeId.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 1..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | POCD_HD000040 |
14. ClinicalDocument.templateId | |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
16. ClinicalDocument.id | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
18. ClinicalDocument.code | |
Control | 1..1 |
Binding | For example codes, see FHIRDocumentTypeCodes |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
20. ClinicalDocument.title | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ST |
22. ClinicalDocument.sdtcStatusCode | |
Definition | The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient. |
Control | 0..1 |
Binding | The codes SHALL be taken from ActStatus |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
XML Format | In the XML format, this property has the namespace urn:hl7-org:sdtc .In the XML format, this property has the actual namestatusCode . |
24. ClinicalDocument.effectiveTime | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/TS |
26. ClinicalDocument.confidentialityCode | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
28. ClinicalDocument.languageCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from AllLanguages |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
30. ClinicalDocument.setId | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
32. ClinicalDocument.versionNumber | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/INT |
34. ClinicalDocument.copyTime | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/TS |
36. ClinicalDocument.recordTarget | |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/RecordTarget |
38. ClinicalDocument.author | |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Author |
40. ClinicalDocument.dataEnterer | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/DataEnterer |
42. ClinicalDocument.informant | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Informant |
44. ClinicalDocument.custodian | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Custodian |
46. ClinicalDocument.informationRecipient | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient |
48. ClinicalDocument.legalAuthenticator | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator |
50. ClinicalDocument.authenticator | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Authenticator |
52. ClinicalDocument.participant | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Participant1 |
54. ClinicalDocument.inFulfillmentOf | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf |
56. ClinicalDocument.documentationOf | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf |
58. ClinicalDocument.relatedDocument | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument |
60. ClinicalDocument.authorization | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Authorization |
62. ClinicalDocument.componentOf | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ComponentOf |
64. ClinicalDocument.component | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Component |
Guidance on how to interpret the contents of this table can be found here
0. ClinicalDocument | |
Definition | Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type. Base definition for all types defined in FHIR type system. |
Short | Base for all types and resources |
Control | 10..1* |
Is Modifier | false |
Validation | Instances of this type are validated by templateId |
XML Format | In the XML format, this property has the namespace urn:hl7-org:v3 . |
2. ClinicalDocument.classCode | |
Control | 0..1 |
Binding | For example codes, see ActClass |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | DOCCLIN |
4. ClinicalDocument.moodCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from ActMood |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | EVN |
6. ClinicalDocument.realmCode | |
Definition | When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
8. ClinicalDocument.typeId | |
Definition | ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
10. ClinicalDocument.typeId.root | |
Definition | Identifies the type as an HL7 Registered model |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Root |
Fixed Value | 2.16.840.1.113883.1.3 |
12. ClinicalDocument.typeId.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 1..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Extension |
Fixed Value | POCD_HD000040 |
14. ClinicalDocument.templateId | |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
16. ClinicalDocument.id | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
18. ClinicalDocument.code | |
Control | 1..1 |
Binding | For example codes, see FHIRDocumentTypeCodes |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
20. ClinicalDocument.title | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ST |
22. ClinicalDocument.sdtcStatusCode | |
Definition | The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient. |
Control | 0..1 |
Binding | The codes SHALL be taken from ActStatus |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
XML Format | In the XML format, this property has the namespace urn:hl7-org:sdtc .In the XML format, this property has the actual namestatusCode . |
24. ClinicalDocument.effectiveTime | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/TS |
26. ClinicalDocument.confidentialityCode | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
28. ClinicalDocument.languageCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from AllLanguages |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
30. ClinicalDocument.setId | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
32. ClinicalDocument.versionNumber | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/INT |
34. ClinicalDocument.copyTime | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/TS |
36. ClinicalDocument.recordTarget | |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/RecordTarget |
38. ClinicalDocument.author | |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Author |
40. ClinicalDocument.dataEnterer | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/DataEnterer |
42. ClinicalDocument.informant | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Informant |
44. ClinicalDocument.custodian | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Custodian |
46. ClinicalDocument.informationRecipient | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient |
48. ClinicalDocument.legalAuthenticator | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator |
50. ClinicalDocument.authenticator | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Authenticator |
52. ClinicalDocument.participant | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Participant1 |
54. ClinicalDocument.inFulfillmentOf | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf |
56. ClinicalDocument.documentationOf | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf |
58. ClinicalDocument.relatedDocument | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument |
60. ClinicalDocument.authorization | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Authorization |
62. ClinicalDocument.componentOf | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ComponentOf |
64. ClinicalDocument.component | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Component |
Guidance on how to interpret the contents of this table can be found here
0. ClinicalDocument | |
Definition | Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type. |
Short | Base for all types and resources |
Control | 1..1 |
Is Modifier | false |
Validation | Instances of this type are validated by templateId |
XML Format | In the XML format, this property has the namespace urn:hl7-org:v3 . |
2. ClinicalDocument.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
4. ClinicalDocument.classCode | |
Control | 0..1 |
Binding | For example codes, see ActClass |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | DOCCLIN |
6. ClinicalDocument.moodCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from ActMood |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | EVN |
8. ClinicalDocument.realmCode | |
Definition | When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
10. ClinicalDocument.typeId | |
Definition | ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
12. ClinicalDocument.typeId.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
14. ClinicalDocument.typeId.assigningAuthorityName | |
Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Assigning Authority Name |
16. ClinicalDocument.typeId.displayable | |
Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
Control | 0..1 |
Type | boolean(bl: Boolean) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Displayable |
18. ClinicalDocument.typeId.root | |
Definition | Identifies the type as an HL7 Registered model |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Root |
Fixed Value | 2.16.840.1.113883.1.3 |
20. ClinicalDocument.typeId.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 1..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Extension |
Fixed Value | POCD_HD000040 |
22. ClinicalDocument.templateId | |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
24. ClinicalDocument.id | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
26. ClinicalDocument.code | |
Control | 1..1 |
Binding | For example codes, see FHIRDocumentTypeCodes |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
28. ClinicalDocument.title | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ST |
30. ClinicalDocument.sdtcStatusCode | |
Definition | The statusCode extension attribute allows the implementer to identify a ClinicalDocument that is in other than the completed state. It was created to support the Structured Form Definition IG to identify that the document itself is an unfinished product currently being completed for a patient. |
Control | 0..1 |
Binding | The codes SHALL be taken from ActStatus |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
XML Format | In the XML format, this property has the namespace urn:hl7-org:sdtc .In the XML format, this property has the actual namestatusCode . |
32. ClinicalDocument.effectiveTime | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/TS |
34. ClinicalDocument.confidentialityCode | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
36. ClinicalDocument.languageCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from AllLanguages |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
38. ClinicalDocument.setId | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
40. ClinicalDocument.versionNumber | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/INT |
42. ClinicalDocument.copyTime | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/TS |
44. ClinicalDocument.recordTarget | |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/RecordTarget |
46. ClinicalDocument.author | |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Author |
48. ClinicalDocument.dataEnterer | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/DataEnterer |
50. ClinicalDocument.informant | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Informant |
52. ClinicalDocument.custodian | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Custodian |
54. ClinicalDocument.informationRecipient | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient |
56. ClinicalDocument.legalAuthenticator | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator |
58. ClinicalDocument.authenticator | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Authenticator |
60. ClinicalDocument.participant | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Participant1 |
62. ClinicalDocument.inFulfillmentOf | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf |
64. ClinicalDocument.documentationOf | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf |
66. ClinicalDocument.relatedDocument | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument |
68. ClinicalDocument.authorization | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Authorization |
70. ClinicalDocument.componentOf | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ComponentOf |
72. ClinicalDocument.component | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Component |