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: Referral Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ReferralNote Version: 3.0.0-ballot
Active as of 2023-12-21 Computable Name: ReferralNote
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.14:2024-05-01

A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.

Examples of referral situations are when a patient is referred from a family physician to a cardiologist for cardiac evaluation or when patient is sent by a cardiologist to an emergency department for angina or when a patient is referred by a nurse practitioner to an audiologist for hearing screening or when a patient is referred by a hospitalist to social services.

Usage:

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

Formal Views of Profile Content

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

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-participant-indirect: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
should-participant-callback: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
... templateId 2..*II
... templateId:referral-note 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
.... @extension 1..1stRequired Pattern: 2024-05-01
... code 1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
..... addr 0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:indirect 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csFixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:callback 0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
..... @typeCode 1..1csFixed Value: CALLBCK
..... associatedEntity C1..1AssociatedEntityshould-addr: SHOULD contain addr
...... @classCode 1..1csFixed Value: ASSIGNED
...... id 1..*II
...... addr 0..*USRealmAddressBase for all types and resources
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*PN
...... scopingOrganization 0..1Organization
... component
.... structuredBody C1..1StructuredBodyap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
should-section-plan-of-treatment: SHOULD contain a Plan of Treatment Section
should-section-results: SHOULD contain a Results Section
should-section-functional-status: SHOULD contain a Functional Status Section
should-section-mental-status: SHOULD contain a Mental Status Section
should-section-nutrition: SHOULD contain a Nutrition Section
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:advanceDirectives 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources
...... component:historyOfPresentIllness 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section 1..1ImmunizationsSectionBase for all types and resources
...... component:problem 1..1InfrastructureRoot
....... section 1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:results 0..1InfrastructureRoot
....... section 1..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 0..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 0..1InfrastructureRoot
....... section 1..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section 1..1NutritionSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 0..1InfrastructureRoot
....... section 1..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 1..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 0..1InfrastructureRoot
....... section 1..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 0..1InfrastructureRoot
....... section 1..1GeneralStatusSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 1..1InfrastructureRoot
....... section 1..1ReasonforReferralSectionBase for all types and resources
...... component:payers 1..1InfrastructureRoot
....... section 1..1PayersSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.participant:indirect.associatedEntity.classCoderequiredINDRoleclassCodes

Constraints

IdGradePath(s)DetailsRequirements
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
should-addrwarningClinicalDocument.informationRecipient.intendedRecipient, ClinicalDocument.participant:callback.associatedEntitySHOULD contain addr
: addr.exists()
should-participant-callbackwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'CALLBCK').exists()
should-participant-indirectwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'IND').exists()
should-section-functional-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Functional Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection'))
should-section-mental-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Mental Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection'))
should-section-nutritionwarningClinicalDocument.component.structuredBodySHOULD contain a Nutrition Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection'))
should-section-plan-of-treatmentwarningClinicalDocument.component.structuredBodySHOULD contain a Plan of Treatment Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'))
should-section-resultswarningClinicalDocument.component.structuredBodySHOULD contain a Results Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection'))
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-participant-indirect: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
should-participant-callback: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
... 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:referral-note 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (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
... informationRecipient 1..1InformationRecipientThe 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.
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
..... @classCode 1..1cs
..... addr C0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @typeCode 1..1csBinding: ParticipationType (required)
..... associatedEntity 1..1AssociatedEntity
.... participant:indirect C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:callback C0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: CALLBCK
..... associatedEntity C1..1AssociatedEntityshould-addr: SHOULD contain addr
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... addr C0..*USRealmAddressBase for all types and resources
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*PN
...... scopingOrganization 0..1Organization
... component 1..1Component
.... structuredBody C1..1StructuredBodyap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
should-section-plan-of-treatment: SHOULD contain a Plan of Treatment Section
should-section-results: SHOULD contain a Results Section
should-section-functional-status: SHOULD contain a Functional Status Section
should-section-mental-status: SHOULD contain a Mental Status Section
should-section-nutrition: SHOULD contain a Nutrition Section
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:advanceDirectives 0..1InfrastructureRoot
....... section C1..1AdvanceDirectivesSectionBase for all types and resources
...... component:historyOfPresentIllness 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section C1..1ImmunizationsSectionBase for all types and resources
...... component:problem 1..1InfrastructureRoot
....... section C1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section C1..1ProceduresSectionBase for all types and resources
...... component:results 0..1InfrastructureRoot
....... section C1..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 0..1InfrastructureRoot
....... section C1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 0..1InfrastructureRoot
....... section C1..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section C1..1NutritionSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 0..1InfrastructureRoot
....... section C1..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 1..1InfrastructureRoot
....... section C1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 0..1InfrastructureRoot
....... section C1..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 0..1InfrastructureRoot
....... section 1..1GeneralStatusSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section C1..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 1..1InfrastructureRoot
....... section 1..1ReasonforReferralSectionBase for all types and resources
...... component:payers 1..1InfrastructureRoot
....... section C1..1PayersSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant:indirect.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:indirect.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:callback.typeCoderequiredFixed Value: CALLBCK
ClinicalDocument.participant:callback.associatedEntity.classCoderequiredFixed Value: ASSIGNED

Constraints

IdGradePath(s)DetailsRequirements
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callback**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callbackWhen 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, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.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, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.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.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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})?'))
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.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:advanceDirectives.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.sectionSHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-immunization-activityerrorClinicalDocument.component.structuredBody.component:immunizations.sectionSHALL contain at least one Immunization Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
shall-problem-concern-acterrorClinicalDocument.component.structuredBody.component:problem.sectionSHALL contain at least one Problem Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct'))
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
shall-result-orgerrorClinicalDocument.component.structuredBody.component:results.sectionSHALL contain at least one Result Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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)
shall-vital-signs-orgerrorClinicalDocument.component.structuredBody.component:vitalSigns.sectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-addrwarningClinicalDocument.informationRecipient.intendedRecipient, ClinicalDocument.participant:callback.associatedEntitySHOULD contain addr
: addr.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-coverage-activitywarningClinicalDocument.component.structuredBody.component:payers.sectionSHOULD contain Coverage Activity
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/CoverageActivity'))
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-non-med-supplywarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Non-Medicinal Supply Activity
: entry.where(supply.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NonMedicinalSupplyActivity'))
should-nutritional-status-obswarningClinicalDocument.component.structuredBody.component:nutrition.sectionSHOULD contain Nutritional Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionalStatusObservation'))
should-participant-callbackwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'CALLBCK').exists()
should-participant-indirectwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'IND').exists()
should-procedure-act-procedurewarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Procedure Activity Procedure
: entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-section-functional-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Functional Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection'))
should-section-mental-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Mental Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection'))
should-section-nutritionwarningClinicalDocument.component.structuredBodySHOULD contain a Nutrition Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection'))
should-section-plan-of-treatmentwarningClinicalDocument.component.structuredBodySHOULD contain a Plan of Treatment Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'))
should-section-resultswarningClinicalDocument.component.structuredBodySHOULD contain a Results Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection'))
should-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-us-codewarningClinicalDocument.author.assignedAuthorSHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.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.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time**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**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-participant-indirect: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
should-participant-callback: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
... @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:referral-note 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... @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 Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... 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 1..1InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 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 C0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 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
..... 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
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
.... participant:indirect C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase 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
...... scopingOrganization 0..1Organization
.... participant:callback C0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator 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: ParticipationType (required)
Fixed Value: CALLBCK
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-addr: SHOULD contain addr
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
...... addr C0..*USRealmAddressBase for all types and resources
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name 1..*PN
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1Order
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMoodIntent (required)
Fixed Value: RQO
..... id 1..*II
..... code 0..1CEBinding: v3 Code System ActCode (example)
..... priorityCode 0..1CEBinding: ActPriority (example)
... documentationOf 0..*DocumentationOf
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CE
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... @operator 0..1csBinding: SetOperator (required)
...... low C1..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
...... center 0..1TS
...... width 0..1PQ
...... high C0..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
...... functionCode C0..1CE
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Care Team Member Function (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... time C0..1USRealmDateTimeIntervalBase for all types and resources
...... assignedEntity C1..1AssignedEntity
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... id 1..*II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root C0..1oid, uuid, ruid
........ @extension 0..1st
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
....... addr 0..*AD
....... telecom 0..*TEL
....... assignedPerson 0..1Person
....... representedOrganization 0..1Organization
....... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
........ id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... relatedDocument 0..*RelatedDocument
... authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1CSBinding: ActStatus (required)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csFixed Value: completed
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C1..1EncompassingEncounter
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: ENC
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 1..*II
..... code 0..1CEBinding: Act Encounter Codes (preferred)
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
..... sdtcAdmissionReferralSourceCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity C1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... nonXMLBody 0..1NonXMLBody
.... structuredBody C1..1StructuredBodyap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
should-section-plan-of-treatment: SHOULD contain a Plan of Treatment Section
should-section-results: SHOULD contain a Results Section
should-section-functional-status: SHOULD contain a Functional Status Section
should-section-mental-status: SHOULD contain a Mental Status Section
should-section-nutrition: SHOULD contain a Nutrition Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... Slices for component 5..*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:planOfTreatment 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:advanceDirectives 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
...... component:historyOfPresentIllness 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..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 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..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 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..1ImmunizationsSectionBase for all types and resources
...... component:problem 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..1ProblemSectionBase for all types and resources
...... component:procedures 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..1ProceduresSectionBase for all types and resources
...... component:results 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..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 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..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 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..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 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..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 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..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 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..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 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..1NutritionSectionBase for all types and resources
...... component:mentalStatus 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..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 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..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 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..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 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..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 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..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 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..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 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..1GeneralStatusSectionBase for all types and resources
...... component:medications 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..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 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..1ReasonforReferralSectionBase for all types and resources
...... component:payers 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..1PayersSectionBase 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:referral-note.nullFlavorrequiredCDANullFlavor
ClinicalDocument.coderequiredReferralDocumentType
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.participant:indirect.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:indirect.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:indirect.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:indirect.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.typeCoderequiredFixed Value: CALLBCK
ClinicalDocument.participant:callback.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:callback.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.participant:callback.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeexampleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeexampleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operatorrequiredSetOperator
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.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:planOfTreatment.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:planOfTreatment.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:advanceDirectives.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:advanceDirectives.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:historyOfPresentIllness.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:historyOfPresentIllness.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:immunizations.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:immunizations.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:problem.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:problem.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:results.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:results.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:vitalSigns.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:functionalStatus.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:functionalStatus.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:nutrition.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:nutrition.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:mentalStatus.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:mentalStatus.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalEquip.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalEquip.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:generalStatus.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:generalStatus.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForReferral.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForReferral.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:payers.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:payers.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-32905errorClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntityThis assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
: assignedPerson.exists() or representedOrganization.exists()
4537-5402errorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
4537-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.empty() or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callback**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callbackWhen 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, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
ivl-ts-centererrorClinicalDocument.participant.time, ClinicalDocument.participant:indirect.time, ClinicalDocument.participant:callback.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.participant.time, ClinicalDocument.participant:indirect.time, ClinicalDocument.participant:callback.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.participant.time, ClinicalDocument.participant:indirect.time, ClinicalDocument.participant:callback.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.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:advanceDirectives.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.sectionSHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-immunization-activityerrorClinicalDocument.component.structuredBody.component:immunizations.sectionSHALL contain at least one Immunization Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
shall-problem-concern-acterrorClinicalDocument.component.structuredBody.component:problem.sectionSHALL contain at least one Problem Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct'))
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
shall-result-orgerrorClinicalDocument.component.structuredBody.component:results.sectionSHALL contain at least one Result Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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)
shall-vital-signs-orgerrorClinicalDocument.component.structuredBody.component:vitalSigns.sectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-addrwarningClinicalDocument.informationRecipient.intendedRecipient, ClinicalDocument.participant:callback.associatedEntitySHOULD contain addr
: addr.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-coverage-activitywarningClinicalDocument.component.structuredBody.component:payers.sectionSHOULD contain Coverage Activity
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/CoverageActivity'))
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-non-med-supplywarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Non-Medicinal Supply Activity
: entry.where(supply.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NonMedicinalSupplyActivity'))
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.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-nutritional-status-obswarningClinicalDocument.component.structuredBody.component:nutrition.sectionSHOULD contain Nutritional Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionalStatusObservation'))
should-participant-callbackwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'CALLBCK').exists()
should-participant-indirectwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'IND').exists()
should-preferenceIndwarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain preferenceInd
: preferenceInd.exists()
should-procedure-act-procedurewarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Procedure Activity Procedure
: entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
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-section-functional-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Functional Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection'))
should-section-mental-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Mental Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection'))
should-section-nutritionwarningClinicalDocument.component.structuredBodySHOULD contain a Nutrition Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection'))
should-section-plan-of-treatmentwarningClinicalDocument.component.structuredBodySHOULD contain a Plan of Treatment Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'))
should-section-resultswarningClinicalDocument.component.structuredBodySHOULD contain a Results Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection'))
should-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.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.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecom, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD 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

This structure is derived from USRealmHeader

Summary

Mandatory: 11 elements (6 nested mandatory elements)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-participant-indirect: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
should-participant-callback: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
... templateId 2..*II
... templateId:referral-note 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
.... @extension 1..1stRequired Pattern: 2024-05-01
... code 1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
..... addr 0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:indirect 0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csFixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:callback 0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
..... @typeCode 1..1csFixed Value: CALLBCK
..... associatedEntity C1..1AssociatedEntityshould-addr: SHOULD contain addr
...... @classCode 1..1csFixed Value: ASSIGNED
...... id 1..*II
...... addr 0..*USRealmAddressBase for all types and resources
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*PN
...... scopingOrganization 0..1Organization
... component
.... structuredBody C1..1StructuredBodyap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
should-section-plan-of-treatment: SHOULD contain a Plan of Treatment Section
should-section-results: SHOULD contain a Results Section
should-section-functional-status: SHOULD contain a Functional Status Section
should-section-mental-status: SHOULD contain a Mental Status Section
should-section-nutrition: SHOULD contain a Nutrition Section
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:advanceDirectives 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources
...... component:historyOfPresentIllness 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section 1..1ImmunizationsSectionBase for all types and resources
...... component:problem 1..1InfrastructureRoot
....... section 1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:results 0..1InfrastructureRoot
....... section 1..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 0..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 0..1InfrastructureRoot
....... section 1..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section 1..1NutritionSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 0..1InfrastructureRoot
....... section 1..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 1..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 0..1InfrastructureRoot
....... section 1..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 0..1InfrastructureRoot
....... section 1..1GeneralStatusSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 1..1InfrastructureRoot
....... section 1..1ReasonforReferralSectionBase for all types and resources
...... component:payers 1..1InfrastructureRoot
....... section 1..1PayersSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.participant:indirect.associatedEntity.classCoderequiredINDRoleclassCodes

Constraints

IdGradePath(s)DetailsRequirements
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
should-addrwarningClinicalDocument.informationRecipient.intendedRecipient, ClinicalDocument.participant:callback.associatedEntitySHOULD contain addr
: addr.exists()
should-participant-callbackwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'CALLBCK').exists()
should-participant-indirectwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'IND').exists()
should-section-functional-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Functional Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection'))
should-section-mental-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Mental Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection'))
should-section-nutritionwarningClinicalDocument.component.structuredBodySHOULD contain a Nutrition Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection'))
should-section-plan-of-treatmentwarningClinicalDocument.component.structuredBodySHOULD contain a Plan of Treatment Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'))
should-section-resultswarningClinicalDocument.component.structuredBodySHOULD contain a Results Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection'))
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-participant-indirect: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
should-participant-callback: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
... 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:referral-note 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (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
... informationRecipient 1..1InformationRecipientThe 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.
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
..... @classCode 1..1cs
..... addr C0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @typeCode 1..1csBinding: ParticipationType (required)
..... associatedEntity 1..1AssociatedEntity
.... participant:indirect C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:callback C0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: CALLBCK
..... associatedEntity C1..1AssociatedEntityshould-addr: SHOULD contain addr
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... addr C0..*USRealmAddressBase for all types and resources
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*PN
...... scopingOrganization 0..1Organization
... component 1..1Component
.... structuredBody C1..1StructuredBodyap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
should-section-plan-of-treatment: SHOULD contain a Plan of Treatment Section
should-section-results: SHOULD contain a Results Section
should-section-functional-status: SHOULD contain a Functional Status Section
should-section-mental-status: SHOULD contain a Mental Status Section
should-section-nutrition: SHOULD contain a Nutrition Section
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:advanceDirectives 0..1InfrastructureRoot
....... section C1..1AdvanceDirectivesSectionBase for all types and resources
...... component:historyOfPresentIllness 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section C1..1ImmunizationsSectionBase for all types and resources
...... component:problem 1..1InfrastructureRoot
....... section C1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section C1..1ProceduresSectionBase for all types and resources
...... component:results 0..1InfrastructureRoot
....... section C1..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 0..1InfrastructureRoot
....... section C1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 0..1InfrastructureRoot
....... section C1..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section C1..1NutritionSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 0..1InfrastructureRoot
....... section C1..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 1..1InfrastructureRoot
....... section C1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 0..1InfrastructureRoot
....... section C1..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 0..1InfrastructureRoot
....... section 1..1GeneralStatusSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section C1..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 1..1InfrastructureRoot
....... section 1..1ReasonforReferralSectionBase for all types and resources
...... component:payers 1..1InfrastructureRoot
....... section C1..1PayersSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant:indirect.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:indirect.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:callback.typeCoderequiredFixed Value: CALLBCK
ClinicalDocument.participant:callback.associatedEntity.classCoderequiredFixed Value: ASSIGNED

Constraints

IdGradePath(s)DetailsRequirements
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callback**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callbackWhen 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, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.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, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.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.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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})?'))
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.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:advanceDirectives.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.sectionSHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-immunization-activityerrorClinicalDocument.component.structuredBody.component:immunizations.sectionSHALL contain at least one Immunization Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
shall-problem-concern-acterrorClinicalDocument.component.structuredBody.component:problem.sectionSHALL contain at least one Problem Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct'))
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
shall-result-orgerrorClinicalDocument.component.structuredBody.component:results.sectionSHALL contain at least one Result Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.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)
shall-vital-signs-orgerrorClinicalDocument.component.structuredBody.component:vitalSigns.sectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-addrwarningClinicalDocument.informationRecipient.intendedRecipient, ClinicalDocument.participant:callback.associatedEntitySHOULD contain addr
: addr.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-coverage-activitywarningClinicalDocument.component.structuredBody.component:payers.sectionSHOULD contain Coverage Activity
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/CoverageActivity'))
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-non-med-supplywarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Non-Medicinal Supply Activity
: entry.where(supply.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NonMedicinalSupplyActivity'))
should-nutritional-status-obswarningClinicalDocument.component.structuredBody.component:nutrition.sectionSHOULD contain Nutritional Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionalStatusObservation'))
should-participant-callbackwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'CALLBCK').exists()
should-participant-indirectwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'IND').exists()
should-procedure-act-procedurewarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Procedure Activity Procedure
: entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-section-functional-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Functional Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection'))
should-section-mental-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Mental Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection'))
should-section-nutritionwarningClinicalDocument.component.structuredBodySHOULD contain a Nutrition Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection'))
should-section-plan-of-treatmentwarningClinicalDocument.component.structuredBodySHOULD contain a Plan of Treatment Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'))
should-section-resultswarningClinicalDocument.component.structuredBodySHOULD contain a Results Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection'))
should-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-us-codewarningClinicalDocument.author.assignedAuthorSHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.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.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time**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**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-participant-indirect: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
should-participant-callback: SHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
... @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:referral-note 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... @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 Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... 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 1..1InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient C1..1IntendedRecipientshould-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 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 C0..*USRealmAddressBase for all types and resources
..... telecom 0..*TEL
..... informationRecipient 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
..... 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
... Slices for participant C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
.... participant:indirect C0..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity 1..1AssociatedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase 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
...... scopingOrganization 0..1Organization
.... participant:callback C0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator 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: ParticipationType (required)
Fixed Value: CALLBCK
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... functionCode 0..1CE
..... time C0..1USRealmDateTimeIntervalBase for all types and resources
..... associatedEntity C1..1AssociatedEntityshould-addr: SHOULD contain addr
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (example)
...... addr C0..*USRealmAddressBase for all types and resources
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name 1..*PN
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1Order
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMoodIntent (required)
Fixed Value: RQO
..... id 1..*II
..... code 0..1CEBinding: v3 Code System ActCode (example)
..... priorityCode 0..1CEBinding: ActPriority (example)
... documentationOf 0..*DocumentationOf
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CE
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... @operator 0..1csBinding: SetOperator (required)
...... low C1..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
...... center 0..1TS
...... width 0..1PQ
...... high C0..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
...... functionCode C0..1CE
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Care Team Member Function (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... time C0..1USRealmDateTimeIntervalBase for all types and resources
...... assignedEntity C1..1AssignedEntity
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... id 1..*II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root C0..1oid, uuid, ruid
........ @extension 0..1st
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
....... addr 0..*AD
....... telecom 0..*TEL
....... assignedPerson 0..1Person
....... representedOrganization 0..1Organization
....... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
........ id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... relatedDocument 0..*RelatedDocument
... authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1CSBinding: ActStatus (required)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csFixed Value: completed
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C1..1EncompassingEncounter
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: ENC
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 1..*II
..... code 0..1CEBinding: Act Encounter Codes (preferred)
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
..... sdtcAdmissionReferralSourceCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity C1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... nonXMLBody 0..1NonXMLBody
.... structuredBody C1..1StructuredBodyap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
should-section-plan-of-treatment: SHOULD contain a Plan of Treatment Section
should-section-results: SHOULD contain a Results Section
should-section-functional-status: SHOULD contain a Functional Status Section
should-section-mental-status: SHOULD contain a Mental Status Section
should-section-nutrition: SHOULD contain a Nutrition Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... Slices for component 5..*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:planOfTreatment 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:advanceDirectives 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
...... component:historyOfPresentIllness 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..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 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..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 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..1ImmunizationsSectionBase for all types and resources
...... component:problem 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..1ProblemSectionBase for all types and resources
...... component:procedures 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..1ProceduresSectionBase for all types and resources
...... component:results 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..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 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..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 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..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 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..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 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..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 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..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 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..1NutritionSectionBase for all types and resources
...... component:mentalStatus 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..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 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..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 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..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 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..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 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..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 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..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 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..1GeneralStatusSectionBase for all types and resources
...... component:medications 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..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 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..1ReasonforReferralSectionBase for all types and resources
...... component:payers 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..1PayersSectionBase 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:referral-note.nullFlavorrequiredCDANullFlavor
ClinicalDocument.coderequiredReferralDocumentType
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.participant:indirect.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:indirect.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:indirect.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:indirect.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.typeCoderequiredFixed Value: CALLBCK
ClinicalDocument.participant:callback.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:callback.associatedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.participant:callback.associatedEntity.codeexampleRoleCode
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
ClinicalDocument.participant:callback.associatedEntity.associatedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeexampleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeexampleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operatorrequiredSetOperator
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.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:planOfTreatment.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:planOfTreatment.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:advanceDirectives.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:advanceDirectives.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:historyOfPresentIllness.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:historyOfPresentIllness.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:immunizations.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:immunizations.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:problem.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:problem.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:results.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:results.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:vitalSigns.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:functionalStatus.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:functionalStatus.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:nutrition.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:nutrition.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:mentalStatus.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:mentalStatus.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalEquip.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalEquip.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:generalStatus.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:generalStatus.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForReferral.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForReferral.typeId.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:payers.nullFlavorrequiredCDANullFlavor
ClinicalDocument.component.structuredBody.component:payers.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-32905errorClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntityThis assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
: assignedPerson.exists() or representedOrganization.exists()
4537-5402errorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
4537-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.empty() or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callback**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:indirect, ClinicalDocument.participant:callbackWhen 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, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
ivl-ts-centererrorClinicalDocument.participant.time, ClinicalDocument.participant:indirect.time, ClinicalDocument.participant:callback.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.participant.time, ClinicalDocument.participant:indirect.time, ClinicalDocument.participant:callback.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.participant.time, ClinicalDocument.participant:indirect.time, ClinicalDocument.participant:callback.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.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:advanceDirectives.sectionSHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer'))
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.sectionSHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct'))
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-immunization-activityerrorClinicalDocument.component.structuredBody.component:immunizations.sectionSHALL contain at least one Immunization Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity'))
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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.name, ClinicalDocument.participant:indirect.associatedEntity.associatedPerson.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
shall-problem-concern-acterrorClinicalDocument.component.structuredBody.component:problem.sectionSHALL contain at least one Problem Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProblemConcernAct'))
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
shall-result-orgerrorClinicalDocument.component.structuredBody.component:results.sectionSHALL contain at least one Result Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultOrganizer'))
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.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)
shall-vital-signs-orgerrorClinicalDocument.component.structuredBody.component:vitalSigns.sectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-addrwarningClinicalDocument.informationRecipient.intendedRecipient, ClinicalDocument.participant:callback.associatedEntitySHOULD contain addr
: addr.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-coverage-activitywarningClinicalDocument.component.structuredBody.component:payers.sectionSHOULD contain Coverage Activity
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/CoverageActivity'))
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-non-med-supplywarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Non-Medicinal Supply Activity
: entry.where(supply.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NonMedicinalSupplyActivity'))
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.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-nutritional-status-obswarningClinicalDocument.component.structuredBody.component:nutrition.sectionSHOULD contain Nutritional Status Observation
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionalStatusObservation'))
should-participant-callbackwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'CALLBCK').exists()
should-participant-indirectwarningClinicalDocumentSHOULD contain zero or more [0..*] participant such that it SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC)
: participant.where(typeCode = 'IND').exists()
should-preferenceIndwarningClinicalDocument.recordTarget.patientRole.patient.languageCommunicationSHOULD contain preferenceInd
: preferenceInd.exists()
should-procedure-act-procedurewarningClinicalDocument.component.structuredBody.component:medicalEquip.sectionSHOULD contain Procedure Activity Procedure
: entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
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-section-functional-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Functional Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection'))
should-section-mental-statuswarningClinicalDocument.component.structuredBodySHOULD contain a Mental Status Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection'))
should-section-nutritionwarningClinicalDocument.component.structuredBodySHOULD contain a Nutrition Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection'))
should-section-plan-of-treatmentwarningClinicalDocument.component.structuredBodySHOULD contain a Plan of Treatment Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'))
should-section-resultswarningClinicalDocument.component.structuredBodySHOULD contain a Results Section
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection'))
should-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-telecomwarningClinicalDocument.informationRecipient.intendedRecipientSHOULD contain telecom
: telecom.exists()
should-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.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.informationRecipient.intendedRecipient.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecom, ClinicalDocument.participant:callback.associatedEntity.addrSHOULD 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

This structure is derived from USRealmHeader

Summary

Mandatory: 11 elements (6 nested mandatory elements)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel