Consolidated CDA
3.0.0-ballot - ballot
Consolidated CDA
3.0.0-ballot - ballot
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: USRealmHeader | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:2024-05-01 | ||||
This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents. Further specification, such as ClinicalDocument/code, are provided in document templates that conform to this template.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClinicalDocument
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalDocument | C | 1..1 | ClinicalDocument | XML 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 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant |
 realmCode | 1..1 | CS | ||
  @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | ||
 @extension | 1..1 | st | ||
 Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
  templateId:us-realm | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
 @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
| id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| code | C | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). 4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
 effectiveTime | 1..1 | USRealmDateTime | Base for all types and resources | |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @nullFlavor | 0..0 | |||
| @code | 1..1 | cs | ||
| languageCode | 1..1 | CS | ||
| setId | 0..1 | II | ||
| versionNumber | 0..1 | INT | ||
| recordTarget | 1..* | RecordTarget | The 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..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | 1..* | USRealmAddress | (USCDI) Address | |
| telecom | C | 1..* | TEL | (USCDI) Phone Number / Email should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| name | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | (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) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd | 0..1 | BL | sdtc:deceasedInd | |
| sdtcDeceasedTime | C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc (USCDI) Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | (USCDI) Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML 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..1 | CE | (USCDI) Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc (USCDI) Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | 0..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 0..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| birthplace | 0..1 | Birthplace | ||
| place | 1..1 | Place | ||
| addr | C | 1..1 | AD | 4537-5402: If 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). 4537-5403: If 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). should-country: SHOULD contain country |
| item | ||||
| country | 0..1 | ADXP | Binding: Country2 (required) | |
| languageCommunication | C | 0..* | LanguageCommunication | should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| languageCode | 1..1 | CS | ||
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..* | ON | ||
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| time | 1..1 | USRealmDateTime | Base for all types and resources | |
| assignedAuthor | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:npi | C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor | 0..1 | cs | If NPI is unknown, set @nullFlavor to UNK | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
 (Choice of one) | 1..1 | |||
 assignedPerson | 0..1 | Person | ||
 name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| manufacturerModelName | 1..1 | SC | ||
| softwareName | 1..1 | SC | ||
| dataEnterer | 0..1 | DataEnterer | The 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. | |
| time | 0..1 | USRealmDateTime | Base for all types and resources | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider | 0..* | Informant | The 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..1 | AssignedEntity | ||
 id | 1..* | II | If 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). | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| relatedEntity | 0..0 | |||
| informant:non-provider | 0..* | Informant | The 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. | |
| assignedEntity | 0..0 | |||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The 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..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..1 | ON | ||
| telecom | C | 1..1 | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | 1..1 | USRealmAddress | Base for all types and resources | |
| informationRecipient | 0..* | InformationRecipient | The 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 | 1..1 | IntendedRecipient | ||
| id | 0..* | II | ||
| informationRecipient | 0..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| receivedOrganization | 0..1 | Organization | ||
| name | 1..1 | ON | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | The 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. | |
| time | 1..1 | USRealmDateTime | Base for all types and resources | |
| signatureCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | 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. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | 0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| time | 1..1 | USRealmDateTime | Base for all types and resources | |
| signatureCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | 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. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | ||
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| participant | C | 0..* | Participant1 | The 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). 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When 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). |
| time | 0..1 | USRealmDateTimeInterval | Base for all types and resources | |
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
| order | 1..1 | Order | ||
| id | 1..* | II | ||
| documentationOf | 0..* | DocumentationOf | ||
| serviceEvent | C | 1..1 | ServiceEvent | A 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. should-us-performer: SHOULD contain performer |
| effectiveTime | 1..1 | USRealmDateTimeInterval | Base for all types and resources | |
| low | 1..1 | IVXB_TS | **MAY** be precise to at least the second | |
| performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode | C | 0..1 | CE | should-us-code: SHOULD contain code |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| time | 0..1 | USRealmDateTimeInterval | Base for all types and resources | |
| assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| authorization | 0..* | Authorization | The 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. | |
| consent | 1..1 | Consent | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. | |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | ||
| componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
| encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime | 1..1 | USRealmDateTimeInterval | Base for all types and resources | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.confidentialityCode | preferred | HL7BasicConfidentialityKind |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country | required | Country2 |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32948 | error | ClinicalDocument.code | This 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' | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| ts-shall-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | C | 1..1 | ClinicalDocument | XML 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 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant |
| realmCode | 1..1 | CS | ||
 @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
| id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| code | C | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) 4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateTime | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @code | 1..1 | cs | ||
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| setId | 0..1 | II | ||
| versionNumber | 0..1 | INT | ||
| recordTarget | 1..* | RecordTarget | The 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..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddress | (USCDI) Address |
| telecom | C | 1..* | TEL | (USCDI) Phone Number / Email should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | (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) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime | C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc (USCDI) Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | (USCDI) Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML 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..1 | CE | (USCDI) Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc (USCDI) Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddress | Base for all types and resources |
| telecom | C | 0..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| birthplace | 0..1 | Birthplace | ||
| place | 1..1 | Place | ||
| addr | C | 1..1 | AD | 4537-5402: If 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). 4537-5403: If 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). should-country: SHOULD contain country |
| languageCommunication | C | 0..* | LanguageCommunication | should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..* | ON | ||
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:npi | C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor | 0..1 | cs | If NPI is unknown, set @nullFlavor to UNK Binding: CDANullFlavor (required) | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (example) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| (Choice of one) | 1..1 | |||
| assignedPerson | 0..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| dataEnterer | 0..1 | DataEnterer | The 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. | |
| time | C | 0..1 | USRealmDateTime | Base for all types and resources |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider | 0..* | Informant | The 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..1 | AssignedEntity | ||
| id | 1..* | II | If 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). | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| informant:non-provider | 0..* | Informant | The 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..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The 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..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..1 | ON | ||
| telecom | C | 1..1 | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddress | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | The 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 | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| id | 0..* | II | ||
| informationRecipient | 0..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| receivedOrganization | 0..1 | Organization | ||
| name | 1..1 | ON | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | The 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. | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | 0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (example) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| participant | C | 0..* | Participant1 | The 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). 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When 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 | 1..1 | cs | Binding: ParticipationType (required) | |
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| id | 1..* | II | ||
| documentationOf | 0..* | DocumentationOf | ||
| serviceEvent | C | 1..1 | ServiceEvent | A 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. should-us-performer: SHOULD contain performer |
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second |
| performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode | C | 0..1 | CE | should-us-code: SHOULD contain code |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| authorization | 0..* | Authorization | The 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. | |
| consent | 1..1 | Consent | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The 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..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
| encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| component | 1..1 | Component | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | example | FHIRDocumentTypeCodes |
| ClinicalDocument.confidentialityCode | preferred | HL7BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.code | example | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.authenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.authenticator.assignedEntity.code | example | RoleCode |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.consent.code | example | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32948 | error | ClinicalDocument.code | This 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' | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | 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 | The 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() | |
| 81-9372 | error | 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 | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If 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')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| pn-no-ls | error | ClinicalDocument.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 | No 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-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA 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' | |
| ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-shall-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.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-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | C | 1..1 | ClinicalDocument | XML 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 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: ActClass (example) Fixed Value: DOCCLIN | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| realmCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: US | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| typeId | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
| id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| code | C | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) 4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| sdtcStatusCode | 0..1 | CS | XML Namespace: urn:hl7-org:sdtc XML: statusCode (urn:hl7-org:sdtc) Binding: ActStatus (required) | |
| effectiveTime | C | 1..1 | USRealmDateTime | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @code | 1..1 | cs | ||
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| setId | 0..1 | II | ||
| versionNumber | 0..1 | INT | ||
| copyTime | 0..1 | TS | ||
| recordTarget | 1..* | RecordTarget | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| patientRole | 1..1 | PatientRole | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | C | 1..* | USRealmAddress | (USCDI) Address |
| telecom | C | 1..* | TEL | (USCDI) Phone Number / Email should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
 useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 0..1 | II | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | (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) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime | C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc (USCDI) Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcMultipleBirthInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | (USCDI) Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML 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..1 | CE | (USCDI) Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc (USCDI) Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddress | Base for all types and resources |
| telecom | C | 0..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| place | 1..1 | Place | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | 0..1 | EN | ||
| addr | C | 1..1 | AD | 4537-5402: If 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). 4537-5403: If 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). should-country: SHOULD contain country |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @isNotOrdered | 0..1 | bl | ||
| @use | 0..* | cs | Binding: CDAPostalAddressUse (required) | |
| item | C | 0..* | Base | Choice Group: This is a repeating choice group that does not appear directly in the instance |
| (Choice of one) | 1..1 | |||
| delimiter | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
 @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
 xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DEL | |
| country | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CNT | |
| state | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STA | |
| county | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CPA | |
| city | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CTY | |
| postalCode | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: SAL | |
| houseNumber | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: BNN | |
| direction | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DIR | |
| streetName | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STR | |
| streetNameBase | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STB | |
| streetNameType | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STTYP | |
| additionalLocator | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: ADL | |
| unitID | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: UNID | |
| unitType | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: UNIT | |
| careOf | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CAR | |
| censusTract | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: BNS | |
| postBox | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: POB | |
| precinct | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: PRE | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| languageCommunication | C | 0..* | LanguageCommunication | should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| name | 1..* | ON | ||
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| functionCode | 0..1 | CE | ||
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:npi | C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor | 0..1 | cs | If NPI is unknown, set @nullFlavor to UNK Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| (Choice of one) | 1..1 | |||
| assignedPerson | 0..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code | 0..1 | CE | Binding: EntityCode (example) | |
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| time | C | 0..1 | USRealmDateTime | Base for all types and resources |
| assignedEntity | 1..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider | 0..* | Informant | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | If 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..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| informant:non-provider | 0..* | Informant | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The 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. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: CST | |
| assignedCustodian | 1..1 | AssignedCustodian | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| name | 1..1 | ON | ||
| telecom | C | 1..1 | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddress | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: XInformationRecipient (2.0.0) (required) | |
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| receivedOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 0..* | II | ||
| name | 1..1 | ON | ||
| telecom | 0..* | TEL | ||
| addr | 0..* | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| participant | C | 0..* | Participant1 | The 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). 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When 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). |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| functionCode | 0..1 | CE | ||
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipFulfills (2.0.0) (required) Fixed Value: FLFS | |
| order | 1..1 | Order | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: v3 Code System ActCode (example) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| documentationOf | 0..* | DocumentationOf | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC | |
| serviceEvent | C | 1..1 | ServiceEvent | A 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. should-us-performer: SHOULD contain performer |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| id | 0..* | II | ||
| code | 0..1 | CE | ||
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | ts | Either @value or low/high should be present, but not both Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive | 0..1 | bl | ||
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | C | 0..1 | IVXB_TS | **MAY** be precise to at least the second |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive | 0..1 | bl | ||
| performer | 0..* | Performer1 | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode | C | 0..1 | CE | should-us-code: SHOULD contain code |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| relatedDocument | 0..* | RelatedDocument | ||
| authorization | 0..* | Authorization | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH | |
| consent | 1..1 | Consent | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| id | 0..* | II | ||
| code | 0..1 | CE | The 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..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| componentOf | 0..1 | ComponentOf | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (example) | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | ||
| location | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.classCode | example | Fixed Value: DOCCLIN |
| ClinicalDocument.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.realmCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.code | example | FHIRDocumentTypeCodes |
| ClinicalDocument.sdtcStatusCode | required | ActStatus |
| ClinicalDocument.confidentialityCode | preferred | HL7BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT |
| ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.recordTarget.patientRole.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT |
| ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.use | required | CDAPostalAddressUse |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICS |
| ClinicalDocument.author.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.typeCode | required | Fixed Value: AUT |
| ClinicalDocument.author.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.author.assignedAuthor.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.code | example | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | example | EntityCode |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| ClinicalDocument.dataEnterer.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.dataEnterer.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:provider.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.informant:provider.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:non-provider.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:non-provider.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:non-provider.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:non-provider.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.custodian.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.typeCode | required | Fixed Value: CST |
| ClinicalDocument.custodian.assignedCustodian.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.informationRecipient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.typeCode | required | XInformationRecipient |
| ClinicalDocument.informationRecipient.intendedRecipient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICS |
| ClinicalDocument.legalAuthenticator.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA |
| ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.typeCode | required | Fixed Value: AUTHEN |
| ClinicalDocument.authenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.authenticator.signatureCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.authenticator.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.code | example | RoleCode |
| ClinicalDocument.authenticator.assignedEntity.code.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.participant.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.participant.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.inFulfillmentOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS |
| ClinicalDocument.inFulfillmentOf.order.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO |
| ClinicalDocument.inFulfillmentOf.order.code | example | ActCode |
| ClinicalDocument.inFulfillmentOf.order.priorityCode | example | ActPriority |
| ClinicalDocument.documentationOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC |
| ClinicalDocument.documentationOf.serviceEvent.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass |
| ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH |
| ClinicalDocument.authorization.consent.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.consent.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.authorization.consent.code | example | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.authorization.consent.statusCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.componentOf.encompassingEncounter.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC |
| ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | example | USEncounterDischargeDisposition |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32948 | error | ClinicalDocument.code | This 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' | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | 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 | The 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() | |
| 81-9372 | error | 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 | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If 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')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If 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-1 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item | Can only have only one of the possible item elements in each choice : (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1 | |
| ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| pn-no-ls | error | ClinicalDocument.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 | No 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-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA 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-null | error | ClinicalDocument.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.precinct | xmlText and nullFlavor are mutually exclusive (one must be present) : (xmlText | nullFlavor).count() = 1 | |
| ts-shall-day | error | ClinicalDocument.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-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.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-minute | warning | ClinicalDocument.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 ClinicalDocument
Summary
Mandatory: 23 elements (37 nested mandatory elements)
Prohibited: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ClinicalDocument
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | C | 1..1 | ClinicalDocument | XML 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 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant |
| realmCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | ||
| @extension | 1..1 | st | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
| id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| code | C | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). 4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | 1..1 | USRealmDateTime | Base for all types and resources | |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @nullFlavor | 0..0 | |||
| @code | 1..1 | cs | ||
| languageCode | 1..1 | CS | ||
| setId | 0..1 | II | ||
| versionNumber | 0..1 | INT | ||
| recordTarget | 1..* | RecordTarget | The 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..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | 1..* | USRealmAddress | (USCDI) Address | |
| telecom | C | 1..* | TEL | (USCDI) Phone Number / Email should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| name | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | (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) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd | 0..1 | BL | sdtc:deceasedInd | |
| sdtcDeceasedTime | C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc (USCDI) Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | (USCDI) Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML 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..1 | CE | (USCDI) Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc (USCDI) Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | 0..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 0..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| birthplace | 0..1 | Birthplace | ||
| place | 1..1 | Place | ||
| addr | C | 1..1 | AD | 4537-5402: If 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). 4537-5403: If 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). should-country: SHOULD contain country |
| item | ||||
| country | 0..1 | ADXP | Binding: Country2 (required) | |
| languageCommunication | C | 0..* | LanguageCommunication | should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| languageCode | 1..1 | CS | ||
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..* | ON | ||
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| time | 1..1 | USRealmDateTime | Base for all types and resources | |
| assignedAuthor | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:npi | C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor | 0..1 | cs | If NPI is unknown, set @nullFlavor to UNK | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| (Choice of one) | 1..1 | |||
| assignedPerson | 0..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| manufacturerModelName | 1..1 | SC | ||
| softwareName | 1..1 | SC | ||
| dataEnterer | 0..1 | DataEnterer | The 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. | |
| time | 0..1 | USRealmDateTime | Base for all types and resources | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider | 0..* | Informant | The 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..1 | AssignedEntity | ||
| id | 1..* | II | If 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). | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| relatedEntity | 0..0 | |||
| informant:non-provider | 0..* | Informant | The 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. | |
| assignedEntity | 0..0 | |||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The 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..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..1 | ON | ||
| telecom | C | 1..1 | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | 1..1 | USRealmAddress | Base for all types and resources | |
| informationRecipient | 0..* | InformationRecipient | The 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 | 1..1 | IntendedRecipient | ||
| id | 0..* | II | ||
| informationRecipient | 0..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| receivedOrganization | 0..1 | Organization | ||
| name | 1..1 | ON | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | The 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. | |
| time | 1..1 | USRealmDateTime | Base for all types and resources | |
| signatureCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | 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. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | 0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| time | 1..1 | USRealmDateTime | Base for all types and resources | |
| signatureCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | 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. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | ||
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 1..* | USRealmAddress | Base for all types and resources | |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| participant | C | 0..* | Participant1 | The 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). 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When 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). |
| time | 0..1 | USRealmDateTimeInterval | Base for all types and resources | |
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
| order | 1..1 | Order | ||
| id | 1..* | II | ||
| documentationOf | 0..* | DocumentationOf | ||
| serviceEvent | C | 1..1 | ServiceEvent | A 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. should-us-performer: SHOULD contain performer |
| effectiveTime | 1..1 | USRealmDateTimeInterval | Base for all types and resources | |
| low | 1..1 | IVXB_TS | **MAY** be precise to at least the second | |
| performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode | C | 0..1 | CE | should-us-code: SHOULD contain code |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| time | 0..1 | USRealmDateTimeInterval | Base for all types and resources | |
| assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| authorization | 0..* | Authorization | The 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. | |
| consent | 1..1 | Consent | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. | |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | ||
| componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
| encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime | 1..1 | USRealmDateTimeInterval | Base for all types and resources | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.confidentialityCode | preferred | HL7BasicConfidentialityKind |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country | required | Country2 |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32948 | error | ClinicalDocument.code | This 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' | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| ts-shall-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | C | 1..1 | ClinicalDocument | XML 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 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant |
| realmCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
| id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| code | C | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) 4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateTime | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @code | 1..1 | cs | ||
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| setId | 0..1 | II | ||
| versionNumber | 0..1 | INT | ||
| recordTarget | 1..* | RecordTarget | The 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..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddress | (USCDI) Address |
| telecom | C | 1..* | TEL | (USCDI) Phone Number / Email should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | (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) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime | C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc (USCDI) Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | (USCDI) Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML 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..1 | CE | (USCDI) Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc (USCDI) Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddress | Base for all types and resources |
| telecom | C | 0..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| birthplace | 0..1 | Birthplace | ||
| place | 1..1 | Place | ||
| addr | C | 1..1 | AD | 4537-5402: If 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). 4537-5403: If 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). should-country: SHOULD contain country |
| languageCommunication | C | 0..* | LanguageCommunication | should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..* | ON | ||
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:npi | C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor | 0..1 | cs | If NPI is unknown, set @nullFlavor to UNK Binding: CDANullFlavor (required) | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (example) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| (Choice of one) | 1..1 | |||
| assignedPerson | 0..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| dataEnterer | 0..1 | DataEnterer | The 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. | |
| time | C | 0..1 | USRealmDateTime | Base for all types and resources |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider | 0..* | Informant | The 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..1 | AssignedEntity | ||
| id | 1..* | II | If 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). | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| informant:non-provider | 0..* | Informant | The 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..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The 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..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| name | 1..1 | ON | ||
| telecom | C | 1..1 | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddress | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | The 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 | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| id | 0..* | II | ||
| informationRecipient | 0..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| receivedOrganization | 0..1 | Organization | ||
| name | 1..1 | ON | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | The 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. | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | 0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @code | 1..1 | cs | Required Pattern: S | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (example) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| participant | C | 0..* | Participant1 | The 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). 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When 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 | 1..1 | cs | Binding: ParticipationType (required) | |
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| id | 1..* | II | ||
| documentationOf | 0..* | DocumentationOf | ||
| serviceEvent | C | 1..1 | ServiceEvent | A 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. should-us-performer: SHOULD contain performer |
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second |
| performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode | C | 0..1 | CE | should-us-code: SHOULD contain code |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| id | 1..* | II | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| authorization | 0..* | Authorization | The 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. | |
| consent | 1..1 | Consent | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The 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..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
| encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| component | 1..1 | Component | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | example | FHIRDocumentTypeCodes |
| ClinicalDocument.confidentialityCode | preferred | HL7BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.code | example | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.authenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.authenticator.assignedEntity.code | example | RoleCode |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.consent.code | example | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32948 | error | ClinicalDocument.code | This 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' | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | 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 | The 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() | |
| 81-9372 | error | 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 | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If 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')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
| ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| pn-no-ls | error | ClinicalDocument.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 | No 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-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA 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' | |
| ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
| ts-shall-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.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-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | C | 1..1 | ClinicalDocument | XML 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 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: ActClass (example) Fixed Value: DOCCLIN | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| realmCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: US | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| typeId | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Fixed Value: POCD_HD000040 | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
| id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
| code | C | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) 4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| sdtcStatusCode | 0..1 | CS | XML Namespace: urn:hl7-org:sdtc XML: statusCode (urn:hl7-org:sdtc) Binding: ActStatus (required) | |
| effectiveTime | C | 1..1 | USRealmDateTime | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| @code | 1..1 | cs | ||
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| setId | 0..1 | II | ||
| versionNumber | 0..1 | INT | ||
| copyTime | 0..1 | TS | ||
| recordTarget | 1..* | RecordTarget | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| patientRole | 1..1 | PatientRole | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | C | 1..* | USRealmAddress | (USCDI) Address |
| telecom | C | 1..* | TEL | (USCDI) Phone Number / Email should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 0..1 | II | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | (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) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcDeceasedInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime | C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc (USCDI) Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
| sdtcMultipleBirthInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | (USCDI) Race Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML 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..1 | CE | (USCDI) Ethnicity Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc (USCDI) Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddress | Base for all types and resources |
| telecom | C | 0..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| place | 1..1 | Place | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | 0..1 | EN | ||
| addr | C | 1..1 | AD | 4537-5402: If 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). 4537-5403: If 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). should-country: SHOULD contain country |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @isNotOrdered | 0..1 | bl | ||
| @use | 0..* | cs | Binding: CDAPostalAddressUse (required) | |
| item | C | 0..* | Base | Choice Group: This is a repeating choice group that does not appear directly in the instance |
| (Choice of one) | 1..1 | |||
| delimiter | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DEL | |
| country | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CNT | |
| state | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STA | |
| county | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CPA | |
| city | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CTY | |
| postalCode | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: SAL | |
| houseNumber | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: BNN | |
| direction | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DIR | |
| streetName | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STR | |
| streetNameBase | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STB | |
| streetNameType | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: STTYP | |
| additionalLocator | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: ADL | |
| unitID | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: UNID | |
| unitType | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: UNIT | |
| careOf | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CAR | |
| censusTract | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: BNS | |
| postBox | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: POB | |
| precinct | C | 0..1 | ADXP | |
| (Choice of one) | 1..1 | |||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| @representation | 0..1 | cs | Fixed Value: TXT | |
| @mediaType | 0..1 | cs | Fixed Value: text/plain | |
| @language | 0..1 | cs | ||
| @partType | 0..1 | cs | Fixed Value: PRE | |
| xmlText | 0..1 | st | Allows for mixed text content | |
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| languageCommunication | C | 0..* | LanguageCommunication | should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| name | 1..* | ON | ||
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| functionCode | 0..1 | CE | ||
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:npi | C | 0..1 | II | should-extension: SHOULD contain extension |
| @nullFlavor | 0..1 | cs | If NPI is unknown, set @nullFlavor to UNK Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| (Choice of one) | 1..1 | |||
| assignedPerson | 0..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code | 0..1 | CE | Binding: EntityCode (example) | |
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| time | C | 0..1 | USRealmDateTime | Base for all types and resources |
| assignedEntity | 1..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
| informant:provider | 0..* | Informant | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | If 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..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| informant:non-provider | 0..* | Informant | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The 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. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: CST | |
| assignedCustodian | 1..1 | AssignedCustodian | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| name | 1..1 | ON | ||
| telecom | C | 1..1 | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddress | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: XInformationRecipient (2.0.0) (required) | |
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| receivedOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 0..* | II | ||
| name | 1..1 | ON | ||
| telecom | 0..* | TEL | ||
| addr | 0..* | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (example) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | MAY contain '2.16.840.1.113883.4.6' (NPI) | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| time | C | 1..1 | USRealmDateTime | Base for all types and resources |
| signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML 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..1 | AssignedEntity | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddress | Base for all types and resources |
| telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Fixed Value: PRS | |
| @determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
| code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| participant | C | 0..* | Participant1 | The 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). 4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When 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). |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| functionCode | 0..1 | CE | ||
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipFulfills (2.0.0) (required) Fixed Value: FLFS | |
| order | 1..1 | Order | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: v3 Code System ActCode (example) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| documentationOf | 0..* | DocumentationOf | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC | |
| serviceEvent | C | 1..1 | ServiceEvent | A 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. should-us-performer: SHOULD contain performer |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| id | 0..* | II | ||
| code | 0..1 | CE | ||
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | ts | Either @value or low/high should be present, but not both Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive | 0..1 | bl | ||
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | C | 0..1 | IVXB_TS | **MAY** be precise to at least the second |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @inclusive | 0..1 | bl | ||
| performer | 0..* | Performer1 | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| functionCode | C | 0..1 | CE | should-us-code: SHOULD contain code |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | C | 0..1 | USRealmDateTimeInterval | Base for all types and resources |
| assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| relatedDocument | 0..* | RelatedDocument | ||
| authorization | 0..* | Authorization | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH | |
| consent | 1..1 | Consent | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| id | 0..* | II | ||
| code | 0..1 | CE | The 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..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| componentOf | 0..1 | ComponentOf | The 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..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
| effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources |
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (example) | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | ||
| location | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.classCode | example | Fixed Value: DOCCLIN |
| ClinicalDocument.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.realmCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.code | example | FHIRDocumentTypeCodes |
| ClinicalDocument.sdtcStatusCode | required | ActStatus |
| ClinicalDocument.confidentialityCode | preferred | HL7BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT |
| ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.recordTarget.patientRole.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT |
| ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.use | required | CDAPostalAddressUse |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguages |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICS |
| ClinicalDocument.author.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.typeCode | required | Fixed Value: AUT |
| ClinicalDocument.author.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.author.assignedAuthor.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.code | example | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | example | EntityCode |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| ClinicalDocument.dataEnterer.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.dataEnterer.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:provider.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.informant:provider.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:non-provider.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:non-provider.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informant:non-provider.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:non-provider.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.custodian.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.typeCode | required | Fixed Value: CST |
| ClinicalDocument.custodian.assignedCustodian.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.informationRecipient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.typeCode | required | XInformationRecipient |
| ClinicalDocument.informationRecipient.intendedRecipient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICS |
| ClinicalDocument.legalAuthenticator.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA |
| ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.typeCode | required | Fixed Value: AUTHEN |
| ClinicalDocument.authenticator.signatureCode | required | CDASignatureCode |
| ClinicalDocument.authenticator.signatureCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.authenticator.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.code | example | RoleCode |
| ClinicalDocument.authenticator.assignedEntity.code.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.participant.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.participant.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.inFulfillmentOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS |
| ClinicalDocument.inFulfillmentOf.order.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO |
| ClinicalDocument.inFulfillmentOf.order.code | example | ActCode |
| ClinicalDocument.inFulfillmentOf.order.priorityCode | example | ActPriority |
| ClinicalDocument.documentationOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC |
| ClinicalDocument.documentationOf.serviceEvent.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass |
| ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | CareTeamMemberFunction |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH |
| ClinicalDocument.authorization.consent.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.consent.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.authorization.consent.code | example | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.authorization.consent.statusCode.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.componentOf.encompassingEncounter.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC |
| ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | example | USEncounterDischargeDisposition |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavor | required | CDANullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
| 4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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')) | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If 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})?')) | |
| 4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
| 4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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') | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
| 4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
| 4537-32948 | error | ClinicalDocument.code | This 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' | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
| 81-9371 | error | 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 | The 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() | |
| 81-9372 | error | 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 | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
| 81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If 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')) | |
| 81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | If 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-1 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item | Can only have only one of the possible item elements in each choice : (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1 | |
| ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
| ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
| pn-no-ls | error | ClinicalDocument.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 | No 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-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
| shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
| shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
| shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
| shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-country | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
| should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
| should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
| should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
| should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
| should-npi | warning | ClinicalDocument.recordTarget.patientRole.providerOrganization.id.root, ClinicalDocument.dataEnterer.assignedEntity.id.root, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.root, ClinicalDocument.authenticator.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.root | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
| should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
| should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
| should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
| should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
| should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
| should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
| should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
| should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
| should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-use | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
| should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
| signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA 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-null | error | ClinicalDocument.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.precinct | xmlText and nullFlavor are mutually exclusive (one must be present) : (xmlText | nullFlavor).count() = 1 | |
| ts-shall-day | error | ClinicalDocument.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-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.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-minute | warning | ClinicalDocument.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 ClinicalDocument
Summary
Mandatory: 23 elements (37 nested mandatory elements)
Prohibited: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0-ballot based on FHIR 5.0.0. Generated 2023-12-21
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