todo the unique id of a clinical document 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. specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note) the title of the document Represents an identifier that is common across all document revisions used to version successive replacement documents If this document replaces another who the document is about Author (contributed content to document) a participant who has attested to the accuracy of the document expected to receive a copy org which maintains the document. the main Act, such as a colonoscopy or an appendectomy, being documented context of the document Document is broken into sections See Extensions When authoring happened who/what authored the final document The type of attestation the authenticator offers When document attested who attested the document type of section (recommended) the section creation time (sections are often re-used in several documents). if section author different to document 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 if section different to document provided information in section the actual content of the section nested Section When authoring happened who/what authored the section The person authenticated the document in their personal capacity The person authenticated the document in their professional capacity The person authenticated the document and accepted legal responsibility for it's content The organization authenticated the document as consistent with their policies and procedures