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: Entry Reference

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/EntryReference Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: EntryReference
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.4.122

This template represents the act of referencing another entry in the same CDA document instance. Its purpose is to remove the need to repeat the complete XML representation of the referred entry when relating one entry to another. This template can be used to reference many types of Act class derivations, such as encounters, observations, procedures etc., as it is often necessary when authoring CDA documents to repeatedly reference other Acts of these types. For example, in a Care Plan it is necessary to repeatedly relate Health Concerns, Goals, Activities and Outcomes.

The id is required and must be the same id as the entry/id it is referencing. The id cannot be a null value. Act/Code is set to nullFlavor=”NP” (Not Present). This means the value is not present in the message (in act/Code).

Usage:

Formal Views of Profile Content

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

This structure is derived from Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:entry-reference 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.122
..... @extension 0..0
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
.... @nullFlavor 0..0
... code 1..1CD
.... @nullFlavor 1..1csFixed Value: NP
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CS
.... @code 0..1csMAY be set to "completed"

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:entry-reference 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.122
... @classCode 1..1csBinding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1csBinding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... code 1..1CDBinding: v3 Code System ActCode (example)
.... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NP
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 0..1csMAY be set to "completed"

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.classCoderequiredFixed Value: ACT
Act.moodCoderequiredFixed Value: EVN
Act.codeexampleActCode
Act.code.nullFlavorrequiredFixed Value: NP
Act.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @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:entry-reference 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.122
... @classCode 1..1csBinding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1csBinding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1bl
... id 1..*IIThe ID must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. The ID cannot have Null value (e.g., nullFlavor is not allowed).
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 0..1oid, uuid, ruid
.... @extension 0..1st
... code 1..1CDBinding: v3 Code System ActCode (example)
.... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NP
.... @code 0..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
.... qualifier 0..*CR
.... translation 0..*CD
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 0..1csMAY be set to "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)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.nullFlavorrequiredCDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
Act.templateId:entry-reference.nullFlavorrequiredCDANullFlavor
Act.classCoderequiredFixed Value: ACT
Act.moodCoderequiredFixed Value: EVN
Act.codeexampleActCode
Act.code.nullFlavorrequiredFixed Value: NP
Act.text.nullFlavorrequiredCDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Act.text.mediaTypeexampleMediaType
Act.text.representationrequiredBinaryDataEncoding
Act.statusCoderequiredActStatus
Act.statusCode.nullFlavorrequiredCDANullFlavor
Act.priorityCodeexampleActPriority
Act.languageCoderequiredAllLanguages

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Act

Summary

Mandatory: 6 elements
Fixed Value: 3 elements
Prohibited: 2 elements

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the value of value:root

Differential View

This structure is derived from Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:entry-reference 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.122
..... @extension 0..0
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
.... @nullFlavor 0..0
... code 1..1CD
.... @nullFlavor 1..1csFixed Value: NP
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CS
.... @code 0..1csMAY be set to "completed"

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:entry-reference 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.122
... @classCode 1..1csBinding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1csBinding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... code 1..1CDBinding: v3 Code System ActCode (example)
.... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NP
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 0..1csMAY be set to "completed"

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.classCoderequiredFixed Value: ACT
Act.moodCoderequiredFixed Value: EVN
Act.codeexampleActCode
Act.code.nullFlavorrequiredFixed Value: NP
Act.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @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:entry-reference 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.122
... @classCode 1..1csBinding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1csBinding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1bl
... id 1..*IIThe ID must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. The ID cannot have Null value (e.g., nullFlavor is not allowed).
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 0..1oid, uuid, ruid
.... @extension 0..1st
... code 1..1CDBinding: v3 Code System ActCode (example)
.... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NP
.... @code 0..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
.... qualifier 0..*CR
.... translation 0..*CD
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 0..1csMAY be set to "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)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.nullFlavorrequiredCDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
Act.templateId:entry-reference.nullFlavorrequiredCDANullFlavor
Act.classCoderequiredFixed Value: ACT
Act.moodCoderequiredFixed Value: EVN
Act.codeexampleActCode
Act.code.nullFlavorrequiredFixed Value: NP
Act.text.nullFlavorrequiredCDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Act.text.mediaTypeexampleMediaType
Act.text.representationrequiredBinaryDataEncoding
Act.statusCoderequiredActStatus
Act.statusCode.nullFlavorrequiredCDANullFlavor
Act.priorityCodeexampleActPriority
Act.languageCoderequiredAllLanguages

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Act

Summary

Mandatory: 6 elements
Fixed Value: 3 elements
Prohibited: 2 elements

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the value of value:root

 

Other representations of profile: CSV, Excel