HL7 Document Document 1 1 Mandatory true A documentation of clinical observations and services that are aggregated together into a single statement of clinical meaning that establishes it's own context. A clinical document is composed of a set of resources that include both human and computer readable portions. A human must attest to the accuracy of the human readable portion, and may authenticate and/or sign the entire whole For document based framework Confidentiality? Language? Consent? Signatures Document.id 1 1 Mandatory id true the unique id of a clinical document Each document needs a unique identifier so other documents and underlying infrastructure can reference it must be globally unique. UUIDs are recommended Document.instant 1 1 Mandatory instant true the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. Document.type 1 1 Mandatory CodeableConcept DocumentType true specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note) Document.title 0 1 Optional string false the title of the document It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of Document.type (e.g. a "consultation" or "progress note"). Where these display names are rendered to the clinician, or where the document has a unique title, the Document.title value should be used Document.setId 0 1 Conditional cannot have both setId and replaces id true Represents an identifier that is common across all document revisions Document.version 0 1 Optional integer true used to version successive replacement documents An integer value is recommended Document.replaces 0 1 Conditional cannot have both setId and replaces id true If this document replaces another Document.subject 1 1 Mandatory Resource(Patient|Group) true who the document is about Document.author 1 unbounded Mandatory false Author (contributed content to document) Document.author.time 0 1 Optional dateTime false When authoring happened Document.author.party 1 1 Mandatory Resource(Person|Device) false who/what authored the final document Document.attestor 0 unbounded Optional false a participant who has attested to the accuracy of the document Document.attestor.mode 1 1 Mandatory code DocumentAuthenticationMode false The type of attestation the authenticator offers Document.attestor.time 0 1 Optional dateTime false When document attested Document.attestor.party 0 1 Optional Resource(Person|Organisation) false who attested the document Document.recipient 0 unbounded Optional Resource(Person|Organization) false expected to receive a copy Document.custodian 1 1 Mandatory Resource(Organization) false org which maintains the document. Document.event 0 1 Optional Resource(Any) false the main Act, such as a colonoscopy or an appendectomy, being documented The event needs to be consistent with the type element, though can provide further information if desired Document.encounter 0 1 Optional Resource(Admission|InterestOfCare) false context of the document Document.section 1 unbounded Mandatory false Document is broken into sections Document.section.type 0 1 Optional CodeableConcept DocumentSectionType false type of section (recommended) Document.section.instant 0 1 Optional instant false the section creation time (sections are often re-used in several documents). Document.section.author 0 1 Optional false if section author different to document Document.section.author.time 0 1 Optional dateTime false When authoring happened Document.section.author.party 1 1 Mandatory Resource(Person|Device) false who/what authored the section Document.section.enterer 0 1 Optional Resource(Person|Device) false The person or device that performed the data entry leading to this section. Where there is more than one candidate, pick the most proximal to the message. Can provide other enterers in extensions Document.section.subject 0 1 Optional Resource(Person|Group) true if section different to document Document.section.informant 0 1 Optional Resource(Person) false provided information in section Document.section.content 0 1 Conditional a section must have content or one or more sections Resource(Any) true the actual content of the section Document.section.section 0 unbounded Conditional a section must have content or one or more sections false nested Section Document.section.section.# 1 1 Mandatory @Document.Section false contents as for a section Document.extensions 0 1 Optional false See Extensions Document.text 1 1 Mandatory Narrative false