Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Care Plan

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/CarePlan Version: 3.0.0-ballot
Active as of 2023-12-21 Computable Name: CarePlan
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2024-05-01

CARE PLAN FRAMEWORK

A Care Plan is a consensus-driven dynamic plan that represents a patient’s and Care Team Member’s prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patient’ss care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.

A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patients life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care.

The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic.

Key differentiators between a Care Plan CDA and CCD (another snapshot in time document): There are 2 required sections:

  • Health Concerns
  • Activities

There are 2 optional sections:

  • Goals
  • Outcomes Provides the ability to identify patient and provider priorities with each act Provides a header participant to indicate occurrences of Care Plan review

A care plan document can include entry references from the information in these sections to the information (entries) in other sections.

Usage:

  • This Logical Model 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 USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
should-informationRecipient: SHOULD contain informationRecipient
should-componentOf: SHOULD contain componentOf
... templateId 2..*II
... templateId:care-plan 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
.... @extension 1..1stRequired Pattern: 2024-05-01
... code 1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
.... @code 1..1csBinding: Care Plan Document Type (required)
... versionNumber 0..1INT
... informationRecipient
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
should-informationRecipient: SHOULD contain informationRecipient
should-receivedOrganization: SHOULD contain receivedOrganization
..... id 1..*II
..... addr 0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... name 1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... receivedOrganization C0..1Organizationshould-id: SHOULD contain id
should-standardIndustryClassCode: SHOULD contain standardIndustryClassCode
...... id 0..*II
...... standardIndustryClassCode 0..1CEBinding: Healthcare Provider Taxonomy (required)
... authenticator
.... time 1..1USRealmDateTimeBase for all types and resources
.... signatureCode 1..1CS
.... sdtcSignatureText 0..1EDThe prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the signatureText element
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... code 1..1CE
...... @code 1..1csRequired Pattern: ONESELF
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.111
... Slices for participant 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csFixed Value: VRF
..... functionCode 1..1CE
...... @code 1..1csRequired Pattern: 425268008
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... time 1..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
...... @classCode 1..1csFixed Value: ASSIGNED
...... id 1..*II
...... code 0..1CE
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
.... participant:participant2 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csFixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*PN
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent.classCode
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent 1..1ServiceEventThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
...... @classCode 1..1csFixed Value: PCPR
...... effectiveTime 1..1USRealmDateTimeIntervalBase for all types and resources
....... low 1..1IVXB_TS**MAY** be precise to at least the second
....... high 0..1IVXB_TS**MAY** be precise to at least the second
...... performer 1..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... assignedEntity 1..1AssignedEntity
........ id 1..*II
........ code 0..1CE
........ assignedPerson 1..1Person
......... name 1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by exists:parentDocument
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... @typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... id 1..*II
...... setId 1..1II
...... versionNumber 1..1INT
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter 1..1EncompassingEncounter
..... effectiveTime 1..1USRealmDateTimeIntervalBase for all types and resources
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
should-section-healthstatus: SHOULD contain a Health Status Evaluations and Outcomes Section
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:component1 1..1InfrastructureRoot
....... section 1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... section 1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.code.coderequiredCarePlanDocumentType
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCoderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredX_ActRelationshipDocument

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
should-addrwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain addr
: addr.exists()
should-codewarningClinicalDocument.participant:participant1.associatedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-idwarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain id
: id.exists()
should-informationRecipientwarningClinicalDocument, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain informationRecipient
: informationRecipient.exists()
should-receivedOrganizationwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain receivedOrganization
: receivedOrganization.exists()
should-section-healthstatuswarningClinicalDocument.component.structuredBodySHOULD contain a Health Status Evaluations and Outcomes Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection'))
should-setIdwarningClinicalDocumentSHOULD contain setId
: setId.exists()
should-standardIndustryClassCodewarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain standardIndustryClassCode
: standardIndustryClassCode.exists()
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-versionNumberwarningClinicalDocumentSHOULD contain versionNumber
: versionNumber.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
should-informationRecipient: SHOULD contain informationRecipient
should-componentOf: SHOULD contain componentOf
... realmCode 1..1CS
.... @code 1..1csRequired Pattern: US
... typeId 1..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:care-plan 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1csBinding: Care Plan Document Type (required)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
... languageCode 1..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... recordTarget 1..*RecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patient
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1AssignedEntity
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... addr C1..*USRealmAddressBase for all types and resources
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.

There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganization
...... id 1..*II
...... name 1..1ON
...... telecom C1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @typeCode 1..1csBinding: ParticipationType (required)
..... associatedEntity 1..1AssociatedEntity
.... participant:participant1 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: VRF
..... functionCode 1..1CE
...... @code 1..1csRequired Pattern: 425268008
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... time C1..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... code 0..1CEBinding: v3 Code System RoleCode (example)
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
.... participant:participant2 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*PN
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent.classCode
.... documentationOf:All Slices Content/Rules for all slices
..... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... @classCode 1..1csBinding: ActClass (required)
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... low C1..1IVXB_TS**MAY** be precise to at least the second
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent C1..1ServiceEventThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: PCPR
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... low C1..1IVXB_TS**MAY** be precise to at least the second
....... high C0..1IVXB_TS**MAY** be precise to at least the second
...... performer 1..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... assignedEntity C1..1AssignedEntity
........ id 1..*II
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ assignedPerson 1..1Person
......... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by exists:parentDocument
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... @typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... id 1..*II
...... setId 1..1II
...... versionNumber 1..1INT
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter C1..1EncompassingEncounter
..... id 1..*II
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
should-section-healthstatus: SHOULD contain a Health Status Evaluations and Outcomes Section
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... section C1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section C1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section C1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... section C1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... section C1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.coderequiredCarePlanDocumentType
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: VRF
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.participant:participant1.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant:participant2.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCoderequiredFixed Value: PCPR
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredX_ActRelationshipDocument

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
: typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33')
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
: (assignedPerson | assignedAuthoringDevice).count() = 1
4537-21000errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
: sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true')
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32993errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
: sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists()
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
: item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty()
81-10024errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrIf the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
ivl-ts-centererrorClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty()
shall-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:component5.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-goal-obserrorClinicalDocument.component.structuredBody.component:component2.sectionSHALL contain at least one Goal Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/GoalObservation'))
shall-health-concern-acterrorClinicalDocument.component.structuredBody.component:component1.sectionSHALL contain at least one Health Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL have at most one of each: state, city, postalCode, and country
: (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1)
shall-max-suffixerrorClinicalDocument.recordTarget.patientRole.patient.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-outcome-obserrorClinicalDocument.component.structuredBody.component:component4.sectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.participant:participant1.associatedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-health-status-obswarningClinicalDocument.component.structuredBody.component:component1.sectionSHOULD contain Health Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation'))
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-informationRecipientwarningClinicalDocumentSHOULD contain informationRecipient
: informationRecipient.exists()
should-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InterventionAct'))
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-planned-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Planned Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlannedInterventionAct'))
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-responsiblePartywarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain responsibleParty
: responsibleParty.exists()
should-section-healthstatuswarningClinicalDocument.component.structuredBodySHOULD contain a Health Status Evaluations and Outcomes Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection'))
should-setIdwarningClinicalDocumentSHOULD contain setId
: setId.exists()
should-us-codewarningClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEvent, ClinicalDocument.documentationOf:documentationOf1.serviceEventSHOULD contain performer
: performer.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-versionNumberwarningClinicalDocumentSHOULD contain versionNumber
: versionNumber.exists()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
should-informationRecipient: SHOULD contain informationRecipient
should-componentOf: SHOULD contain componentOf
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CS
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: US
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..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
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:care-plan 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
..... @extension 1..1stRequired Pattern: 2024-05-01
... id 1..1II**SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csBinding: Care Plan Document Type (required)
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... languageCode 1..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... patientRole 1..1PatientRole
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patient
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... sdtcDeceasedInd 0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C0..1TSXML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... sdtcRaceCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (required)
...... guardian C0..*Guardian
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressBase for all types and resources
....... telecom C0..*TEL
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1url
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
........ sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... 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..1st
......... templateId 0..*II
......... @classCode 1..1csFixed Value: PRS
......... @determinerCode 0..1csFixed Value: INSTANCE
......... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... place 1..1Place
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name 0..1EN
........ addr C1..1AD
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @isNotOrdered 0..1bl
......... @use 0..*csBinding: CDAPostalAddressUse (required)
......... item C0..*BaseChoice Group: This is a repeating choice group that does not appear directly in the instance
.......... (Choice of one) 1..1
........... delimiter C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DEL
........... country C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CNT
........... state C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STA
........... county C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CPA
........... city C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CTY
........... postalCode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ZIP
........... streetAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: SAL
........... houseNumber C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNR
........... houseNumberNumeric C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNN
........... direction C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DIR
........... streetName C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STR
........... streetNameBase C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STB
........... streetNameType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STTYP
........... additionalLocator C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ADL
........... unitID C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNID
........... unitType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNIT
........... careOf C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CAR
........... censusTract C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CEN
........... deliveryAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DAL
........... deliveryInstallationType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINST
........... deliveryInstallationArea C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTA
........... deliveryInstallationQualifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTQ
........... deliveryMode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMOD
........... deliveryModeIdentifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMODID
........... buildingNumberSuffix C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNS
........... postBox C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: POB
........... precinct C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: PRE
........... xmlText 0..1stAllows for mixed text content
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication C0..*LanguageCommunication
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... languageCode 1..1CSBinding: AllLanguages (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..*ON
...... telecom C1..*TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... functionCode 0..1CE
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @nullFlavor 0..1csIf NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEOnly if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: v3 Code System RoleCode (example)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... assignedAuthoringDevice 0..1AuthoringDevice
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassDevice (required)
Fixed Value: DEV
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 0..1CEBinding: EntityCode (example)
....... manufacturerModelName 1..1SCBinding: Manufacturer Model Name Example (example)
....... softwareName 1..1SCBinding: Software Name Example (example)
....... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: ENT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C0..1USRealmDateTimeBase for all types and resources
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... assignedEntity 1..1AssignedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr C1..*USRealmAddressBase for all types and resources
...... telecom 0..*TEL
...... assignedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... representedOrganization 0..1Organization
...... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
....... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.&#10;&#10;There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: CST
.... assignedCustodian 1..1AssignedCustodian
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1CustodianOrganization
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..1ON
...... telecom C1..1TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
should-informationRecipient: SHOULD contain informationRecipient
should-receivedOrganization: SHOULD contain receivedOrganization
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 1..1cs
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... receivedOrganization C0..1Organizationshould-id: SHOULD contain id
should-standardIndustryClassCode: SHOULD contain standardIndustryClassCode
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorThe legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: LA
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 0..1oid, uuid, ruidMAY contain '2.16.840.1.113883.4.6' (NPI)
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTHEN
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the signatureText element
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 1..1CEBinding: v3 Code System RoleCode (example)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
Required Pattern: ONESELF
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.111
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
.... participant:participant1 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: VRF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 1..1CE
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csRequired Pattern: 425268008
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... time C1..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 0..1Person
...... scopingOrganization 0..1Organization
.... participant:participant2 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name 1..*PN
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1Order
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMoodIntent (required)
Fixed Value: RQO
..... id 1..*II
..... code 0..1CEBinding: v3 Code System ActCode (example)
..... priorityCode 0..1CEBinding: ActPriority (example)
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent.classCode
.... documentationOf:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
..... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: ActClass (required)
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... id 0..*II
...... code 0..1CE
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @operator 0..1csBinding: SetOperator (required)
....... low C1..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
....... center 0..1TS
....... width 0..1PQ
....... high C0..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
...... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... functionCode C0..1CE
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @code 0..1csBinding: Care Team Member Function (preferred)
........ @codeSystem 0..1oid, uuid, ruid
........ @codeSystemName 0..1st
........ @codeSystemVersion 0..1st
........ @displayName 0..1st
........ @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
........ @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time C0..1USRealmDateTimeIntervalBase for all types and resources
....... assignedEntity C1..1AssignedEntity
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ id 1..*II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root C0..1oid, uuid, ruid
......... @extension 0..1st
........ sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
........ sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
......... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... documentationOf:documentationOf1 1..1DocumentationOf
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
..... serviceEvent C1..1ServiceEventThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: PCPR
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... id 0..*II
...... code 0..1CE
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @operator 0..1csBinding: SetOperator (required)
....... low C1..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
....... center 0..1TS
....... width 0..1PQ
....... high C0..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
...... performer 1..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... functionCode C0..1CE
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @code 0..1csBinding: Care Team Member Function (preferred)
........ @codeSystem 0..1oid, uuid, ruid
........ @codeSystemName 0..1st
........ @codeSystemVersion 0..1st
........ @displayName 0..1st
........ @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
........ @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time C0..1USRealmDateTimeIntervalBase for all types and resources
....... assignedEntity C1..1AssignedEntity
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ id 1..*II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root C0..1oid, uuid, ruid
......... @extension 0..1st
........ sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 1..1Person
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... 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..1st
......... templateId 0..*II
......... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
......... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
......... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
......... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
......... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
.......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.......... 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..1st
.......... templateId 0..*II
.......... @classCode 1..1csFixed Value: PRS
.......... @determinerCode 0..1csFixed Value: INSTANCE
.......... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
........ representedOrganization 0..1Organization
........ sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
......... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by exists:parentDocument
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: ActClassClinicalDocument (required)
Fixed Value: DOCCLIN
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... id 1..*II
...... code 0..1CDBinding: FHIRDocumentTypeCodes (example)
...... text 0..1ED
...... setId 1..1II
...... versionNumber 1..1INT
... authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1CSBinding: ActStatus (required)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csFixed Value: completed
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C1..1EncompassingEncounter
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: ENC
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 1..*II
..... code 0..1CEBinding: Act Encounter Codes (preferred)
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
..... sdtcAdmissionReferralSourceCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity C1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... nonXMLBody 0..1NonXMLBody
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
should-section-healthstatus: SHOULD contain a Health Status Evaluations and Outcomes Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.nullFlavorrequiredCDANullFlavor
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.realmCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.templateId:us-realm.nullFlavorrequiredCDANullFlavor
ClinicalDocument.templateId:care-plan.nullFlavorrequiredCDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.code.coderequiredCarePlanDocumentType
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
ClinicalDocument.recordTarget.patientRole.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.userequiredCDAPostalAddressUse
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
ClinicalDocument.author.assignedAuthor.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.codeexampleRoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeexampleEntityCode
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelNameexampleManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareNameexampleSoftwareNameExample
ClinicalDocument.dataEnterer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:provider.contextControlCoderequiredFixed Value: OP
ClinicalDocument.informant:provider.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:non-provider.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:non-provider.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:non-provider.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:non-provider.contextControlCoderequiredFixed Value: OP
ClinicalDocument.custodian.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: CST
ClinicalDocument.custodian.assignedCustodian.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.informationRecipient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredXInformationRecipient
ClinicalDocument.informationRecipient.intendedRecipient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCoderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.typeCoderequiredFixed Value: AUTHEN
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.authenticator.signatureCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.codeexampleRoleCode
ClinicalDocument.authenticator.assignedEntity.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.code.codepreferredPattern: ONESELF
ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: VRF
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant1.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.participant:participant1.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant:participant2.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:participant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant2.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:participant2.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeexampleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeexampleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operatorrequiredSetOperator
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf:documentationOf1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCoderequiredFixed Value: PCPR
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.operatorrequiredSetOperator
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredX_ActRelationshipDocument
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.classCoderequiredFixed Value: DOCCLIN
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.authorization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUTH
ClinicalDocument.authorization.consent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.consent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization.consent.codeexampleActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
ClinicalDocument.authorization.consent.statusCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: COMP
ClinicalDocument.componentOf.encompassingEncounter.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeexampleUSEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
ClinicalDocument.component.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: COMP
ClinicalDocument.component.structuredBody.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
ClinicalDocument.component.structuredBody.languageCoderequiredAllLanguages
ClinicalDocument.component.structuredBody.component.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component2.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component2.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component3.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component3.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component4.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component4.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component5.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component5.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
1198-32905errorClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntityThis assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
: assignedPerson.exists() or representedOrganization.exists()
4537-5402errorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
4537-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.empty() or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
: typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33')
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
: (assignedPerson | assignedAuthoringDevice).count() = 1
4537-21000errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
: sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true')
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32993errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
: sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists()
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
: item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty()
81-10024errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
AD-1errorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.itemCan only have only one of the possible item elements in each choice
: (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1
ivl-ts-centererrorClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.participant:participant2.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.participant:participant2.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.participant:participant2.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty()
shall-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:component5.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-goal-obserrorClinicalDocument.component.structuredBody.component:component2.sectionSHALL contain at least one Goal Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/GoalObservation'))
shall-health-concern-acterrorClinicalDocument.component.structuredBody.component:component1.sectionSHALL contain at least one Health Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL have at most one of each: state, city, postalCode, and country
: (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1)
shall-max-suffixerrorClinicalDocument.recordTarget.patientRole.patient.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-outcome-obserrorClinicalDocument.component.structuredBody.component:component4.sectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-addrwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain addr
: addr.exists()
should-codewarningClinicalDocument.participant:participant1.associatedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-health-status-obswarningClinicalDocument.component.structuredBody.component:component1.sectionSHOULD contain Health Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation'))
should-idwarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-informationRecipientwarningClinicalDocument, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain informationRecipient
: informationRecipient.exists()
should-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InterventionAct'))
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-npiwarningClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-planned-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Planned Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlannedInterventionAct'))
should-preferenceIndwarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain preferenceInd
: preferenceInd.exists()
should-proficiencyLevelCodewarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain proficiencyLevelCode
: proficiencyLevelCode.exists()
should-receivedOrganizationwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain receivedOrganization
: receivedOrganization.exists()
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-responsiblePartywarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain responsibleParty
: responsibleParty.exists()
should-section-healthstatuswarningClinicalDocument.component.structuredBodySHOULD contain a Health Status Evaluations and Outcomes Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection'))
should-setIdwarningClinicalDocumentSHOULD contain setId
: setId.exists()
should-standardIndustryClassCodewarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain standardIndustryClassCode
: standardIndustryClassCode.exists()
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEvent, ClinicalDocument.documentationOf:documentationOf1.serviceEventSHOULD contain performer
: performer.exists()
should-us-telecomwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain telecom
: telecom.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
should-versionNumberwarningClinicalDocumentSHOULD contain versionNumber
: versionNumber.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
text-nullerrorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinctxmlText and nullFlavor are mutually exclusive (one must be present)
: (xmlText | nullFlavor).count() = 1
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10

This structure is derived from USRealmHeader

Summary

Mandatory: 13 elements (13 nested mandatory elements)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.participant is sliced based on the value of value:typeCode
  • The element ClinicalDocument.documentationOf is sliced based on the value of value:serviceEvent.classCode
  • The element ClinicalDocument.relatedDocument is sliced based on the value of exists:parentDocument
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of profile:section

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
should-informationRecipient: SHOULD contain informationRecipient
should-componentOf: SHOULD contain componentOf
... templateId 2..*II
... templateId:care-plan 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
.... @extension 1..1stRequired Pattern: 2024-05-01
... code 1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
.... @code 1..1csBinding: Care Plan Document Type (required)
... versionNumber 0..1INT
... informationRecipient
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
should-informationRecipient: SHOULD contain informationRecipient
should-receivedOrganization: SHOULD contain receivedOrganization
..... id 1..*II
..... addr 0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... name 1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... receivedOrganization C0..1Organizationshould-id: SHOULD contain id
should-standardIndustryClassCode: SHOULD contain standardIndustryClassCode
...... id 0..*II
...... standardIndustryClassCode 0..1CEBinding: Healthcare Provider Taxonomy (required)
... authenticator
.... time 1..1USRealmDateTimeBase for all types and resources
.... signatureCode 1..1CS
.... sdtcSignatureText 0..1EDThe prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the signatureText element
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... code 1..1CE
...... @code 1..1csRequired Pattern: ONESELF
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.111
... Slices for participant 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csFixed Value: VRF
..... functionCode 1..1CE
...... @code 1..1csRequired Pattern: 425268008
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... time 1..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
...... @classCode 1..1csFixed Value: ASSIGNED
...... id 1..*II
...... code 0..1CE
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
.... participant:participant2 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csFixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*PN
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent.classCode
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent 1..1ServiceEventThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
...... @classCode 1..1csFixed Value: PCPR
...... effectiveTime 1..1USRealmDateTimeIntervalBase for all types and resources
....... low 1..1IVXB_TS**MAY** be precise to at least the second
....... high 0..1IVXB_TS**MAY** be precise to at least the second
...... performer 1..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... assignedEntity 1..1AssignedEntity
........ id 1..*II
........ code 0..1CE
........ assignedPerson 1..1Person
......... name 1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by exists:parentDocument
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... @typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... id 1..*II
...... setId 1..1II
...... versionNumber 1..1INT
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter 1..1EncompassingEncounter
..... effectiveTime 1..1USRealmDateTimeIntervalBase for all types and resources
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
should-section-healthstatus: SHOULD contain a Health Status Evaluations and Outcomes Section
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:component1 1..1InfrastructureRoot
....... section 1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... section 1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.code.coderequiredCarePlanDocumentType
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCoderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredX_ActRelationshipDocument

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
should-addrwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain addr
: addr.exists()
should-codewarningClinicalDocument.participant:participant1.associatedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-idwarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain id
: id.exists()
should-informationRecipientwarningClinicalDocument, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain informationRecipient
: informationRecipient.exists()
should-receivedOrganizationwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain receivedOrganization
: receivedOrganization.exists()
should-section-healthstatuswarningClinicalDocument.component.structuredBodySHOULD contain a Health Status Evaluations and Outcomes Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection'))
should-setIdwarningClinicalDocumentSHOULD contain setId
: setId.exists()
should-standardIndustryClassCodewarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain standardIndustryClassCode
: standardIndustryClassCode.exists()
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-versionNumberwarningClinicalDocumentSHOULD contain versionNumber
: versionNumber.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
should-informationRecipient: SHOULD contain informationRecipient
should-componentOf: SHOULD contain componentOf
... realmCode 1..1CS
.... @code 1..1csRequired Pattern: US
... typeId 1..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:care-plan 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1csBinding: Care Plan Document Type (required)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
... languageCode 1..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... recordTarget 1..*RecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patient
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1AssignedEntity
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... addr C1..*USRealmAddressBase for all types and resources
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.&#10;&#10;There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganization
...... id 1..*II
...... name 1..1ON
...... telecom C1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @typeCode 1..1csBinding: ParticipationType (required)
..... associatedEntity 1..1AssociatedEntity
.... participant:participant1 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: VRF
..... functionCode 1..1CE
...... @code 1..1csRequired Pattern: 425268008
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... time C1..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... code 0..1CEBinding: v3 Code System RoleCode (example)
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
.... participant:participant2 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*PN
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent.classCode
.... documentationOf:All Slices Content/Rules for all slices
..... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... @classCode 1..1csBinding: ActClass (required)
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... low C1..1IVXB_TS**MAY** be precise to at least the second
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent C1..1ServiceEventThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: PCPR
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... low C1..1IVXB_TS**MAY** be precise to at least the second
....... high C0..1IVXB_TS**MAY** be precise to at least the second
...... performer 1..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... assignedEntity C1..1AssignedEntity
........ id 1..*II
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ assignedPerson 1..1Person
......... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by exists:parentDocument
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... @typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... id 1..*II
...... setId 1..1II
...... versionNumber 1..1INT
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter C1..1EncompassingEncounter
..... id 1..*II
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
should-section-healthstatus: SHOULD contain a Health Status Evaluations and Outcomes Section
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... section C1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section C1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section C1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... section C1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... section C1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.coderequiredCarePlanDocumentType
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: VRF
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.participant:participant1.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant:participant2.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCoderequiredFixed Value: PCPR
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredX_ActRelationshipDocument

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
: typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33')
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
: (assignedPerson | assignedAuthoringDevice).count() = 1
4537-21000errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
: sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true')
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32993errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
: sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists()
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
: item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty()
81-10024errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrIf the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
ivl-ts-centererrorClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty()
shall-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:component5.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-goal-obserrorClinicalDocument.component.structuredBody.component:component2.sectionSHALL contain at least one Goal Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/GoalObservation'))
shall-health-concern-acterrorClinicalDocument.component.structuredBody.component:component1.sectionSHALL contain at least one Health Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL have at most one of each: state, city, postalCode, and country
: (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1)
shall-max-suffixerrorClinicalDocument.recordTarget.patientRole.patient.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-outcome-obserrorClinicalDocument.component.structuredBody.component:component4.sectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.participant:participant1.associatedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-health-status-obswarningClinicalDocument.component.structuredBody.component:component1.sectionSHOULD contain Health Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation'))
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-informationRecipientwarningClinicalDocumentSHOULD contain informationRecipient
: informationRecipient.exists()
should-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InterventionAct'))
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-planned-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Planned Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlannedInterventionAct'))
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-responsiblePartywarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain responsibleParty
: responsibleParty.exists()
should-section-healthstatuswarningClinicalDocument.component.structuredBodySHOULD contain a Health Status Evaluations and Outcomes Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection'))
should-setIdwarningClinicalDocumentSHOULD contain setId
: setId.exists()
should-us-codewarningClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEvent, ClinicalDocument.documentationOf:documentationOf1.serviceEventSHOULD contain performer
: performer.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-versionNumberwarningClinicalDocumentSHOULD contain versionNumber
: versionNumber.exists()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
should-informationRecipient: SHOULD contain informationRecipient
should-componentOf: SHOULD contain componentOf
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CS
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: US
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..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
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:care-plan 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
..... @extension 1..1stRequired Pattern: 2024-05-01
... id 1..1II**SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csBinding: Care Plan Document Type (required)
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... languageCode 1..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... patientRole 1..1PatientRole
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patient
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... sdtcDeceasedInd 0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C0..1TSXML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... sdtcRaceCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (required)
...... guardian C0..*Guardian
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressBase for all types and resources
....... telecom C0..*TEL
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1url
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
........ sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... 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..1st
......... templateId 0..*II
......... @classCode 1..1csFixed Value: PRS
......... @determinerCode 0..1csFixed Value: INSTANCE
......... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... place 1..1Place
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name 0..1EN
........ addr C1..1AD
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @isNotOrdered 0..1bl
......... @use 0..*csBinding: CDAPostalAddressUse (required)
......... item C0..*BaseChoice Group: This is a repeating choice group that does not appear directly in the instance
.......... (Choice of one) 1..1
........... delimiter C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DEL
........... country C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CNT
........... state C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STA
........... county C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CPA
........... city C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CTY
........... postalCode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ZIP
........... streetAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: SAL
........... houseNumber C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNR
........... houseNumberNumeric C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNN
........... direction C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DIR
........... streetName C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STR
........... streetNameBase C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STB
........... streetNameType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STTYP
........... additionalLocator C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ADL
........... unitID C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNID
........... unitType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNIT
........... careOf C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CAR
........... censusTract C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CEN
........... deliveryAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DAL
........... deliveryInstallationType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINST
........... deliveryInstallationArea C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTA
........... deliveryInstallationQualifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTQ
........... deliveryMode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMOD
........... deliveryModeIdentifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMODID
........... buildingNumberSuffix C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNS
........... postBox C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: POB
........... precinct C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: PRE
........... xmlText 0..1stAllows for mixed text content
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication C0..*LanguageCommunication
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... languageCode 1..1CSBinding: AllLanguages (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..*ON
...... telecom C1..*TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... functionCode 0..1CE
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @nullFlavor 0..1csIf NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEOnly if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: v3 Code System RoleCode (example)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... assignedAuthoringDevice 0..1AuthoringDevice
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassDevice (required)
Fixed Value: DEV
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 0..1CEBinding: EntityCode (example)
....... manufacturerModelName 1..1SCBinding: Manufacturer Model Name Example (example)
....... softwareName 1..1SCBinding: Software Name Example (example)
....... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: ENT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C0..1USRealmDateTimeBase for all types and resources
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... assignedEntity 1..1AssignedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr C1..*USRealmAddressBase for all types and resources
...... telecom 0..*TEL
...... assignedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... representedOrganization 0..1Organization
...... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
....... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... relatedEntity 1..1RelatedEntity
... custodian 1..1CustodianThe custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.&#10;&#10;There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: CST
.... assignedCustodian 1..1AssignedCustodian
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1CustodianOrganization
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..1ON
...... telecom C1..1TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
should-informationRecipient: SHOULD contain informationRecipient
should-receivedOrganization: SHOULD contain receivedOrganization
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 1..1cs
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... receivedOrganization C0..1Organizationshould-id: SHOULD contain id
should-standardIndustryClassCode: SHOULD contain standardIndustryClassCode
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorThe legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: LA
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 0..1oid, uuid, ruidMAY contain '2.16.840.1.113883.4.6' (NPI)
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTHEN
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the signatureText element
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 1..1CEBinding: v3 Code System RoleCode (example)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
Required Pattern: ONESELF
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.111
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
.... participant:participant1 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: VRF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 1..1CE
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csRequired Pattern: 425268008
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... time C1..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 0..1Person
...... scopingOrganization 0..1Organization
.... participant:participant2 C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name 1..*PN
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1Order
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMoodIntent (required)
Fixed Value: RQO
..... id 1..*II
..... code 0..1CEBinding: v3 Code System ActCode (example)
..... priorityCode 0..1CEBinding: ActPriority (example)
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent.classCode
.... documentationOf:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
..... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: ActClass (required)
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... id 0..*II
...... code 0..1CE
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @operator 0..1csBinding: SetOperator (required)
....... low C1..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
....... center 0..1TS
....... width 0..1PQ
....... high C0..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
...... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... functionCode C0..1CE
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @code 0..1csBinding: Care Team Member Function (preferred)
........ @codeSystem 0..1oid, uuid, ruid
........ @codeSystemName 0..1st
........ @codeSystemVersion 0..1st
........ @displayName 0..1st
........ @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
........ @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time C0..1USRealmDateTimeIntervalBase for all types and resources
....... assignedEntity C1..1AssignedEntity
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ id 1..*II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root C0..1oid, uuid, ruid
......... @extension 0..1st
........ sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
........ sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
......... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... documentationOf:documentationOf1 1..1DocumentationOf
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
..... serviceEvent C1..1ServiceEventThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: PCPR
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... id 0..*II
...... code 0..1CE
...... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @operator 0..1csBinding: SetOperator (required)
....... low C1..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
....... center 0..1TS
....... width 0..1PQ
....... high C0..1IVXB_TS**MAY** be precise to at least the second
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
...... performer 1..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... functionCode C0..1CE
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @code 0..1csBinding: Care Team Member Function (preferred)
........ @codeSystem 0..1oid, uuid, ruid
........ @codeSystemName 0..1st
........ @codeSystemVersion 0..1st
........ @displayName 0..1st
........ @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
........ @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time C0..1USRealmDateTimeIntervalBase for all types and resources
....... assignedEntity C1..1AssignedEntity
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ 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..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ id 1..*II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root C0..1oid, uuid, ruid
......... @extension 0..1st
........ sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 1..1Person
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... 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..1st
......... templateId 0..*II
......... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
......... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
......... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
......... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
......... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
.......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.......... 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..1st
.......... templateId 0..*II
.......... @classCode 1..1csFixed Value: PRS
.......... @determinerCode 0..1csFixed Value: INSTANCE
.......... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
........ representedOrganization 0..1Organization
........ sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
......... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by exists:parentDocument
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: ActClassClinicalDocument (required)
Fixed Value: DOCCLIN
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... id 1..*II
...... code 0..1CDBinding: FHIRDocumentTypeCodes (example)
...... text 0..1ED
...... setId 1..1II
...... versionNumber 1..1INT
... authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1CSBinding: ActStatus (required)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csFixed Value: completed
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C1..1EncompassingEncounter
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: ENC
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 1..*II
..... code 0..1CEBinding: Act Encounter Codes (preferred)
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
..... sdtcAdmissionReferralSourceCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity C1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... 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..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... 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..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... nonXMLBody 0..1NonXMLBody
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
should-section-healthstatus: SHOULD contain a Health Status Evaluations and Outcomes Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... 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..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... 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..1st
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section C1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.nullFlavorrequiredCDANullFlavor
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.realmCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.templateId:us-realm.nullFlavorrequiredCDANullFlavor
ClinicalDocument.templateId:care-plan.nullFlavorrequiredCDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.code.coderequiredCarePlanDocumentType
ClinicalDocument.sdtcStatusCoderequiredActStatus
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
ClinicalDocument.recordTarget.patientRole.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.userequiredCDAPostalAddressUse
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
ClinicalDocument.author.assignedAuthor.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.codeexampleRoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeexampleEntityCode
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelNameexampleManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareNameexampleSoftwareNameExample
ClinicalDocument.dataEnterer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:provider.contextControlCoderequiredFixed Value: OP
ClinicalDocument.informant:provider.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:non-provider.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:non-provider.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informant:non-provider.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:non-provider.contextControlCoderequiredFixed Value: OP
ClinicalDocument.custodian.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: CST
ClinicalDocument.custodian.assignedCustodian.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.informationRecipient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredXInformationRecipient
ClinicalDocument.informationRecipient.intendedRecipient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCoderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.typeCoderequiredFixed Value: AUTHEN
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.authenticator.signatureCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.codeexampleRoleCode
ClinicalDocument.authenticator.assignedEntity.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.code.codepreferredPattern: ONESELF
ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: VRF
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant1.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.participant:participant1.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant:participant2.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:participant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant2.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:participant2.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeexampleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeexampleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operatorrequiredSetOperator
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf:documentationOf1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCoderequiredFixed Value: PCPR
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.operatorrequiredSetOperator
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredX_ActRelationshipDocument
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.classCoderequiredFixed Value: DOCCLIN
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.authorization.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUTH
ClinicalDocument.authorization.consent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.consent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization.consent.codeexampleActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
ClinicalDocument.authorization.consent.statusCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: COMP
ClinicalDocument.componentOf.encompassingEncounter.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeexampleUSEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
ClinicalDocument.component.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: COMP
ClinicalDocument.component.structuredBody.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
ClinicalDocument.component.structuredBody.languageCoderequiredAllLanguages
ClinicalDocument.component.structuredBody.component.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component2.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component2.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component3.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component3.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component4.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component4.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component5.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component5.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
1198-32905errorClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntityThis assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
: assignedPerson.exists() or representedOrganization.exists()
4537-5402errorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
4537-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.empty() or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
: typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33')
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
: (assignedPerson | assignedAuthoringDevice).count() = 1
4537-21000errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
: sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true')
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32993errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
: sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists()
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
: item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty()
81-10024errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
AD-1errorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.itemCan only have only one of the possible item elements in each choice
: (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1
ivl-ts-centererrorClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.participant:participant2.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.participant:participant2.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.participant:participant2.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty()
shall-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:component5.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-goal-obserrorClinicalDocument.component.structuredBody.component:component2.sectionSHALL contain at least one Goal Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/GoalObservation'))
shall-health-concern-acterrorClinicalDocument.component.structuredBody.component:component1.sectionSHALL contain at least one Health Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL have at most one of each: state, city, postalCode, and country
: (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1)
shall-max-suffixerrorClinicalDocument.recordTarget.patientRole.patient.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-outcome-obserrorClinicalDocument.component.structuredBody.component:component4.sectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-addrwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain addr
: addr.exists()
should-codewarningClinicalDocument.participant:participant1.associatedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-health-status-obswarningClinicalDocument.component.structuredBody.component:component1.sectionSHOULD contain Health Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation'))
should-idwarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-informationRecipientwarningClinicalDocument, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain informationRecipient
: informationRecipient.exists()
should-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InterventionAct'))
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-npiwarningClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-planned-intervention-actwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Planned Intervention Act
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlannedInterventionAct'))
should-preferenceIndwarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain preferenceInd
: preferenceInd.exists()
should-proficiencyLevelCodewarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain proficiencyLevelCode
: proficiencyLevelCode.exists()
should-receivedOrganizationwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain receivedOrganization
: receivedOrganization.exists()
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-responsiblePartywarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain responsibleParty
: responsibleParty.exists()
should-section-healthstatuswarningClinicalDocument.component.structuredBodySHOULD contain a Health Status Evaluations and Outcomes Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection'))
should-setIdwarningClinicalDocumentSHOULD contain setId
: setId.exists()
should-standardIndustryClassCodewarningClinicalDocument.informationRecipient.intendedRecipient.receivedOrganizationSHOULD contain standardIndustryClassCode
: standardIndustryClassCode.exists()
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEvent, ClinicalDocument.documentationOf:documentationOf1.serviceEventSHOULD contain performer
: performer.exists()
should-us-telecomwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain telecom
: telecom.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
should-versionNumberwarningClinicalDocumentSHOULD contain versionNumber
: versionNumber.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
text-nullerrorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinctxmlText and nullFlavor are mutually exclusive (one must be present)
: (xmlText | nullFlavor).count() = 1
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10

This structure is derived from USRealmHeader

Summary

Mandatory: 13 elements (13 nested mandatory elements)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.participant is sliced based on the value of value:typeCode
  • The element ClinicalDocument.documentationOf is sliced based on the value of value:serviceEvent.classCode
  • The element ClinicalDocument.relatedDocument is sliced based on the value of exists:parentDocument
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of profile:section

 

Other representations of profile: CSV, Excel