Clinical Document Architecture V2.0.1
2.1.0-draft1 - 1st Draft

This page is part of the CDA: Clinical Document Architecture (v2.1.0-draft1: CDA 2.1 Draft) 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/fhir/cda/StructureDefinition/ClinicalDocument Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: CDAR2.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 Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1BaseXML Namespace: urn:hl7-org:v3
Base for all types and resources
... @classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... @moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 1..1II
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (extensible)
... title 0..1ED
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: HumanLanguage (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..1Component2

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
ClinicalDocument.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 1..1II
... templateId 0..*II
... code 1..1CEBinding: FHIRDocumentTypeCodes (extensible)
... title 0..1ED
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: HumanLanguage (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..1Component2

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
ClinicalDocument.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from Base

Summary

Mandatory: 0 element (11 nested mandatory elements)
Fixed Value: 2 elements

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1BaseXML Namespace: urn:hl7-org:v3
Base for all types and resources
... @classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... @moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 1..1II
... templateId 0..*II
... id 1..1II
... code 1..1CEBinding: FHIRDocumentTypeCodes (extensible)
... title 0..1ED
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: HumanLanguage (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..1Component2

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
ClinicalDocument.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... typeId 1..1II
... templateId 0..*II
... code 1..1CEBinding: FHIRDocumentTypeCodes (extensible)
... title 0..1ED
... effectiveTime 1..1TS
... confidentialityCode 1..1CE
... languageCode 0..1CSBinding: HumanLanguage (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..1Component2

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
ClinicalDocument.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

This structure is derived from Base

Summary

Mandatory: 0 element (11 nested mandatory elements)
Fixed Value: 2 elements

 

Other representations of profile: CSV, Excel