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

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

Logical Model: US Realm Header for Patient Generated Document

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeaderforPatientGeneratedDocument Version: 3.0.0-ballot
Active as of 2023-12-21 Computable Name: USRealmHeaderforPatientGeneratedDocument
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.29.1:2024-05-01

This template is designed to be used in conjunction with the US Realm Header. It includes additional conformances which further constrain the US Realm Header. The Patient Generated Document Header template is not a separate document type. The document body may contain any structured or unstructured content from C-CDA.

Usage:

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

Formal Views of Profile Content

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

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... templateId 2..*II
... templateId:us-patient-gen-doc 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.29.1
.... @extension 1..1stRequired Pattern: 2024-05-01
... recordTarget 1..1RecordTargetThe recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.
.... patientRole 1..1PatientRole
..... id 1..*II
..... patient C1..1Patientshould-languageCommunication: SHOULD contain languageCommunication
...... guardian C0..*Guardianshould-id: SHOULD contain id
should-code: SHOULD contain code
....... id 0..*II
....... code 0..1CE
...... languageCommunication
....... preferenceInd 0..1BLIndicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1.
..... providerOrganization 0..1OrganizationIf present, this organization represents the provider organization where the person is claiming to be a patient.
.... assignedAuthor C1..1AssignedAuthorshould-code: SHOULD contain code
..... id 1..*II
..... code 0..1CEWhen the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.
...... @code 1..1csBinding: Personal And Legal Relationship Role Type (preferred)
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author.
.... assignedEntity 1..1AssignedEntity
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
.... relatedEntity 1..1RelatedEntity
..... code C0..1CEshould-code-attr: SHOULD contain @code
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
... custodian 1..1CustodianThe custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganizationThe representedCustodianOrganization may be the person when the document is not maintained by an organization.
...... id 1..*IIThe combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way.
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.
.... intendedRecipient C1..1IntendedRecipientshould-id: SHOULD contain id
..... id C0..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
should-root: SHOULD contain @root
...... @root 0..1oid, uuid, ruidFor a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.
... legalAuthenticator 0..1LegalAuthenticatorIn a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... assignedEntity 1..1AssignedEntity
..... id 1..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
..... code 0..1CE
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
..... id 1..*IIThe combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way.
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... participant 0..*Participant1The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)
.... @typeCode 1..1csUnless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
.... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1Order
..... id 1..*IIA scheduled appointment or service event in a practice management system may be represented using this id element.
... documentationOf 0..*DocumentationOf
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-code: SHOULD contain code
should-performer: SHOULD contain performer
..... code 0..1CEThe code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1csWhen indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode
...... functionCode C0..1CEshould-code-attr: SHOULD contain @code
...... assignedEntity 1..1AssignedEntity
....... id 1..*IIThe combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way.
....... code 0..1CEIf the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set
Binding: Personal And Legal Relationship Role Type (preferred)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.author.assignedAuthor.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.dataEnterer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.informant:non-provider.relatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.legalAuthenticator.assignedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.authenticator.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant.associatedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType

Constraints

IdGradePath(s)DetailsRequirements
should-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEventSHOULD contain code
: code.exists()
should-code-attrwarningClinicalDocument.informant:non-provider.relatedEntity.code, ClinicalDocument.documentationOf.serviceEvent.performer.functionCodeSHOULD contain @code
: code.exists()
should-idwarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain id
: id.exists()
should-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-rootwarningClinicalDocument.informationRecipient.intendedRecipient.idSHOULD contain @root
: root.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... realmCode 1..1CS
.... @code 1..1csRequired Pattern: US
... typeId 1..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:us-patient-gen-doc 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.29.1
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
... languageCode 1..1CSBinding: AllLanguages (required)
... recordTarget 1..1RecordTargetThe recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patientshould-languageCommunication: SHOULD contain languageCommunication
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
...... guardian C0..*Guardianshould-id: SHOULD contain id
should-code: SHOULD contain code
....... id 0..*II
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... guardianPerson 1..1Person
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... providerOrganization 0..1OrganizationIf present, this organization represents the provider organization where the person is claiming to be a patient.
...... id 1..*II
...... name 1..*ON
...... telecom C1..*TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressBase for all types and resources
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate.
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthorshould-code: SHOULD contain code
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... code 0..1CEWhen the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.
Binding: v3 Code System RoleCode (example)
...... @code 1..1csBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author.
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1AssignedEntity
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... addr C1..*USRealmAddressBase for all types and resources
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... relatedEntity 1..1RelatedEntity
...... @classCode 1..1csBinding: RoleClassMutualRelationship (required)
...... code C0..1CEBinding: PersonalRelationshipRoleType (example)
should-code-attr: SHOULD contain @code
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
... custodian 1..1CustodianThe custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganizationThe representedCustodianOrganization may be the person when the document is not maintained by an organization.
...... id 1..*IIThe combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way.
...... name 1..1ON
...... telecom C1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.
.... intendedRecipient C1..1IntendedRecipientshould-id: SHOULD contain id
..... @classCode 1..1cs
..... id C0..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
should-root: SHOULD contain @root
...... @root 0..1oid, uuid, ruidFor a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.
... legalAuthenticator 0..1LegalAuthenticatorIn a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @code 1..1csRequired Pattern: S
.... assignedEntity 1..1AssignedEntity
..... id 1..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @code 1..1csRequired Pattern: S
.... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
..... id 1..*IIThe combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way.
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... participant C0..*Participant1The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)
.... @typeCode 1..1csUnless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
Binding: ParticipationType (required)
.... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
..... @classCode 1..1csBinding: RoleClassAssociative (required)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1Order
..... @classCode 1..1csBinding: ActClass (required)
..... id 1..*IIA scheduled appointment or service event in a practice management system may be represented using this id element.
... documentationOf 0..*DocumentationOf
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-code: SHOULD contain code
should-performer: SHOULD contain performer
..... @classCode 1..1csBinding: ActClass (required)
..... code 0..1CEThe code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
...... low C1..1IVXB_TS**MAY** be precise to at least the second
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1csWhen indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode
Binding: x_ServiceEventPerformer (required)
...... functionCode C0..1CEshould-code-attr: SHOULD contain @code
...... assignedEntity C1..1AssignedEntity
....... id 1..*IIThe combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way.
....... code 0..1CEIf the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set
Binding: Personal And Legal Relationship Role Type (preferred)
... component 1..1Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.author.assignedAuthor.codeexampleRoleCode
ClinicalDocument.author.assignedAuthor.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.dataEnterer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.informant:non-provider.relatedEntity.classCoderequiredRoleClassMutualRelationship
ClinicalDocument.informant:non-provider.relatedEntity.codeexamplePersonalRelationshipRoleType
ClinicalDocument.informant:non-provider.relatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.authenticator.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant.associatedEntity.classCoderequiredRoleClassAssociative
ClinicalDocument.participant.associatedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType

Constraints

IdGradePath(s)DetailsRequirements
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participantWhen participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
: typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33')
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
: (assignedPerson | assignedAuthoringDevice).count() = 1
4537-21000errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
: sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true')
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32993errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
: sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists()
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
: item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty()
81-10024errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
ivl-ts-centererrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty()
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL have at most one of each: state, city, postalCode, and country
: (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1)
shall-max-suffixerrorClinicalDocument.recordTarget.patientRole.patient.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEventSHOULD contain code
: code.exists()
should-code-attrwarningClinicalDocument.informant:non-provider.relatedEntity.code, ClinicalDocument.documentationOf.serviceEvent.performer.functionCodeSHOULD contain @code
: code.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-idwarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-rootwarningClinicalDocument.informationRecipient.intendedRecipient.idSHOULD contain @root
: root.exists()
should-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-us-telecomwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain telecom
: telecom.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.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-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.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
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CS
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: US
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:us-patient-gen-doc 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.29.1
..... @extension 1..1stRequired Pattern: 2024-05-01
... id 1..1II**SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... languageCode 1..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..1RecordTargetThe recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... patientRole 1..1PatientRole
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patientshould-languageCommunication: SHOULD contain languageCommunication
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... sdtcDeceasedInd 0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C0..1TSXML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... sdtcRaceCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (required)
...... guardian C0..*Guardianshould-id: SHOULD contain id
should-code: SHOULD contain code
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressBase for all types and resources
....... telecom C0..*TEL
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1url
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
........ sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... realmCode 0..*CS
......... typeId 0..1II
.......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.......... @assigningAuthorityName 0..1st
.......... @displayable 0..1bl
.......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.......... @extension 1..1st
......... templateId 0..*II
......... @classCode 1..1csFixed Value: PRS
......... @determinerCode 0..1csFixed Value: INSTANCE
......... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... place 1..1Place
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name 0..1EN
........ addr C1..1AD
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @isNotOrdered 0..1bl
......... @use 0..*csBinding: CDAPostalAddressUse (required)
......... item C0..*BaseChoice Group: This is a repeating choice group that does not appear directly in the instance
.......... (Choice of one) 1..1
........... delimiter C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DEL
........... country C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CNT
........... state C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STA
........... county C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CPA
........... city C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CTY
........... postalCode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ZIP
........... streetAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: SAL
........... houseNumber C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNR
........... houseNumberNumeric C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNN
........... direction C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DIR
........... streetName C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STR
........... streetNameBase C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STB
........... streetNameType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STTYP
........... additionalLocator C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ADL
........... unitID C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNID
........... unitType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNIT
........... careOf C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CAR
........... censusTract C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CEN
........... deliveryAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DAL
........... deliveryInstallationType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINST
........... deliveryInstallationArea C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTA
........... deliveryInstallationQualifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTQ
........... deliveryMode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMOD
........... deliveryModeIdentifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMODID
........... buildingNumberSuffix C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNS
........... postBox C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: POB
........... precinct C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: PRE
........... xmlText 0..1stAllows for mixed text content
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication C0..*LanguageCommunication
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... languageCode 1..1CSBinding: AllLanguages (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BLIndicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1.
..... providerOrganization 0..1OrganizationIf present, this organization represents the provider organization where the person is claiming to be a patient.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..*ON
...... telecom C1..*TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... functionCode 0..1CE
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthorshould-code: SHOULD contain code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @nullFlavor 0..1csIf NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEWhen the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.
Binding: v3 Code System RoleCode (example)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csBinding: Personal And Legal Relationship Role Type (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... assignedAuthoringDevice 0..1AuthoringDevice
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassDevice (required)
Fixed Value: DEV
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 0..1CEBinding: EntityCode (example)
....... manufacturerModelName 1..1SCBinding: Manufacturer Model Name Example (example)
....... softwareName 1..1SCBinding: Software Name Example (example)
....... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: ENT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C0..1USRealmDateTimeBase for all types and resources
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... assignedEntity 1..1AssignedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr C1..*USRealmAddressBase for all types and resources
...... telecom 0..*TEL
...... assignedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... representedOrganization 0..1Organization
...... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
....... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... relatedEntity 1..1RelatedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: RoleClassMutualRelationship (required)
...... code C0..1CEBinding: PersonalRelationshipRoleType (example)
should-code-attr: SHOULD contain @code
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr 0..*AD
...... telecom 0..*TEL
...... effectiveTime 0..1IVL_TS
...... relatedPerson 0..1Person
... custodian 1..1CustodianThe custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: CST
.... assignedCustodian 1..1AssignedCustodian
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1CustodianOrganizationThe representedCustodianOrganization may be the person when the document is not maintained by an organization.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*IIThe combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way.
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..1ON
...... telecom C1..1TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient C1..1IntendedRecipientshould-id: SHOULD contain id
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1cs
..... id C0..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
should-root: SHOULD contain @root
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 0..1oid, uuid, ruidFor a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... receivedOrganization 0..1Organization
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorIn a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: LA
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 0..1oid, uuid, ruidMAY contain '2.16.840.1.113883.4.6' (NPI)
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTHEN
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*IIThe combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 0..1csBinding: Healthcare Provider Taxonomy (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... participant C0..*Participant1The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 1..1csUnless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
Binding: ParticipationType (required)
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... functionCode 0..1CE
.... time C0..1USRealmDateTimeIntervalBase for all types and resources
.... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: RoleClassAssociative (required)
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr 0..*AD
..... telecom 0..*TEL
..... associatedPerson 0..1Person
..... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1Order
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMoodIntent (required)
Fixed Value: RQO
..... id 1..*IIA scheduled appointment or service event in a practice management system may be represented using this id element.
..... code 0..1CEBinding: v3 Code System ActCode (example)
..... priorityCode 0..1CEBinding: ActPriority (example)
... documentationOf 0..*DocumentationOf
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-code: SHOULD contain code
should-performer: SHOULD contain performer
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... @operator 0..1csBinding: SetOperator (required)
...... low C1..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
...... center 0..1TS
...... width 0..1PQ
...... high C0..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 1..1csWhen indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode
Binding: x_ServiceEventPerformer (required)
...... functionCode C0..1CEshould-code-attr: SHOULD contain @code
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Care Team Member Function (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... time C0..1USRealmDateTimeIntervalBase for all types and resources
...... assignedEntity C1..1AssignedEntity
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... id 1..*IIThe combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way.
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root C0..1oid, uuid, ruid
........ @extension 0..1st
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEIf the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set
Binding: Personal And Legal Relationship Role Type (preferred)
....... addr 0..*AD
....... telecom 0..*TEL
....... assignedPerson 0..1Person
....... representedOrganization 0..1Organization
....... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
........ id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... relatedDocument 0..*RelatedDocument
... authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1CSBinding: ActStatus (required)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csFixed Value: completed
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C1..1EncompassingEncounter
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: ENC
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 1..*II
..... code 0..1CEBinding: Act Encounter Codes (preferred)
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
..... sdtcAdmissionReferralSourceCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity C1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component

doco Documentation for this format

Terminology Bindings

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

Constraints

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

This structure is derived from USRealmHeader

Summary

Mandatory: 3 elements

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... templateId 2..*II
... templateId:us-patient-gen-doc 1..1II
.... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.29.1
.... @extension 1..1stRequired Pattern: 2024-05-01
... recordTarget 1..1RecordTargetThe recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.
.... patientRole 1..1PatientRole
..... id 1..*II
..... patient C1..1Patientshould-languageCommunication: SHOULD contain languageCommunication
...... guardian C0..*Guardianshould-id: SHOULD contain id
should-code: SHOULD contain code
....... id 0..*II
....... code 0..1CE
...... languageCommunication
....... preferenceInd 0..1BLIndicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1.
..... providerOrganization 0..1OrganizationIf present, this organization represents the provider organization where the person is claiming to be a patient.
.... assignedAuthor C1..1AssignedAuthorshould-code: SHOULD contain code
..... id 1..*II
..... code 0..1CEWhen the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.
...... @code 1..1csBinding: Personal And Legal Relationship Role Type (preferred)
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author.
.... assignedEntity 1..1AssignedEntity
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
.... relatedEntity 1..1RelatedEntity
..... code C0..1CEshould-code-attr: SHOULD contain @code
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
... custodian 1..1CustodianThe custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganizationThe representedCustodianOrganization may be the person when the document is not maintained by an organization.
...... id 1..*IIThe combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way.
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.
.... intendedRecipient C1..1IntendedRecipientshould-id: SHOULD contain id
..... id C0..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
should-root: SHOULD contain @root
...... @root 0..1oid, uuid, ruidFor a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.
... legalAuthenticator 0..1LegalAuthenticatorIn a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... assignedEntity 1..1AssignedEntity
..... id 1..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
..... code 0..1CE
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
..... id 1..*IIThe combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way.
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... participant 0..*Participant1The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)
.... @typeCode 1..1csUnless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
.... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1Order
..... id 1..*IIA scheduled appointment or service event in a practice management system may be represented using this id element.
... documentationOf 0..*DocumentationOf
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-code: SHOULD contain code
should-performer: SHOULD contain performer
..... code 0..1CEThe code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1csWhen indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode
...... functionCode C0..1CEshould-code-attr: SHOULD contain @code
...... assignedEntity 1..1AssignedEntity
....... id 1..*IIThe combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way.
....... code 0..1CEIf the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set
Binding: Personal And Legal Relationship Role Type (preferred)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.author.assignedAuthor.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.dataEnterer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.informant:non-provider.relatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.legalAuthenticator.assignedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.authenticator.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.participant.associatedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType

Constraints

IdGradePath(s)DetailsRequirements
should-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEventSHOULD contain code
: code.exists()
should-code-attrwarningClinicalDocument.informant:non-provider.relatedEntity.code, ClinicalDocument.documentationOf.serviceEvent.performer.functionCodeSHOULD contain @code
: code.exists()
should-idwarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain id
: id.exists()
should-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-rootwarningClinicalDocument.informationRecipient.intendedRecipient.idSHOULD contain @root
: root.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... realmCode 1..1CS
.... @code 1..1csRequired Pattern: US
... typeId 1..1II
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:us-patient-gen-doc 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.29.1
..... @extension 1..1stRequired Pattern: 2024-05-01
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
... languageCode 1..1CSBinding: AllLanguages (required)
... recordTarget 1..1RecordTargetThe recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patientshould-languageCommunication: SHOULD contain languageCommunication
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
...... guardian C0..*Guardianshould-id: SHOULD contain id
should-code: SHOULD contain code
....... id 0..*II
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... guardianPerson 1..1Person
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... providerOrganization 0..1OrganizationIf present, this organization represents the provider organization where the person is claiming to be a patient.
...... id 1..*II
...... name 1..*ON
...... telecom C1..*TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressBase for all types and resources
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate.
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthorshould-code: SHOULD contain code
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... code 0..1CEWhen the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.
Binding: v3 Code System RoleCode (example)
...... @code 1..1csBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author.
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1AssignedEntity
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... addr C1..*USRealmAddressBase for all types and resources
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... relatedEntity 1..1RelatedEntity
...... @classCode 1..1csBinding: RoleClassMutualRelationship (required)
...... code C0..1CEBinding: PersonalRelationshipRoleType (example)
should-code-attr: SHOULD contain @code
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
... custodian 1..1CustodianThe custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganizationThe representedCustodianOrganization may be the person when the document is not maintained by an organization.
...... id 1..*IIThe combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way.
...... name 1..1ON
...... telecom C1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.
.... intendedRecipient C1..1IntendedRecipientshould-id: SHOULD contain id
..... @classCode 1..1cs
..... id C0..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
should-root: SHOULD contain @root
...... @root 0..1oid, uuid, ruidFor a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.
... legalAuthenticator 0..1LegalAuthenticatorIn a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @code 1..1csRequired Pattern: S
.... assignedEntity 1..1AssignedEntity
..... id 1..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @code 1..1csRequired Pattern: S
.... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
..... id 1..*IIThe combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way.
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... participant C0..*Participant1The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)
.... @typeCode 1..1csUnless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
Binding: ParticipationType (required)
.... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
..... @classCode 1..1csBinding: RoleClassAssociative (required)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1Order
..... @classCode 1..1csBinding: ActClass (required)
..... id 1..*IIA scheduled appointment or service event in a practice management system may be represented using this id element.
... documentationOf 0..*DocumentationOf
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-code: SHOULD contain code
should-performer: SHOULD contain performer
..... @classCode 1..1csBinding: ActClass (required)
..... code 0..1CEThe code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
...... low C1..1IVXB_TS**MAY** be precise to at least the second
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1csWhen indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode
Binding: x_ServiceEventPerformer (required)
...... functionCode C0..1CEshould-code-attr: SHOULD contain @code
...... assignedEntity C1..1AssignedEntity
....... id 1..*IIThe combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way.
....... code 0..1CEIf the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set
Binding: Personal And Legal Relationship Role Type (preferred)
... component 1..1Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
ClinicalDocument.confidentialityCodepreferredHL7BasicConfidentialityKind
ClinicalDocument.languageCoderequiredAllLanguages
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.author.assignedAuthor.codeexampleRoleCode
ClinicalDocument.author.assignedAuthor.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.dataEnterer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.informant:non-provider.relatedEntity.classCoderequiredRoleClassMutualRelationship
ClinicalDocument.informant:non-provider.relatedEntity.codeexamplePersonalRelationshipRoleType
ClinicalDocument.informant:non-provider.relatedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.code.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
ClinicalDocument.authenticator.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader
ClinicalDocument.participant.typeCoderequiredParticipationType
ClinicalDocument.participant.associatedEntity.classCoderequiredRoleClassAssociative
ClinicalDocument.participant.associatedEntity.codepreferredPersonalAndLegalRelationshipRoleType
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredPersonalAndLegalRelationshipRoleType

Constraints

IdGradePath(s)DetailsRequirements
4537-6380errorClinicalDocumentIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
: setId.exists() implies versionNumber.exists()
4537-6387errorClinicalDocumentIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
: versionNumber.exists() implies setId.exists()
4537-10006errorClinicalDocument.participant**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participantWhen participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
: typeCode = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33')
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
: (assignedPerson | assignedAuthoringDevice).count() = 1
4537-21000errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
: sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true')
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32993errorClinicalDocument.recordTarget.patientRole.patientIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
: sdtcDeceasedInd.exists(value='true') implies sdtcDeceasedTime.exists()
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
: item.xmlText.empty()
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
: conformsTo('http://hl7.org/cda/us/ccda/StructureDefinition/USRealmPatientNamePTNUSFIELDED') or item.xmlText.exists()
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
: item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty()
81-10024errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.state.exists(nullFlavor.exists() or xmlText.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state'))
81-10025errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrIf the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
: nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?'))
ivl-ts-centererrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf a time interval contains @value, then it shall be precise to at least the day.
: value.exists() implies value.toString().length() >= 10
ivl-value-shouldwarningClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (item.delimiter | item.family | item.given | item.prefix | item.suffix).where(qualifier.where($this = 'LS').exists()).empty()
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain exactly one [1..1] city (CONF:81-7292).
: nullFlavor.exists() or item.city.count() = 1
shall-familyerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain exactly one [1..1] family (CONF:81-7159).
: nullFlavor.exists() or item.family.count() = 1
shall-givenerrorClinicalDocument.recordTarget.patientRole.patient.nameSHALL contain at least one [1..*] given (CONF:81-7157).
: nullFlavor.exists() or item.given.exists()
shall-max-ad-partserrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL have at most one of each: state, city, postalCode, and country
: (item.state.empty() or item.state.count() = 1) and (item.city.empty() or item.city.count() = 1) and (item.postalCode.empty() or item.postalCode.count() = 1) and (item.country.empty() or item.country.count() = 1)
shall-max-suffixerrorClinicalDocument.recordTarget.patientRole.patient.nameThere may be at most one suffix
: (item.suffix.empty() or item.suffix.count() = 1)
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEventSHOULD contain code
: code.exists()
should-code-attrwarningClinicalDocument.informant:non-provider.relatedEntity.code, ClinicalDocument.documentationOf.serviceEvent.performer.functionCodeSHOULD contain @code
: code.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-idwarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipientSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-relatedParticipantwarningClinicalDocumentDocuments SHOULD contain a RelatedPerson participant
: participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists()
should-rootwarningClinicalDocument.informationRecipient.intendedRecipient.idSHOULD contain @root
: root.exists()
should-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-us-telecomwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain telecom
: telecom.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.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-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.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

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... @classCode 0..1csBinding: ActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CS
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: US
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stFixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2024-05-01
.... templateId:us-patient-gen-doc 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.29.1
..... @extension 1..1stRequired Pattern: 2024-05-01
... id 1..1II**SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code C1..1CE**SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... sdtcStatusCode 0..1CSXML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime C1..1USRealmDateTimeBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
.... @code 1..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... languageCode 1..1CSBinding: AllLanguages (required)
... setId 0..1II
... versionNumber 0..1INT
... copyTime 0..1TS
... recordTarget 1..1RecordTargetThe recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... patientRole 1..1PatientRole
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddress(USCDI) Address
..... telecom C1..*TEL(USCDI) Phone Number / Email
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient C1..1Patientshould-languageCommunication: SHOULD contain languageCommunication
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS(USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
...... sdtcDeceasedInd 0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C0..1TSXML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CE(USCDI) Race
Binding: Race Category Excluding Nulls (required)
...... sdtcRaceCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (required)
...... ethnicGroupCode 1..1CE(USCDI) Ethnicity
Binding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (required)
...... guardian C0..*Guardianshould-id: SHOULD contain id
should-code: SHOULD contain code
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressBase for all types and resources
....... telecom C0..*TEL
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @value 0..1url
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
........ sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... realmCode 0..*CS
......... typeId 0..1II
.......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.......... @assigningAuthorityName 0..1st
.......... @displayable 0..1bl
.......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.......... @extension 1..1st
......... templateId 0..*II
......... @classCode 1..1csFixed Value: PRS
......... @determinerCode 0..1csFixed Value: INSTANCE
......... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... place 1..1Place
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 0..1csBinding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name 0..1EN
........ addr C1..1AD
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @isNotOrdered 0..1bl
......... @use 0..*csBinding: CDAPostalAddressUse (required)
......... item C0..*BaseChoice Group: This is a repeating choice group that does not appear directly in the instance
.......... (Choice of one) 1..1
........... delimiter C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DEL
........... country C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CNT
........... state C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STA
........... county C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CPA
........... city C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CTY
........... postalCode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ZIP
........... streetAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: SAL
........... houseNumber C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNR
........... houseNumberNumeric C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNN
........... direction C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DIR
........... streetName C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STR
........... streetNameBase C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STB
........... streetNameType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: STTYP
........... additionalLocator C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: ADL
........... unitID C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNID
........... unitType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: UNIT
........... careOf C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CAR
........... censusTract C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: CEN
........... deliveryAddressLine C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DAL
........... deliveryInstallationType C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINST
........... deliveryInstallationArea C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTA
........... deliveryInstallationQualifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DINSTQ
........... deliveryMode C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMOD
........... deliveryModeIdentifier C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: DMODID
........... buildingNumberSuffix C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: BNS
........... postBox C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: POB
........... precinct C0..1ADXP
............ (Choice of one) 1..1
............. @nullFlavor 0..1csBinding: CDANullFlavor (required)
............. xmlText 0..1stAllows for mixed text content
............ @representation 0..1csFixed Value: TXT
............ @mediaType 0..1csFixed Value: text/plain
............ @language 0..1cs
............ @partType 0..1csFixed Value: PRE
........... xmlText 0..1stAllows for mixed text content
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication C0..*LanguageCommunication
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... languageCode 1..1CSBinding: AllLanguages (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BLIndicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1.
..... providerOrganization 0..1OrganizationIf present, this organization represents the provider organization where the person is claiming to be a patient.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..*ON
...... telecom C1..*TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... functionCode 0..1CE
.... time C1..1USRealmDateTimeBase for all types and resources
.... assignedAuthor C1..1AssignedAuthorshould-code: SHOULD contain code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:npi C0..1II
....... @nullFlavor 0..1csIf NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEWhen the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.
Binding: v3 Code System RoleCode (example)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csBinding: Personal And Legal Relationship Role Type (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... assignedAuthoringDevice 0..1AuthoringDevice
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassDevice (required)
Fixed Value: DEV
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 0..1CEBinding: EntityCode (example)
....... manufacturerModelName 1..1SCBinding: Manufacturer Model Name Example (example)
....... softwareName 1..1SCBinding: Software Name Example (example)
....... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: ENT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C0..1USRealmDateTimeBase for all types and resources
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for informant 0..*InformantSlice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... assignedEntity 1..1AssignedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..*IIIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr C1..*USRealmAddressBase for all types and resources
...... telecom 0..*TEL
...... assignedPerson 1..1Person
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ realmCode 0..*CS
........ typeId 0..1II
......... @nullFlavor 0..1csBinding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1st
......... @displayable 0..1bl
......... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1st
........ templateId 0..*II
........ @classCode 1..1csFixed Value: PRS
........ @determinerCode 0..1csFixed Value: INSTANCE
........ code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... representedOrganization 0..1Organization
...... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
....... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... informant:non-provider 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... relatedEntity 1..1RelatedEntity
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 1..1csBinding: RoleClassMutualRelationship (required)
...... code C0..1CEBinding: PersonalRelationshipRoleType (example)
should-code-attr: SHOULD contain @code
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr 0..*AD
...... telecom 0..*TEL
...... effectiveTime 0..1IVL_TS
...... relatedPerson 0..1Person
... custodian 1..1CustodianThe custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: CST
.... assignedCustodian 1..1AssignedCustodian
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1CustodianOrganizationThe representedCustodianOrganization may be the person when the document is not maintained by an organization.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..*IIThe combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way.
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root C0..1oid, uuid, ruid
....... @extension 0..1st
...... name 1..1ON
...... telecom C1..1TEL
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressBase for all types and resources
... informationRecipient 0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient C1..1IntendedRecipientshould-id: SHOULD contain id
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1cs
..... id C0..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
should-root: SHOULD contain @root
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 0..1oid, uuid, ruidFor a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... receivedOrganization 0..1Organization
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorIn a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: LA
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*IIThe combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 0..1oid, uuid, ruidMAY contain '2.16.840.1.113883.4.6' (NPI)
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTHEN
.... time C1..1USRealmDateTimeBase for all types and resources
.... signatureCode C1..1CSBinding: CDASignatureCode (required)
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 1..1csRequired Pattern: S
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity C1..1AssignedEntityshould-code: SHOULD contain code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*IIThe combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root C0..1oid, uuid, ruid
...... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 0..1csBinding: Healthcare Provider Taxonomy (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressBase for all types and resources
..... telecom C1..*TEL
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 1..1csFixed Value: PRS
....... @determinerCode 0..1csFixed Value: INSTANCE
....... code 1..1CEXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... participant C0..*Participant1The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 1..1csUnless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
Binding: ParticipationType (required)
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... functionCode 0..1CE
.... time C0..1USRealmDateTimeIntervalBase for all types and resources
.... associatedEntity C1..1AssociatedEntityshould-code: SHOULD contain code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: RoleClassAssociative (required)
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Personal And Legal Relationship Role Type (preferred)
..... addr 0..*AD
..... telecom 0..*TEL
..... associatedPerson 0..1Person
..... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1Order
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMoodIntent (required)
Fixed Value: RQO
..... id 1..*IIA scheduled appointment or service event in a practice management system may be represented using this id element.
..... code 0..1CEBinding: v3 Code System ActCode (example)
..... priorityCode 0..1CEBinding: ActPriority (example)
... documentationOf 0..*DocumentationOf
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: DOC
.... serviceEvent C1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-code: SHOULD contain code
should-performer: SHOULD contain performer
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClass (required)
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @value 0..1tsEither @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... @operator 0..1csBinding: SetOperator (required)
...... low C1..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
...... center 0..1TS
...... width 0..1PQ
...... high C0..1IVXB_TS**MAY** be precise to at least the second
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1bl
..... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 1..1csWhen indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode
Binding: x_ServiceEventPerformer (required)
...... functionCode C0..1CEshould-code-attr: SHOULD contain @code
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @code 0..1csBinding: Care Team Member Function (preferred)
....... @codeSystem 0..1oid, uuid, ruid
....... @codeSystemName 0..1st
....... @codeSystemVersion 0..1st
....... @displayName 0..1st
....... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... time C0..1USRealmDateTimeIntervalBase for all types and resources
...... assignedEntity C1..1AssignedEntity
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1st
....... templateId 0..*II
....... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... id 1..*IIThe combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way.
........ @nullFlavor 0..1csBinding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1st
........ @displayable 0..1bl
........ @root C0..1oid, uuid, ruid
........ @extension 0..1st
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEIf the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set
Binding: Personal And Legal Relationship Role Type (preferred)
....... addr 0..*AD
....... telecom 0..*TEL
....... assignedPerson 0..1Person
....... representedOrganization 0..1Organization
....... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
........ id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... relatedDocument 0..*RelatedDocument
... authorization 0..*AuthorizationThe authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1CSBinding: ActStatus (required)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csFixed Value: completed
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1ComponentOfThe encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C1..1EncompassingEncounter
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: ActClass (required)
Fixed Value: ENC
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 1..*II
..... code 0..1CEBinding: Act Encounter Codes (preferred)
..... effectiveTime C1..1USRealmDateTimeIntervalBase for all types and resources
..... sdtcAdmissionReferralSourceCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CEBinding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity C1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... location 0..1InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component

doco Documentation for this format

Terminology Bindings

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

Constraints

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

This structure is derived from USRealmHeader

Summary

Mandatory: 3 elements

 

Other representations of profile: CSV, Excel