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: Operative Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote Version: 3.0.0-ballot
Active as of 2023-12-21 Computable Name: OperativeNote
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.7:2024-05-01

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.

The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.

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 1..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)
... templateId 2..*II
... templateId:operative-note 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
.... @extension 1..1stRequired Pattern: 2024-05-01
... code 1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
.... @code 1..1csBinding: SurgicalOperationNoteDocumentTypeCode (required)
.... serviceEvent 1..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.
..... code C1..1CEBinding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).

Additional BindingsPurposeDocumentation
ProcedurePreferred Binding
Allowed SNOMED Codes

1198-8487: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low 1..1IVXB_TSLow is required
...... (Choice of one) 1..1
....... width 0..1PQRepresents the duration
....... high 0..1IVXB_TSEquals low if only the date is known
..... Slices for 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.
Slice: Unordered, Open by value:typeCode
...... performer:performer1 1..*Performer1This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1csFixed Value: PPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... performer:performer2 0..*Performer1This performer represents any assistants
....... @typeCode 1..1csFixed Value: SPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... @typeCode 1..1cs
.... consent 1..1Consent
..... @classCode 1..1cs
..... @moodCode 1..1cs
..... statusCode 1..1CS
... component 1..1Component
.... structuredBody 1..1StructuredBody
..... Slices for component 8..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:component1 1..1InfrastructureRoot
....... section 1..1AnesthesiaSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1ComplicationsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1PreoperativeDiagnosisSectionBase for all types and resources
...... component:component4 1..1InfrastructureRoot
....... section 1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component5 1..1InfrastructureRoot
....... section 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component6 1..1InfrastructureRoot
....... section 1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component7 1..1InfrastructureRoot
....... section 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component8 1..1InfrastructureRoot
....... section 1..1PostoperativeDiagnosisSectionBase for all types and resources
...... component:component9 0..1InfrastructureRoot
....... section 1..1ProcedureImplantsSectionBase for all types and resources
...... component:component10 0..1InfrastructureRoot
....... section 1..1OperativeNoteFluidsSectionBase for all types and resources
...... component:component11 0..1InfrastructureRoot
....... section 1..1OperativeNoteSurgicalProcedureSectionBase for all types and resources
...... component:component12 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component13 0..1InfrastructureRoot
....... section 1..1PlannedProcedureSectionBase for all types and resources
...... component:component14 0..1InfrastructureRoot
....... section 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component15 0..1InfrastructureRoot
....... section 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component16 0..1InfrastructureRoot
....... section 1..1SurgicalDrainsSectionBase for all types and resources
...... component:component17 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.code.coderequiredSurgicalOperationNoteDocumentTypeCode
ClinicalDocument.documentationOf.serviceEvent.coderequired
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)

Constraints

IdGradePath(s)DetailsRequirements
1198-8487errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.exists()
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1
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)
... 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:operative-note 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1csBinding: SurgicalOperationNoteDocumentTypeCode (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)
... 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
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... 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)
..... code C1..1CEBinding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).

Additional BindingsPurposeDocumentation
ProcedurePreferred Binding
Allowed SNOMED Codes

1198-8487: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low C1..1IVXB_TSLow is required
...... (Choice of one) 1..1
....... width 0..1PQRepresents the duration
....... high C0..1IVXB_TSEquals low if only the date is known
..... Slices for 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.
Slice: Unordered, Open by value:typeCode
...... performer:All Slices Content/Rules for all slices
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... assignedEntity C1..1AssignedEntity
........ id 1..*II
...... performer:performer1 1..*Performer1This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
Fixed Value: PPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ id 1..*II
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... performer:performer2 0..*Performer1This performer represents any assistants
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
Fixed Value: SPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ id 1..*II
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @classCode 1..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 1..1csBinding: ActMood (required)
Fixed Value: EVN
..... statusCode 1..1CSBinding: ActStatus (required)
...... @code 1..1csFixed Value: completed
... component 1..1Component
.... structuredBody 1..1StructuredBody
..... Slices for component 8..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... section 1..1AnesthesiaSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1ComplicationsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section C1..1PreoperativeDiagnosisSectionBase for all types and resources
...... component:component4 1..1InfrastructureRoot
....... section 1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component5 1..1InfrastructureRoot
....... section 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component6 1..1InfrastructureRoot
....... section 1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component7 1..1InfrastructureRoot
....... section 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component8 1..1InfrastructureRoot
....... section 1..1PostoperativeDiagnosisSectionBase for all types and resources
...... component:component9 0..1InfrastructureRoot
....... section 1..1ProcedureImplantsSectionBase for all types and resources
...... component:component10 0..1InfrastructureRoot
....... section 1..1OperativeNoteFluidsSectionBase for all types and resources
...... component:component11 0..1InfrastructureRoot
....... section 1..1OperativeNoteSurgicalProcedureSectionBase for all types and resources
...... component:component12 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component13 0..1InfrastructureRoot
....... section 1..1PlannedProcedureSectionBase for all types and resources
...... component:component14 0..1InfrastructureRoot
....... section 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component15 0..1InfrastructureRoot
....... section 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component16 0..1InfrastructureRoot
....... section 1..1SurgicalDrainsSectionBase for all types and resources
...... component:component17 0..1InfrastructureRoot
....... section C1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.coderequiredSurgicalOperationNoteDocumentTypeCode
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.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.coderequired
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCoderequiredFixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCoderequiredFixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUTH
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization.consent.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
1198-8487errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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()
4537-16790errorClinicalDocument.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.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.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.documentationOf.serviceEvent.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.documentationOf.serviceEvent.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.documentationOf.serviceEvent.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.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:component17.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-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-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.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.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-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-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-preop-dxwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-us-codewarningClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.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()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.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.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1
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)
... @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:operative-note 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... @extension 1..1stRequired Pattern: 2024-05-01
... id 1..1II**SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code C1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: FHIRDocumentTypeCodes (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csBinding: SurgicalOperationNoteDocumentTypeCode (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 1..1IntendedRecipient
..... @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 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... 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..*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
..... receivedOrganization 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 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... 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 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 of 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 C0..1oid, uuid, ruid
...... @extension 0..1st
..... 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: 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)
..... 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
... 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).
.... @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
... 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)
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... @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 C1..1CEBinding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).

Additional BindingsPurposeDocumentation
ProcedurePreferred Binding
Allowed SNOMED Codes

1198-8487: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... @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_TSLow is required
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
...... center 0..1TS
...... (Choice of one) 1..1
....... width 0..1PQRepresents the duration
....... high C0..1IVXB_TSEquals low if only the date is known
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
..... Slices for 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.
Slice: Unordered, Open by value:typeCode
...... performer: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: 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
...... performer:performer1 1..*Performer1This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @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)
Fixed Value: PPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
........ @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..1AssignedEntityshould-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 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 (required)
........ 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
...... performer:performer2 0..*Performer1This performer represents any assistants
....... @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)
Fixed Value: SPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
........ @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..1AssignedEntityshould-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 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 (required)
........ 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
... relatedDocument 0..*RelatedDocument
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... @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: 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 1..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 1..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 1..1StructuredBody
..... @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 8..*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 1..1AnesthesiaSectionBase 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 1..1ComplicationsSectionBase 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..1PreoperativeDiagnosisSectionBase for all types and resources
...... component:component4 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 1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component5 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 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component6 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 1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component7 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 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component8 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 1..1PostoperativeDiagnosisSectionBase for all types and resources
...... component:component9 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 1..1ProcedureImplantsSectionBase for all types and resources
...... component:component10 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 1..1OperativeNoteFluidsSectionBase for all types and resources
...... component:component11 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 1..1OperativeNoteSurgicalProcedureSectionBase for all types and resources
...... component:component12 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 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component13 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 1..1PlannedProcedureSectionBase for all types and resources
...... component:component14 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 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component15 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 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component16 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 1..1SurgicalDrainsSectionBase for all types and resources
...... component:component17 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:operative-note.nullFlavorrequiredCDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.code.coderequiredSurgicalOperationNoteDocumentTypeCode
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.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
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.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
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.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.coderequired
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.serviceEvent.performer:performer1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCoderequiredFixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCoderequiredFixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
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
ClinicalDocument.component.structuredBody.component:component6.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component6.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component7.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component7.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component8.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component8.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component9.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component9.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component10.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component10.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component11.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component11.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component12.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component12.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component13.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component13.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component14.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component14.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component15.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component15.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component16.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component16.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component17.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component17.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-8487errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participantWhen 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.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.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.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.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.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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.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.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:component17.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.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-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.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-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.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-codewarningClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.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.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-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-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.serviceEvent.performer:performer1.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-preferenceIndwarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain preferenceInd
: preferenceInd.exists()
should-preop-dxwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-proficiencyLevelCodewarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain proficiencyLevelCode
: proficiencyLevelCode.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-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.serviceEvent.performer:performer1.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.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.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()
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**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**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

This structure is derived from USRealmHeader

Summary

Mandatory: 17 elements (3 nested mandatory elements)
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.documentationOf.serviceEvent.performer is sliced based on the value of value:typeCode
  • 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 1..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)
... templateId 2..*II
... templateId:operative-note 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
.... @extension 1..1stRequired Pattern: 2024-05-01
... code 1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
.... @code 1..1csBinding: SurgicalOperationNoteDocumentTypeCode (required)
.... serviceEvent 1..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.
..... code C1..1CEBinding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).

Additional BindingsPurposeDocumentation
ProcedurePreferred Binding
Allowed SNOMED Codes

1198-8487: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low 1..1IVXB_TSLow is required
...... (Choice of one) 1..1
....... width 0..1PQRepresents the duration
....... high 0..1IVXB_TSEquals low if only the date is known
..... Slices for 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.
Slice: Unordered, Open by value:typeCode
...... performer:performer1 1..*Performer1This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1csFixed Value: PPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... performer:performer2 0..*Performer1This performer represents any assistants
....... @typeCode 1..1csFixed Value: SPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... @typeCode 1..1cs
.... consent 1..1Consent
..... @classCode 1..1cs
..... @moodCode 1..1cs
..... statusCode 1..1CS
... component 1..1Component
.... structuredBody 1..1StructuredBody
..... Slices for component 8..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:component1 1..1InfrastructureRoot
....... section 1..1AnesthesiaSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1ComplicationsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1PreoperativeDiagnosisSectionBase for all types and resources
...... component:component4 1..1InfrastructureRoot
....... section 1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component5 1..1InfrastructureRoot
....... section 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component6 1..1InfrastructureRoot
....... section 1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component7 1..1InfrastructureRoot
....... section 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component8 1..1InfrastructureRoot
....... section 1..1PostoperativeDiagnosisSectionBase for all types and resources
...... component:component9 0..1InfrastructureRoot
....... section 1..1ProcedureImplantsSectionBase for all types and resources
...... component:component10 0..1InfrastructureRoot
....... section 1..1OperativeNoteFluidsSectionBase for all types and resources
...... component:component11 0..1InfrastructureRoot
....... section 1..1OperativeNoteSurgicalProcedureSectionBase for all types and resources
...... component:component12 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component13 0..1InfrastructureRoot
....... section 1..1PlannedProcedureSectionBase for all types and resources
...... component:component14 0..1InfrastructureRoot
....... section 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component15 0..1InfrastructureRoot
....... section 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component16 0..1InfrastructureRoot
....... section 1..1SurgicalDrainsSectionBase for all types and resources
...... component:component17 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.code.coderequiredSurgicalOperationNoteDocumentTypeCode
ClinicalDocument.documentationOf.serviceEvent.coderequired
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)

Constraints

IdGradePath(s)DetailsRequirements
1198-8487errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.exists()
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

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)
... 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:operative-note 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1csBinding: SurgicalOperationNoteDocumentTypeCode (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)
... 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
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... 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)
..... code C1..1CEBinding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).

Additional BindingsPurposeDocumentation
ProcedurePreferred Binding
Allowed SNOMED Codes

1198-8487: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low C1..1IVXB_TSLow is required
...... (Choice of one) 1..1
....... width 0..1PQRepresents the duration
....... high C0..1IVXB_TSEquals low if only the date is known
..... Slices for 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.
Slice: Unordered, Open by value:typeCode
...... performer:All Slices Content/Rules for all slices
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
....... assignedEntity C1..1AssignedEntity
........ id 1..*II
...... performer:performer1 1..*Performer1This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
Fixed Value: PPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ id 1..*II
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... performer:performer2 0..*Performer1This performer represents any assistants
....... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
Fixed Value: SPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
........ id 1..*II
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @classCode 1..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 1..1csBinding: ActMood (required)
Fixed Value: EVN
..... statusCode 1..1CSBinding: ActStatus (required)
...... @code 1..1csFixed Value: completed
... component 1..1Component
.... structuredBody 1..1StructuredBody
..... Slices for component 8..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... section 1..1AnesthesiaSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1ComplicationsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section C1..1PreoperativeDiagnosisSectionBase for all types and resources
...... component:component4 1..1InfrastructureRoot
....... section 1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component5 1..1InfrastructureRoot
....... section 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component6 1..1InfrastructureRoot
....... section 1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component7 1..1InfrastructureRoot
....... section 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component8 1..1InfrastructureRoot
....... section 1..1PostoperativeDiagnosisSectionBase for all types and resources
...... component:component9 0..1InfrastructureRoot
....... section 1..1ProcedureImplantsSectionBase for all types and resources
...... component:component10 0..1InfrastructureRoot
....... section 1..1OperativeNoteFluidsSectionBase for all types and resources
...... component:component11 0..1InfrastructureRoot
....... section 1..1OperativeNoteSurgicalProcedureSectionBase for all types and resources
...... component:component12 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component13 0..1InfrastructureRoot
....... section 1..1PlannedProcedureSectionBase for all types and resources
...... component:component14 0..1InfrastructureRoot
....... section 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component15 0..1InfrastructureRoot
....... section 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component16 0..1InfrastructureRoot
....... section 1..1SurgicalDrainsSectionBase for all types and resources
...... component:component17 0..1InfrastructureRoot
....... section C1..1AdvanceDirectivesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.coderequiredSurgicalOperationNoteDocumentTypeCode
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.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.coderequired
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCoderequiredFixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCoderequiredFixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUTH
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization.consent.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
1198-8487errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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()
4537-16790errorClinicalDocument.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.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.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.documentationOf.serviceEvent.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.documentationOf.serviceEvent.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.documentationOf.serviceEvent.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.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:component17.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-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-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.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.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-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-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-preop-dxwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-us-codewarningClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.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()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.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.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

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)
... @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:operative-note 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... @extension 1..1stRequired Pattern: 2024-05-01
... id 1..1II**SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code C1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: FHIRDocumentTypeCodes (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csBinding: SurgicalOperationNoteDocumentTypeCode (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 1..1IntendedRecipient
..... @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 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... 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..*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
..... receivedOrganization 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 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... 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 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 of 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 C0..1oid, uuid, ruid
...... @extension 0..1st
..... 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: 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)
..... 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
... 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).
.... @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
... 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)
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... @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 C1..1CEBinding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).

Additional BindingsPurposeDocumentation
ProcedurePreferred Binding
Allowed SNOMED Codes

1198-8487: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... @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_TSLow is required
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
...... center 0..1TS
...... (Choice of one) 1..1
....... width 0..1PQRepresents the duration
....... high C0..1IVXB_TSEquals low if only the date is known
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
........ @inclusive 0..1bl
..... Slices for 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.
Slice: Unordered, Open by value:typeCode
...... performer: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: 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
...... performer:performer1 1..*Performer1This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @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)
Fixed Value: PPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
........ @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..1AssignedEntityshould-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 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 (required)
........ 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
...... performer:performer2 0..*Performer1This performer represents any assistants
....... @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)
Fixed Value: SPRF
....... functionCode C0..1CEBinding: Care Team Member Function (preferred)
........ @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..1AssignedEntityshould-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 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 (required)
........ 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
... relatedDocument 0..*RelatedDocument
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... @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: 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 1..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 1..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 1..1StructuredBody
..... @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 8..*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 1..1AnesthesiaSectionBase 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 1..1ComplicationsSectionBase 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..1PreoperativeDiagnosisSectionBase for all types and resources
...... component:component4 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 1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component5 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 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component6 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 1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component7 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 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component8 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 1..1PostoperativeDiagnosisSectionBase for all types and resources
...... component:component9 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 1..1ProcedureImplantsSectionBase for all types and resources
...... component:component10 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 1..1OperativeNoteFluidsSectionBase for all types and resources
...... component:component11 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 1..1OperativeNoteSurgicalProcedureSectionBase for all types and resources
...... component:component12 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 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component13 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 1..1PlannedProcedureSectionBase for all types and resources
...... component:component14 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 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component15 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 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component16 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 1..1SurgicalDrainsSectionBase for all types and resources
...... component:component17 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:operative-note.nullFlavorrequiredCDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.code.nullFlavorrequiredCDANullFlavor
ClinicalDocument.code.coderequiredSurgicalOperationNoteDocumentTypeCode
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.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
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.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
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.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.coderequired
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.serviceEvent.performer:performer1.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCoderequiredFixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCoderequiredFixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCodepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
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
ClinicalDocument.component.structuredBody.component:component6.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component6.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component7.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component7.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component8.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component8.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component9.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component9.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component10.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component10.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component11.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component11.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component12.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component12.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component13.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component13.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component14.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component14.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component15.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component15.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component16.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component16.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component17.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:component17.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-8487errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participantWhen 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.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.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.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.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.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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.time, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.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.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:component17.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.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-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.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-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.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-codewarningClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.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.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-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-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.serviceEvent.performer:performer1.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-preferenceIndwarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain preferenceInd
: preferenceInd.exists()
should-preop-dxwarningClinicalDocument.component.structuredBody.component:component3.sectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-proficiencyLevelCodewarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain proficiencyLevelCode
: proficiencyLevelCode.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-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.serviceEvent.performer:performer1.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.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.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()
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**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**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

This structure is derived from USRealmHeader

Summary

Mandatory: 17 elements (3 nested mandatory elements)
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.documentationOf.serviceEvent.performer is sliced based on the value of value:typeCode
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of profile:section

 

Other representations of profile: CSV, Excel