Clinical Document Architecture
2.0.0-sd-ballot - ballot

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

Logical Model: ClinicalDocument (CDA Class)

Official URL: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument Version: 2.0.0-sd-ballot
Active as of 2023-10-27 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

Usage:

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

Formal Views of Profile Content

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

This structure is derived from ANY

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1ANYXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 0..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (example)
... title 0..1ST
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
... author 1..*Author
... dataEnterer 0..1DataEnterer
... informant 0..*Informant
... custodian 1..1Custodian
... informationRecipient 0..*InformationRecipient
... legalAuthenticator 0..1LegalAuthenticator
... authenticator 0..*Authenticator
... participant 0..*Participant1
... inFulfillmentOf 0..*InFulfillmentOf
... documentationOf 0..*DocumentationOf
... relatedDocument 0..*RelatedDocument
... authorization 0..*Authorization
... componentOf 0..1ComponentOf
... component 1..1Component

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.languageCoderequiredAllLanguages
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1ANYXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 0..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (example)
... title 0..1ST
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
... author 1..*Author
... dataEnterer 0..1DataEnterer
... informant 0..*Informant
... custodian 1..1Custodian
... informationRecipient 0..*InformationRecipient
... legalAuthenticator 0..1LegalAuthenticator
... authenticator 0..*Authenticator
... participant 0..*Participant1
... inFulfillmentOf 0..*InFulfillmentOf
... documentationOf 0..*DocumentationOf
... relatedDocument 0..*RelatedDocument
... authorization 0..*Authorization
... componentOf 0..1ComponentOf
... component 1..1Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.languageCoderequiredAllLanguages
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1ANYXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor
Base for all types and resources
Instances of this type are validated by templateId
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (example)
... title 0..1ST
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
... author 1..*Author
... dataEnterer 0..1DataEnterer
... informant 0..*Informant
... custodian 1..1Custodian
... informationRecipient 0..*InformationRecipient
... legalAuthenticator 0..1LegalAuthenticator
... authenticator 0..*Authenticator
... participant 0..*Participant1
... inFulfillmentOf 0..*InFulfillmentOf
... documentationOf 0..*DocumentationOf
... relatedDocument 0..*RelatedDocument
... authorization 0..*Authorization
... componentOf 0..1ComponentOf
... component 1..1Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.nullFlavorrequiredCDANullFlavor
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.languageCoderequiredAllLanguages

This structure is derived from ANY

Summary

Mandatory: 0 element (10 nested mandatory elements)
Fixed Value: 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 & Constraintsdoco
.. ClinicalDocument 1..1ANYXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 0..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (example)
... title 0..1ST
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
... author 1..*Author
... dataEnterer 0..1DataEnterer
... informant 0..*Informant
... custodian 1..1Custodian
... informationRecipient 0..*InformationRecipient
... legalAuthenticator 0..1LegalAuthenticator
... authenticator 0..*Authenticator
... participant 0..*Participant1
... inFulfillmentOf 0..*InFulfillmentOf
... documentationOf 0..*DocumentationOf
... relatedDocument 0..*RelatedDocument
... authorization 0..*Authorization
... componentOf 0..1ComponentOf
... component 1..1Component

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.languageCoderequiredAllLanguages

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1ANYXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 0..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (example)
... title 0..1ST
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
... author 1..*Author
... dataEnterer 0..1DataEnterer
... informant 0..*Informant
... custodian 1..1Custodian
... informationRecipient 0..*InformationRecipient
... legalAuthenticator 0..1LegalAuthenticator
... authenticator 0..*Authenticator
... participant 0..*Participant1
... inFulfillmentOf 0..*InFulfillmentOf
... documentationOf 0..*DocumentationOf
... relatedDocument 0..*RelatedDocument
... authorization 0..*Authorization
... componentOf 0..1ComponentOf
... component 1..1Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.languageCoderequiredAllLanguages

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1ANYXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor
Base for all types and resources
Instances of this type are validated by templateId
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (example)
... title 0..1ST
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
... author 1..*Author
... dataEnterer 0..1DataEnterer
... informant 0..*Informant
... custodian 1..1Custodian
... informationRecipient 0..*InformationRecipient
... legalAuthenticator 0..1LegalAuthenticator
... authenticator 0..*Authenticator
... participant 0..*Participant1
... inFulfillmentOf 0..*InFulfillmentOf
... documentationOf 0..*DocumentationOf
... relatedDocument 0..*RelatedDocument
... authorization 0..*Authorization
... componentOf 0..1ComponentOf
... component 1..1Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.nullFlavorrequiredCDANullFlavor
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.languageCoderequiredAllLanguages

This structure is derived from ANY

Summary

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

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel