Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Logical Model: US Realm Header

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader Version: 3.0.0
Draft as of 2024-05-18 Computable Name: USRealmHeader
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:2024-05-01

This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents. Further specification, such as ClinicalDocument/code, are provided in document templates that conform to this template.

Usage:

Formal Views of Template Content

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

This structure is derived from ClinicalDocument

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 ClinicalDocument XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
should-legalAuthenticator: SHOULD contain legalAuthenticator
should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant
... realmCode 1..1 CS
.... @code 1..1 cs Required Pattern: US
... typeId 1..1 II
.... @root 1..1 oid, uuid, ruid
.... @extension 1..1 st
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
.... @nullFlavor 0..0
.... @code 1..1 cs
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime 1..1 USRealmDateTime Base for all types and resources
... confidentialityCode
.... @nullFlavor 0..0
.... @code 1..1 cs Binding: HL7 BasicConfidentialityKind . (preferred)
... languageCode 1..1 CS
... setId 0..1 II
... versionNumber 0..1 INT
... recordTarget 1..* RecordTarget The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... patientRole 1..1 PatientRole
..... id 1..* II
..... addr 1..* USRealmAddress (USCDI) Address
..... telecom C 1..* TEL (USCDI) Phone Number / Email
should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... patient C 1..1 Patient 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication
...... name 1..* USRealmPatientNamePTNUSFIELDED Base for all types and resources
...... administrativeGenderCode 1..1 CE Binding: Administrative Gender (HL7 V3) . (required)
...... birthTime C 1..1 TS (USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcDeceasedInd 0..1 BL sdtc:deceasedInd
...... sdtcDeceasedTime C 0..1 TS XML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
should-value-att: SHOULD contain @value
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... maritalStatusCode 0..1 CE Binding: Marital Status . (required)
...... religiousAffiliationCode 0..1 CE Binding: Religious Affiliation . (required)
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... sdtcRaceCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
...... sdtcEthnicGroupCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity . (required)
...... guardian C 0..* Guardian should-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
....... code 0..1 CE Binding: Personal And Legal Relationship Role Type . (required)
....... addr 0..* USRealmAddress Base for all types and resources
....... telecom C 0..* TEL should-use: SHOULD contain @use
........ @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
....... guardianPerson 1..1 Person
........ name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
...... birthplace 0..1 Birthplace
....... place 1..1 Place
........ addr C 1..1 AD 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country
......... item
.......... country 0..1 ADXP Binding: Country2 (required)
...... languageCommunication C 0..* LanguageCommunication (USCDI) Preferred Language
should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode
should-preferenceInd: SHOULD contain preferenceInd
....... languageCode 1..1 CS Binding: Language codes with language and optionally a region modifier (required)
....... modeCode 0..1 CE Binding: LanguageAbilityMode . (required)
....... proficiencyLevelCode 0..1 CE Binding: LanguageAbilityProficiency . (required)
....... preferenceInd 0..1 BL
..... providerOrganization 0..1 Organization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..* ON
...... telecom C 1..* TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr 1..* USRealmAddress Base for all types and resources
... author 1..* Author The author element represents the creator of the clinical document. The author may be a device or a person.
.... time 1..1 USRealmDateTime Base for all types and resources
.... assignedAuthor C 1..1 AssignedAuthor 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code
..... Slices for id 1..* II Slice: Unordered, Open by value:root
...... id:npi C 0..1 II should-extension: SHOULD contain extension
....... @nullFlavor 0..1 cs If NPI is unknown, set @nullFlavor to UNK
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1 st
..... code 0..1 CE Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
...... @nullFlavor 0..0
...... @code 1..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1 Person
....... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
...... assignedAuthoringDevice 0..1 AuthoringDevice
....... manufacturerModelName 1..1 SC
....... softwareName 1..1 SC
... dataEnterer 0..1 DataEnterer The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... time 0..1 USRealmDateTime Base for all types and resources
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
... Slices for informant 0..* Informant Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..* Informant The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1 AssignedEntity
...... id 1..* II If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
...... addr 1..* USRealmAddress Base for all types and resources
...... assignedPerson 1..1 Person
....... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
..... relatedEntity 0..0
.... informant:non-provider 0..* Informant The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... assignedEntity 0..0
..... relatedEntity 1..1 RelatedEntity
... custodian 1..1 Custodian The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... assignedCustodian 1..1 AssignedCustodian
..... representedCustodianOrganization 1..1 CustodianOrganization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... sdtcTelecom 0..* TEL The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
...... addr 1..1 USRealmAddress Base for all types and resources
... informationRecipient 0..* InformationRecipient The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... intendedRecipient 1..1 IntendedRecipient
..... id 0..* II
..... informationRecipient 0..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
..... receivedOrganization 0..1 Organization
...... name 1..1 ON
... legalAuthenticator 0..1 LegalAuthenticator The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... time 1..1 USRealmDateTime Base for all types and resources
.... signatureCode 1..1 CS
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root 0..1 oid, uuid, ruid MAY contain '2.16.840.1.113883.4.6' (NPI)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
... authenticator 0..* Authenticator The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... time 1..1 USRealmDateTime Base for all types and resources
.... signatureCode 1..1 CS
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE
...... @code 0..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
... participant C 0..* Participant1 The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
.... time 0..1 USRealmDateTimeInterval Base for all types and resources
... inFulfillmentOf 0..* InFulfillmentOf The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1 Order
..... id 1..* II
... documentationOf 0..* DocumentationOf
.... serviceEvent C 1..1 ServiceEvent A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer
..... effectiveTime 1..1 USRealmDateTimeInterval Base for all types and resources
...... low 1..1 IVXB_TS **MAY** be precise to at least the second
..... performer 0..* Performer1 The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
...... functionCode C 0..1 CE should-code-attr: SHOULD contain @code
....... @code 0..1 cs Binding: Care Team Member Function . (preferred)
...... time 0..1 USRealmDateTimeInterval Base for all types and resources
...... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
....... id 1..* II
........ @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... authorization 0..* Authorization The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... consent 1..1 Consent
..... id 0..* II
..... code 0..1 CE The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
..... statusCode 1..1 CS
...... @code 1..1 cs
... componentOf 0..1 ComponentOf The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter C 1..1 EncompassingEncounter should-responsibleParty: SHOULD contain responsibleParty
..... id 1..* II
..... code 0..1 CE Binding: Act Encounter Codes . (preferred)
..... effectiveTime 1..1 USRealmDateTimeInterval Base for all types and resources
..... responsibleParty 0..1 InfrastructureRoot
...... assignedEntity C 1..1 AssignedEntity 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClinicalDocument.confidentialityCode.codepreferredHL7BasicConfidentialityKind .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.countryrequiredCountry2
http://terminology.hl7.org/ValueSet/v3-Country2
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredLanguageCodesWithLanguageAndOptionallyARegionModifier
http://hl7.org/fhir/us/core/ValueSet/simple-language
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.authenticator.assignedEntity.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5

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')
4537-32993errorClinicalDocument.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()
should-code-attrwarningClinicalDocument.documentationOf.serviceEvent.performer.functionCodeSHOULD contain @code
: code.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-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-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-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, 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.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
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
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 ClinicalDocument XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
should-legalAuthenticator: SHOULD contain legalAuthenticator
should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant
... realmCode 1..1 CS
.... @code 1..1 cs Required Pattern: US
... typeId 1..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1 cs
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
... confidentialityCode 1..1 CE
.... @code 1..1 cs Binding: HL7 BasicConfidentialityKind . (preferred)
... languageCode 1..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... recordTarget 1..* RecordTarget The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... patientRole 1..1 PatientRole
..... id 1..* II
..... addr C 1..* USRealmAddress (USCDI) Address
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL (USCDI) Phone Number / Email
should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... patient C 1..1 Patient 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication
...... name C 1..* USRealmPatientNamePTNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159).
shall-given: SHALL contain at least one [1..*] given (CONF:81-7157).
shall-max-suffix: There may be at most one suffix
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278).
...... administrativeGenderCode 1..1 CE Binding: Administrative Gender (HL7 V3) . (required)
...... birthTime C 1..1 TS (USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcDeceasedInd 0..1 BL XML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C 0..1 TS XML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
should-value-att: SHOULD contain @value
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... maritalStatusCode 0..1 CE Binding: Marital Status . (required)
...... religiousAffiliationCode 0..1 CE Binding: Religious Affiliation . (required)
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... sdtcRaceCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
...... sdtcEthnicGroupCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity . (required)
...... guardian C 0..* Guardian should-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
....... code 0..1 CE Binding: Personal And Legal Relationship Role Type . (required)
....... addr C 0..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
....... telecom C 0..* TEL should-use: SHOULD contain @use
........ @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
....... guardianPerson 1..1 Person
........ name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... birthplace 0..1 Birthplace
....... place 1..1 Place
........ addr C 1..1 AD 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country
...... languageCommunication C 0..* LanguageCommunication (USCDI) Preferred Language
should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode
should-preferenceInd: SHOULD contain preferenceInd
....... languageCode 1..1 CS Binding: Language codes with language and optionally a region modifier (required)
....... modeCode 0..1 CE Binding: LanguageAbilityMode . (required)
....... proficiencyLevelCode 0..1 CE Binding: LanguageAbilityProficiency . (required)
....... preferenceInd 0..1 BL
..... providerOrganization 0..1 Organization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..* ON
...... telecom C 1..* TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
... author 1..* Author The author element represents the creator of the clinical document. The author may be a device or a person.
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedAuthor C 1..1 AssignedAuthor 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code
..... Slices for id 1..* II Slice: Unordered, Open by value:root
...... id:npi C 0..1 II should-extension: SHOULD contain extension
....... @nullFlavor 0..1 cs If NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1 st
..... code 0..1 CE Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: CDARoleCode (example)
...... @code 1..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1 Person
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... assignedAuthoringDevice 0..1 AuthoringDevice
....... manufacturerModelName 1..1 SC Binding: Manufacturer Model Name Example (example)
....... softwareName 1..1 SC Binding: Software Name Example (example)
... dataEnterer 0..1 DataEnterer The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... time C 0..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
... Slices for informant 0..* Informant Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..* Informant The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1 AssignedEntity
...... id 1..* II If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
...... assignedPerson 1..1 Person
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
.... informant:non-provider 0..* Informant The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... relatedEntity 1..1 RelatedEntity
... custodian 1..1 Custodian The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... assignedCustodian 1..1 AssignedCustodian
..... representedCustodianOrganization 1..1 CustodianOrganization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... sdtcTelecom 0..* TEL XML Namespace: urn:hl7-org:sdtc
The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
XML: telecom (urn:hl7-org:sdtc)
...... addr C 1..1 USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
... informationRecipient 0..* InformationRecipient The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... intendedRecipient 1..1 IntendedRecipient
..... id 0..* II
..... informationRecipient 0..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
..... receivedOrganization 0..1 Organization
...... name 1..1 ON
... legalAuthenticator 0..1 LegalAuthenticator The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root 0..1 oid, uuid, ruid MAY contain '2.16.840.1.113883.4.6' (NPI)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
... authenticator 0..* Authenticator The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE Binding: CDARoleCode (example)
...... @code 0..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
... participant C 0..* Participant1 The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
.... @typeCode 1..1 cs Binding: CDAParticipationType (required)
.... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
.... associatedEntity 1..1 AssociatedEntity
... inFulfillmentOf 0..* InFulfillmentOf The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1 Order
..... id 1..* II
... documentationOf 0..* DocumentationOf
.... serviceEvent C 1..1 ServiceEvent A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... low C 1..1 IVXB_TS **MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
..... performer 0..* Performer1 The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
...... functionCode C 0..1 CE should-code-attr: SHOULD contain @code
....... @code 0..1 cs Binding: Care Team Member Function . (preferred)
...... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
....... id 1..* II
........ @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... authorization 0..* Authorization The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... consent 1..1 Consent
..... id 0..* II
..... code 0..1 CE The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1 CS Binding: ActStatus (required)
...... @code 1..1 cs Fixed Value: completed
... componentOf 0..1 ComponentOf The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter C 1..1 EncompassingEncounter should-responsibleParty: SHOULD contain responsibleParty
..... id 1..* II
..... code 0..1 CE Binding: Act Encounter Codes . (preferred)
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
..... responsibleParty 0..1 InfrastructureRoot
...... assignedEntity C 1..1 AssignedEntity 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.confidentialityCode.codepreferredHL7BasicConfidentialityKind .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredLanguageCodesWithLanguageAndOptionallyARegionModifier
http://hl7.org/fhir/us/core/ValueSet/simple-language
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelNameexampleManufacturerModelNameExample
http://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareNameexampleSoftwareNameExample
http://terminology.hl7.org/ValueSet/v3-SoftwareNameExample
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.authenticator.assignedEntity.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.authenticator.assignedEntity.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.participant.typeCoderequiredCDAParticipationType
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authorization.consent.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5

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')
4537-32993errorClinicalDocument.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})?'))
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-code-attrwarningClinicalDocument.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.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-countrywarningClinicalDocument.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-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-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-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-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, 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.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-usewarningClinicalDocument.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.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-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**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 ClinicalDocument XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
should-legalAuthenticator: SHOULD contain legalAuthenticator
should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 1..1 CS
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: US
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1 st Required Pattern: 2024-05-01
... id 1..1 II **SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code 1..1 CE **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1 cs
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
... confidentialityCode 1..1 CE
.... @code 1..1 cs Binding: HL7 BasicConfidentialityKind . (preferred)
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... languageCode 1..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... patientRole 1..1 PatientRole
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C 1..* USRealmAddress (USCDI) Address
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL (USCDI) Phone Number / Email
should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... patient C 1..1 Patient 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..1 II
...... name C 1..* USRealmPatientNamePTNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159).
shall-given: SHALL contain at least one [1..*] given (CONF:81-7157).
shall-max-suffix: There may be at most one suffix
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1 CE Binding: Administrative Gender (HL7 V3) . (required)
...... birthTime C 1..1 TS (USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcDeceasedInd 0..1 BL XML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C 0..1 TS XML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
should-value-att: SHOULD contain @value
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcMultipleBirthInd 0..1 BL XML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1 INT_POS XML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1 CE Binding: Marital Status . (required)
...... religiousAffiliationCode 0..1 CE Binding: Religious Affiliation . (required)
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... sdtcRaceCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
...... sdtcEthnicGroupCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity . (required)
...... guardian C 0..* Guardian should-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: RoleClassAgent (required)
Fixed Value: GUARD
....... id 0..* II
....... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1 CE Binding: Personal And Legal Relationship Role Type . (required)
....... addr C 0..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
....... telecom C 0..* TEL should-use: SHOULD contain @use
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @value 0..1 url
........ useablePeriod 0..*
......... useablePeriod IVL_TS
......... useablePeriod EIVL_TS
......... useablePeriod PIVL_TS
......... useablePeriod SXPR_TS
........ @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
....... guardianPerson 1..1 Person
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
........ sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
........ sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... realmCode 0..* CS
......... typeId 0..1 II
.......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.......... @assigningAuthorityName 0..1 st
.......... @displayable 0..1 bl
.......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.......... @extension 1..1 st
......... templateId 0..* II
......... @classCode 1..1 cs Fixed Value: PRS
......... @determinerCode 0..1 cs Fixed Value: INSTANCE
......... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
....... guardianOrganization 0..1 Organization
...... birthplace 0..1 Birthplace
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... place 1..1 Place
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 0..1 cs Binding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name 0..1 EN
........ addr C 1..1 AD 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @isNotOrdered 0..1 bl
......... @use 0..* cs Binding: CDAPostalAddressUse (required)
......... item C 0..* Base Choice Group: This is a repeating choice group that does not appear directly in the instance
AD-1: Can only have only one of the possible item elements in each choice
.......... (Choice of one) 1..1
........... delimiter C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DEL
........... country C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CNT
........... state C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STA
........... county C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CPA
........... city C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CTY
........... postalCode C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: ZIP
........... streetAddressLine C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: SAL
........... houseNumber C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: BNR
........... houseNumberNumeric C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: BNN
........... direction C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DIR
........... streetName C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STR
........... streetNameBase C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STB
........... streetNameType C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STTYP
........... additionalLocator C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: ADL
........... unitID C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: UNID
........... unitType C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: UNIT
........... careOf C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CAR
........... censusTract C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CEN
........... deliveryAddressLine C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DAL
........... deliveryInstallationType C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DINST
........... deliveryInstallationArea C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DINSTA
........... deliveryInstallationQualifier C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DINSTQ
........... deliveryMode C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DMOD
........... deliveryModeIdentifier C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DMODID
........... buildingNumberSuffix C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: BNS
........... postBox C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: POB
........... precinct C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: PRE
........... xmlText 0..1 st Allows for mixed text content
......... useablePeriod 0..*
.......... useablePeriod IVL_TS
.......... useablePeriod EIVL_TS
.......... useablePeriod PIVL_TS
.......... useablePeriod SXPR_TS
...... languageCommunication C 0..* LanguageCommunication (USCDI) Preferred Language
should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode
should-preferenceInd: SHOULD contain preferenceInd
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... languageCode 1..1 CS Binding: Language codes with language and optionally a region modifier (required)
....... modeCode 0..1 CE Binding: LanguageAbilityMode . (required)
....... proficiencyLevelCode 0..1 CE Binding: LanguageAbilityProficiency . (required)
....... preferenceInd 0..1 BL
..... providerOrganization 0..1 Organization
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..* II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... @extension 0..1 st
...... name 1..* ON
...... telecom C 1..* TEL should-use: SHOULD contain @use
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 url
....... useablePeriod 0..*
........ useablePeriod IVL_TS
........ useablePeriod EIVL_TS
........ useablePeriod PIVL_TS
........ useablePeriod SXPR_TS
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
...... standardIndustryClassCode 0..1 CE Binding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1 OrganizationPartOf
... author 1..* Author The author element represents the creator of the clinical document. The author may be a device or a person.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... functionCode 0..1 CE
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedAuthor C 1..1 AssignedAuthor 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id 1..* II Slice: Unordered, Open by value:root
...... id:npi C 0..1 II should-extension: SHOULD contain extension
....... @nullFlavor 0..1 cs If NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: CDARoleCode (example)
...... @code 1..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
...... @codeSystem 0..1 oid, uuid, ruid
...... @codeSystemName 0..1 st
...... @codeSystemVersion 0..1 st
...... @displayName 0..1 st
...... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1 ED
...... translation 0..* CD
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1 Person
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
....... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 1..1 cs Fixed Value: PRS
........ @determinerCode 0..1 cs Fixed Value: INSTANCE
........ code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... assignedAuthoringDevice 0..1 AuthoringDevice
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: EntityClassDevice (required)
Fixed Value: DEV
....... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 0..1 CE Binding: CDAEntityCode (example)
....... manufacturerModelName 1..1 SC Binding: Manufacturer Model Name Example (example)
....... softwareName 1..1 SC Binding: Software Name Example (example)
....... asMaintainedEntity 0..* MaintainedEntity
..... representedOrganization 0..1 Organization
... dataEnterer 0..1 DataEnterer The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: ENT
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... time C 0..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1 Organization
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for informant 0..* Informant Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..* Informant The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... assignedEntity 1..1 AssignedEntity
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..* II If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
...... telecom 0..* TEL
...... assignedPerson 1..1 Person
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
....... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 1..1 cs Fixed Value: PRS
........ @determinerCode 0..1 cs Fixed Value: INSTANCE
........ code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... representedOrganization 0..1 Organization
...... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
....... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... informant:non-provider 0..* Informant The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... relatedEntity 1..1 RelatedEntity
... custodian 1..1 Custodian The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: CST
.... assignedCustodian 1..1 AssignedCustodian
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1 CustodianOrganization
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..* II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... @extension 0..1 st
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 url
....... useablePeriod 0..*
........ useablePeriod IVL_TS
........ useablePeriod EIVL_TS
........ useablePeriod PIVL_TS
........ useablePeriod SXPR_TS
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... sdtcTelecom 0..* TEL XML Namespace: urn:hl7-org:sdtc
The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
XML: telecom (urn:hl7-org:sdtc)
...... addr C 1..1 USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
... informationRecipient 0..* InformationRecipient The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient 1..1 IntendedRecipient
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAInformationRecipientRole (required)
..... id 0..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..* AD
..... telecom 0..* TEL
..... informationRecipient 0..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... receivedOrganization 0..1 Organization
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..* II
...... name 1..1 ON
...... telecom 0..* TEL
...... addr 0..* AD
...... standardIndustryClassCode 0..1 CE Binding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1 OrganizationPartOf
... legalAuthenticator 0..1 LegalAuthenticator The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: LA
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @code 1..1 cs Required Pattern: S
..... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 0..1 oid, uuid, ruid MAY contain '2.16.840.1.113883.4.6' (NPI)
...... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1 Organization
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... authenticator 0..* Authenticator The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: AUTHEN
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @code 1..1 cs Required Pattern: S
..... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Binding: CDARoleCode (example)
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @code 0..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
...... @codeSystem 0..1 oid, uuid, ruid
...... @codeSystemName 0..1 st
...... @codeSystemVersion 0..1 st
...... @displayName 0..1 st
...... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1 ED
...... translation 0..* CD
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1 Organization
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... participant C 0..* Participant1 The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 1..1 cs Binding: CDAParticipationType (required)
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... functionCode 0..1 CE
.... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
.... associatedEntity 1..1 AssociatedEntity
... inFulfillmentOf 0..* InFulfillmentOf The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1 Order
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
..... @moodCode 0..1 cs Binding: CDAActMoodIntent (required)
Fixed Value: RQO
..... id 1..* II
..... code 0..1 CE Binding: v3 Code System ActCode (example)
..... priorityCode 0..1 CE Binding: ActPriority (example)
... documentationOf 0..* DocumentationOf
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: DOC
.... serviceEvent C 1..1 ServiceEvent A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..* II
..... code 0..1 CE
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 ts Either @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... @operator 0..1 cs Binding: CDASetOperator (required)
...... low C 1..1 IVXB_TS **MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1 bl
...... center 0..1 TS
...... width 0..1 PQ
...... high C 0..1 IVXB_TS **MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1 bl
..... performer 0..* Performer1 The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
...... functionCode C 0..1 CE should-code-attr: SHOULD contain @code
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 0..1 cs Binding: Care Team Member Function . (preferred)
....... @codeSystem 0..1 oid, uuid, ruid
....... @codeSystemName 0..1 st
....... @codeSystemVersion 0..1 st
....... @displayName 0..1 st
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1 ED
....... translation 0..* CD
...... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... id 1..* II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
........ @extension 0..1 st
....... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
....... addr 0..* AD
....... telecom 0..* TEL
....... assignedPerson 0..1 Person
....... representedOrganization 0..1 Organization
....... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
........ id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ActRelationshipAuthorizedBy (required)
Fixed Value: AUTH
.... consent 1..1 Consent
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
Fixed Value: CONS
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..* II
..... code 0..1 CE The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1 CS Binding: ActStatus (required)
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @code 1..1 cs Fixed Value: completed
...... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1 ComponentOf The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C 1..1 EncompassingEncounter should-responsibleParty: SHOULD contain responsibleParty
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
Fixed Value: ENC
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 1..* II
..... code 0..1 CE Binding: Act Encounter Codes . (preferred)
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
..... sdtcAdmissionReferralSourceCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1 CE Binding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1 InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: RESP
...... assignedEntity C 1..1 AssignedEntity 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
..... encounterParticipant 0..* EncounterParticipant
..... location 0..1 InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Binding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1 HealthCareFacility
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.realmCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.templateId:us-realm.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.confidentialityCode.codepreferredHL7BasicConfidentialityKind .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
ClinicalDocument.recordTarget.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.recordTarget.patientRole.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
http://terminology.hl7.org/ValueSet/v3-RoleClassRelationshipFormal
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877
ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
http://terminology.hl7.org/ValueSet/v3-RoleClassAgent
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
http://terminology.hl7.org/ValueSet/v3-RoleClassPassive
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
http://terminology.hl7.org/ValueSet/v3-EntityClassPlace
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.userequiredCDAPostalAddressUse
http://hl7.org/cda/stds/core/ValueSet/CDAPostalAddressUse
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredLanguageCodesWithLanguageAndOptionallyARegionModifier
http://hl7.org/fhir/us/core/ValueSet/simple-language
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCoderequiredFixed Value: ORG
http://terminology.hl7.org/ValueSet/v3-EntityClassOrganization
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
http://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.author.assignedAuthor.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
http://terminology.hl7.org/ValueSet/v3-EntityClassDevice
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeexampleCDAEntityCode
http://hl7.org/cda/stds/core/ValueSet/CDAEntityCode
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelNameexampleManufacturerModelNameExample
http://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareNameexampleSoftwareNameExample
http://terminology.hl7.org/ValueSet/v3-SoftwareNameExample
ClinicalDocument.dataEnterer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.dataEnterer.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.typeCoderequiredFixed Value: INF
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.informant:provider.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.informant:provider.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:non-provider.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:non-provider.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:non-provider.typeCoderequiredFixed Value: INF
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.informant:non-provider.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.custodian.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: CST
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.custodian.assignedCustodian.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
http://terminology.hl7.org/ValueSet/v3-EntityClassOrganization
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.informationRecipient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredXInformationRecipient
http://terminology.hl7.org/ValueSet/v3-xInformationRecipient|2.0.0
ClinicalDocument.informationRecipient.intendedRecipient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.classCoderequiredCDAInformationRecipientRole
http://hl7.org/cda/stds/core/ValueSet/CDAInformationRecipientRole
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
http://terminology.hl7.org/ValueSet/v3-EntityClassOrganization
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
http://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.typeCoderequiredFixed Value: AUTHEN
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.authenticator.signatureCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.authenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.authenticator.assignedEntity.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant.typeCoderequiredCDAParticipationType
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.participant.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
http://terminology.hl7.org/ValueSet/v3-ActRelationshipFulfills|2.0.0
ClinicalDocument.inFulfillmentOf.order.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.order.classCoderequiredCDAActClass
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
http://hl7.org/cda/stds/core/ValueSet/CDAActMoodIntent
ClinicalDocument.inFulfillmentOf.order.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
ClinicalDocument.documentationOf.serviceEvent.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredCDAActClass
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authorization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUTH
http://terminology.hl7.org/ValueSet/v3-ActRelationshipAuthorizedBy
ClinicalDocument.authorization.consent.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.consent.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.authorization.consent.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.authorization.consent.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent
ClinicalDocument.componentOf.encompassingEncounter.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeexampleUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

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')
4537-32993errorClinicalDocument.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-code-attrwarningClinicalDocument.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.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-countrywarningClinicalDocument.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-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-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-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-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, 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.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-usewarningClinicalDocument.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.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
text-nullerrorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinctxmlText and nullFlavor are mutually exclusive (one must be present)
: (xmlText | nullFlavor).count() = 1
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10

This structure is derived from ClinicalDocument

Summary

Mandatory: 25 elements(37 nested mandatory elements)
Prohibited: 5 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of ClinicalDocument.templateId
  • The element 1 is sliced based on the value of ClinicalDocument.author.assignedAuthor.id
  • The element 2 is sliced based on the values of ClinicalDocument.informant

Differential View

This structure is derived from ClinicalDocument

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 ClinicalDocument XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
should-legalAuthenticator: SHOULD contain legalAuthenticator
should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant
... realmCode 1..1 CS
.... @code 1..1 cs Required Pattern: US
... typeId 1..1 II
.... @root 1..1 oid, uuid, ruid
.... @extension 1..1 st
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
.... @nullFlavor 0..0
.... @code 1..1 cs
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime 1..1 USRealmDateTime Base for all types and resources
... confidentialityCode
.... @nullFlavor 0..0
.... @code 1..1 cs Binding: HL7 BasicConfidentialityKind . (preferred)
... languageCode 1..1 CS
... setId 0..1 II
... versionNumber 0..1 INT
... recordTarget 1..* RecordTarget The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... patientRole 1..1 PatientRole
..... id 1..* II
..... addr 1..* USRealmAddress (USCDI) Address
..... telecom C 1..* TEL (USCDI) Phone Number / Email
should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... patient C 1..1 Patient 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication
...... name 1..* USRealmPatientNamePTNUSFIELDED Base for all types and resources
...... administrativeGenderCode 1..1 CE Binding: Administrative Gender (HL7 V3) . (required)
...... birthTime C 1..1 TS (USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcDeceasedInd 0..1 BL sdtc:deceasedInd
...... sdtcDeceasedTime C 0..1 TS XML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
should-value-att: SHOULD contain @value
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... maritalStatusCode 0..1 CE Binding: Marital Status . (required)
...... religiousAffiliationCode 0..1 CE Binding: Religious Affiliation . (required)
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... sdtcRaceCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
...... sdtcEthnicGroupCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity . (required)
...... guardian C 0..* Guardian should-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
....... code 0..1 CE Binding: Personal And Legal Relationship Role Type . (required)
....... addr 0..* USRealmAddress Base for all types and resources
....... telecom C 0..* TEL should-use: SHOULD contain @use
........ @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
....... guardianPerson 1..1 Person
........ name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
...... birthplace 0..1 Birthplace
....... place 1..1 Place
........ addr C 1..1 AD 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country
......... item
.......... country 0..1 ADXP Binding: Country2 (required)
...... languageCommunication C 0..* LanguageCommunication (USCDI) Preferred Language
should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode
should-preferenceInd: SHOULD contain preferenceInd
....... languageCode 1..1 CS Binding: Language codes with language and optionally a region modifier (required)
....... modeCode 0..1 CE Binding: LanguageAbilityMode . (required)
....... proficiencyLevelCode 0..1 CE Binding: LanguageAbilityProficiency . (required)
....... preferenceInd 0..1 BL
..... providerOrganization 0..1 Organization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..* ON
...... telecom C 1..* TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr 1..* USRealmAddress Base for all types and resources
... author 1..* Author The author element represents the creator of the clinical document. The author may be a device or a person.
.... time 1..1 USRealmDateTime Base for all types and resources
.... assignedAuthor C 1..1 AssignedAuthor 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code
..... Slices for id 1..* II Slice: Unordered, Open by value:root
...... id:npi C 0..1 II should-extension: SHOULD contain extension
....... @nullFlavor 0..1 cs If NPI is unknown, set @nullFlavor to UNK
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1 st
..... code 0..1 CE Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
...... @nullFlavor 0..0
...... @code 1..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1 Person
....... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
...... assignedAuthoringDevice 0..1 AuthoringDevice
....... manufacturerModelName 1..1 SC
....... softwareName 1..1 SC
... dataEnterer 0..1 DataEnterer The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... time 0..1 USRealmDateTime Base for all types and resources
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
... Slices for informant 0..* Informant Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..* Informant The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1 AssignedEntity
...... id 1..* II If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
...... addr 1..* USRealmAddress Base for all types and resources
...... assignedPerson 1..1 Person
....... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
..... relatedEntity 0..0
.... informant:non-provider 0..* Informant The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... assignedEntity 0..0
..... relatedEntity 1..1 RelatedEntity
... custodian 1..1 Custodian The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... assignedCustodian 1..1 AssignedCustodian
..... representedCustodianOrganization 1..1 CustodianOrganization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... sdtcTelecom 0..* TEL The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
...... addr 1..1 USRealmAddress Base for all types and resources
... informationRecipient 0..* InformationRecipient The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... intendedRecipient 1..1 IntendedRecipient
..... id 0..* II
..... informationRecipient 0..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
..... receivedOrganization 0..1 Organization
...... name 1..1 ON
... legalAuthenticator 0..1 LegalAuthenticator The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... time 1..1 USRealmDateTime Base for all types and resources
.... signatureCode 1..1 CS
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root 0..1 oid, uuid, ruid MAY contain '2.16.840.1.113883.4.6' (NPI)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
... authenticator 0..* Authenticator The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... time 1..1 USRealmDateTime Base for all types and resources
.... signatureCode 1..1 CS
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE
...... @code 0..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr 1..* USRealmAddress Base for all types and resources
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
... participant C 0..* Participant1 The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
.... time 0..1 USRealmDateTimeInterval Base for all types and resources
... inFulfillmentOf 0..* InFulfillmentOf The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1 Order
..... id 1..* II
... documentationOf 0..* DocumentationOf
.... serviceEvent C 1..1 ServiceEvent A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer
..... effectiveTime 1..1 USRealmDateTimeInterval Base for all types and resources
...... low 1..1 IVXB_TS **MAY** be precise to at least the second
..... performer 0..* Performer1 The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
...... functionCode C 0..1 CE should-code-attr: SHOULD contain @code
....... @code 0..1 cs Binding: Care Team Member Function . (preferred)
...... time 0..1 USRealmDateTimeInterval Base for all types and resources
...... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
....... id 1..* II
........ @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... authorization 0..* Authorization The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... consent 1..1 Consent
..... id 0..* II
..... code 0..1 CE The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
..... statusCode 1..1 CS
...... @code 1..1 cs
... componentOf 0..1 ComponentOf The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter C 1..1 EncompassingEncounter should-responsibleParty: SHOULD contain responsibleParty
..... id 1..* II
..... code 0..1 CE Binding: Act Encounter Codes . (preferred)
..... effectiveTime 1..1 USRealmDateTimeInterval Base for all types and resources
..... responsibleParty 0..1 InfrastructureRoot
...... assignedEntity C 1..1 AssignedEntity 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClinicalDocument.confidentialityCode.codepreferredHL7BasicConfidentialityKind .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.countryrequiredCountry2
http://terminology.hl7.org/ValueSet/v3-Country2
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredLanguageCodesWithLanguageAndOptionallyARegionModifier
http://hl7.org/fhir/us/core/ValueSet/simple-language
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.authenticator.assignedEntity.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5

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')
4537-32993errorClinicalDocument.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()
should-code-attrwarningClinicalDocument.documentationOf.serviceEvent.performer.functionCodeSHOULD contain @code
: code.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-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-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-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, 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.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
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

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 ClinicalDocument XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
should-legalAuthenticator: SHOULD contain legalAuthenticator
should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant
... realmCode 1..1 CS
.... @code 1..1 cs Required Pattern: US
... typeId 1..1 II
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1 cs
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
... confidentialityCode 1..1 CE
.... @code 1..1 cs Binding: HL7 BasicConfidentialityKind . (preferred)
... languageCode 1..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... recordTarget 1..* RecordTarget The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... patientRole 1..1 PatientRole
..... id 1..* II
..... addr C 1..* USRealmAddress (USCDI) Address
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL (USCDI) Phone Number / Email
should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... patient C 1..1 Patient 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication
...... name C 1..* USRealmPatientNamePTNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159).
shall-given: SHALL contain at least one [1..*] given (CONF:81-7157).
shall-max-suffix: There may be at most one suffix
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278).
...... administrativeGenderCode 1..1 CE Binding: Administrative Gender (HL7 V3) . (required)
...... birthTime C 1..1 TS (USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcDeceasedInd 0..1 BL XML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C 0..1 TS XML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
should-value-att: SHOULD contain @value
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... maritalStatusCode 0..1 CE Binding: Marital Status . (required)
...... religiousAffiliationCode 0..1 CE Binding: Religious Affiliation . (required)
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... sdtcRaceCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
...... sdtcEthnicGroupCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity . (required)
...... guardian C 0..* Guardian should-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
....... code 0..1 CE Binding: Personal And Legal Relationship Role Type . (required)
....... addr C 0..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
....... telecom C 0..* TEL should-use: SHOULD contain @use
........ @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
....... guardianPerson 1..1 Person
........ name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... birthplace 0..1 Birthplace
....... place 1..1 Place
........ addr C 1..1 AD 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country
...... languageCommunication C 0..* LanguageCommunication (USCDI) Preferred Language
should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode
should-preferenceInd: SHOULD contain preferenceInd
....... languageCode 1..1 CS Binding: Language codes with language and optionally a region modifier (required)
....... modeCode 0..1 CE Binding: LanguageAbilityMode . (required)
....... proficiencyLevelCode 0..1 CE Binding: LanguageAbilityProficiency . (required)
....... preferenceInd 0..1 BL
..... providerOrganization 0..1 Organization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..* ON
...... telecom C 1..* TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
... author 1..* Author The author element represents the creator of the clinical document. The author may be a device or a person.
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedAuthor C 1..1 AssignedAuthor 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code
..... Slices for id 1..* II Slice: Unordered, Open by value:root
...... id:npi C 0..1 II should-extension: SHOULD contain extension
....... @nullFlavor 0..1 cs If NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1 st
..... code 0..1 CE Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: CDARoleCode (example)
...... @code 1..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1 Person
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... assignedAuthoringDevice 0..1 AuthoringDevice
....... manufacturerModelName 1..1 SC Binding: Manufacturer Model Name Example (example)
....... softwareName 1..1 SC Binding: Software Name Example (example)
... dataEnterer 0..1 DataEnterer The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... time C 0..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
... Slices for informant 0..* Informant Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..* Informant The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... assignedEntity 1..1 AssignedEntity
...... id 1..* II If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
...... assignedPerson 1..1 Person
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
.... informant:non-provider 0..* Informant The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... relatedEntity 1..1 RelatedEntity
... custodian 1..1 Custodian The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... assignedCustodian 1..1 AssignedCustodian
..... representedCustodianOrganization 1..1 CustodianOrganization
...... id 1..* II
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... sdtcTelecom 0..* TEL XML Namespace: urn:hl7-org:sdtc
The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
XML: telecom (urn:hl7-org:sdtc)
...... addr C 1..1 USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
... informationRecipient 0..* InformationRecipient The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... intendedRecipient 1..1 IntendedRecipient
..... id 0..* II
..... informationRecipient 0..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
..... receivedOrganization 0..1 Organization
...... name 1..1 ON
... legalAuthenticator 0..1 LegalAuthenticator The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root 0..1 oid, uuid, ruid MAY contain '2.16.840.1.113883.4.6' (NPI)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
... authenticator 0..* Authenticator The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @code 1..1 cs Required Pattern: S
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
..... code 0..1 CE Binding: CDARoleCode (example)
...... @code 0..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
... participant C 0..* Participant1 The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
.... @typeCode 1..1 cs Binding: CDAParticipationType (required)
.... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
.... associatedEntity 1..1 AssociatedEntity
... inFulfillmentOf 0..* InFulfillmentOf The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... order 1..1 Order
..... id 1..* II
... documentationOf 0..* DocumentationOf
.... serviceEvent C 1..1 ServiceEvent A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... low C 1..1 IVXB_TS **MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
..... performer 0..* Performer1 The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
...... functionCode C 0..1 CE should-code-attr: SHOULD contain @code
....... @code 0..1 cs Binding: Care Team Member Function . (preferred)
...... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
....... id 1..* II
........ @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... authorization 0..* Authorization The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... consent 1..1 Consent
..... id 0..* II
..... code 0..1 CE The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1 CS Binding: ActStatus (required)
...... @code 1..1 cs Fixed Value: completed
... componentOf 0..1 ComponentOf The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... encompassingEncounter C 1..1 EncompassingEncounter should-responsibleParty: SHOULD contain responsibleParty
..... id 1..* II
..... code 0..1 CE Binding: Act Encounter Codes . (preferred)
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
..... responsibleParty 0..1 InfrastructureRoot
...... assignedEntity C 1..1 AssignedEntity 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.confidentialityCode.codepreferredHL7BasicConfidentialityKind .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredLanguageCodesWithLanguageAndOptionallyARegionModifier
http://hl7.org/fhir/us/core/ValueSet/simple-language
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelNameexampleManufacturerModelNameExample
http://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareNameexampleSoftwareNameExample
http://terminology.hl7.org/ValueSet/v3-SoftwareNameExample
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.authenticator.assignedEntity.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.authenticator.assignedEntity.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.participant.typeCoderequiredCDAParticipationType
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authorization.consent.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5

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')
4537-32993errorClinicalDocument.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})?'))
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-code-attrwarningClinicalDocument.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.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-countrywarningClinicalDocument.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-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-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-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-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, 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.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-usewarningClinicalDocument.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.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-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**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 ClinicalDocument XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
should-legalAuthenticator: SHOULD contain legalAuthenticator
should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... @classCode 0..1 cs Binding: CDAActClass (example)
Fixed Value: DOCCLIN
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... realmCode 1..1 CS
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: US
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st Fixed Value: POCD_HD000040
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1 st Required Pattern: 2024-05-01
... id 1..1 II **SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code 1..1 CE **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
Binding: FHIRDocumentTypeCodes (example)
.... @code 1..1 cs
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... sdtcStatusCode 0..1 CS XML Namespace: urn:hl7-org:sdtc
XML: statusCode (urn:hl7-org:sdtc)
Binding: ActStatus (required)
... effectiveTime C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
... confidentialityCode 1..1 CE
.... @code 1..1 cs Binding: HL7 BasicConfidentialityKind . (preferred)
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... languageCode 1..1 CS Binding: AllLanguages (required)
... setId 0..1 II
... versionNumber 0..1 INT
... copyTime 0..1 TS
... recordTarget 1..* RecordTarget The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... patientRole 1..1 PatientRole
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... id 1..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C 1..* USRealmAddress (USCDI) Address
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL (USCDI) Phone Number / Email
should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... patient C 1..1 Patient 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993).
4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true
should-maritalStatusCode: SHOULD contain maritalStatusCode
should-us-languageCommunication: SHOULD contain languageCommunication
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..1 II
...... name C 1..* USRealmPatientNamePTNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
shall-family: SHALL contain exactly one [1..1] family (CONF:81-7159).
shall-given: SHALL contain at least one [1..*] given (CONF:81-7157).
shall-max-suffix: There may be at most one suffix
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1 CE Binding: Administrative Gender (HL7 V3) . (required)
...... birthTime C 1..1 TS (USCDI) Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcDeceasedInd 0..1 BL XML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime C 0..1 TS XML Namespace: urn:hl7-org:sdtc
(USCDI) Date of Death
XML: deceasedTime (urn:hl7-org:sdtc)
should-value-att: SHOULD contain @value
ts-shall-year: **SHALL** be precise to at least the year
ts-should-day: **SHOULD** be precise to at least the day
...... sdtcMultipleBirthInd 0..1 BL XML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1 INT_POS XML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1 CE Binding: Marital Status . (required)
...... religiousAffiliationCode 0..1 CE Binding: Religious Affiliation . (required)
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... sdtcRaceCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
...... sdtcEthnicGroupCode 0..* CE XML Namespace: urn:hl7-org:sdtc
(USCDI) Ethnicity
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity . (required)
...... guardian C 0..* Guardian should-us-code: SHOULD contain code
should-us-addr: SHOULD contain addr
should-us-telecom: SHOULD contain telecom
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: RoleClassAgent (required)
Fixed Value: GUARD
....... id 0..* II
....... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1 CE Binding: Personal And Legal Relationship Role Type . (required)
....... addr C 0..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
....... telecom C 0..* TEL should-use: SHOULD contain @use
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @value 0..1 url
........ useablePeriod 0..*
......... useablePeriod IVL_TS
......... useablePeriod EIVL_TS
......... useablePeriod PIVL_TS
......... useablePeriod SXPR_TS
........ @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
....... guardianPerson 1..1 Person
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
........ sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
........ sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... realmCode 0..* CS
......... typeId 0..1 II
.......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.......... @assigningAuthorityName 0..1 st
.......... @displayable 0..1 bl
.......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.......... @extension 1..1 st
......... templateId 0..* II
......... @classCode 1..1 cs Fixed Value: PRS
......... @determinerCode 0..1 cs Fixed Value: INSTANCE
......... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
....... guardianOrganization 0..1 Organization
...... birthplace 0..1 Birthplace
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... place 1..1 Place
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 0..1 cs Binding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ name 0..1 EN
........ addr C 1..1 AD 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402).
4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
should-country: SHOULD contain country
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @isNotOrdered 0..1 bl
......... @use 0..* cs Binding: CDAPostalAddressUse (required)
......... item C 0..* Base Choice Group: This is a repeating choice group that does not appear directly in the instance
AD-1: Can only have only one of the possible item elements in each choice
.......... (Choice of one) 1..1
........... delimiter C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DEL
........... country C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CNT
........... state C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STA
........... county C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CPA
........... city C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CTY
........... postalCode C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: ZIP
........... streetAddressLine C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: SAL
........... houseNumber C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: BNR
........... houseNumberNumeric C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: BNN
........... direction C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DIR
........... streetName C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STR
........... streetNameBase C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STB
........... streetNameType C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: STTYP
........... additionalLocator C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: ADL
........... unitID C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: UNID
........... unitType C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: UNIT
........... careOf C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CAR
........... censusTract C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: CEN
........... deliveryAddressLine C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DAL
........... deliveryInstallationType C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DINST
........... deliveryInstallationArea C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DINSTA
........... deliveryInstallationQualifier C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DINSTQ
........... deliveryMode C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DMOD
........... deliveryModeIdentifier C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: DMODID
........... buildingNumberSuffix C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: BNS
........... postBox C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: POB
........... precinct C 0..1 ADXP text-null: xmlText and nullFlavor are mutually exclusive (one must be present)
............ (Choice of one) 1..1
............. @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
............. xmlText 0..1 st Allows for mixed text content
............ @representation 0..1 cs Fixed Value: TXT
............ @mediaType 0..1 cs Fixed Value: text/plain
............ @language 0..1 cs
............ @partType 0..1 cs Fixed Value: PRE
........... xmlText 0..1 st Allows for mixed text content
......... useablePeriod 0..*
.......... useablePeriod IVL_TS
.......... useablePeriod EIVL_TS
.......... useablePeriod PIVL_TS
.......... useablePeriod SXPR_TS
...... languageCommunication C 0..* LanguageCommunication (USCDI) Preferred Language
should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode
should-preferenceInd: SHOULD contain preferenceInd
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... languageCode 1..1 CS Binding: Language codes with language and optionally a region modifier (required)
....... modeCode 0..1 CE Binding: LanguageAbilityMode . (required)
....... proficiencyLevelCode 0..1 CE Binding: LanguageAbilityProficiency . (required)
....... preferenceInd 0..1 BL
..... providerOrganization 0..1 Organization
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..* II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... @extension 0..1 st
...... name 1..* ON
...... telecom C 1..* TEL should-use: SHOULD contain @use
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 url
....... useablePeriod 0..*
........ useablePeriod IVL_TS
........ useablePeriod EIVL_TS
........ useablePeriod PIVL_TS
........ useablePeriod SXPR_TS
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
...... standardIndustryClassCode 0..1 CE Binding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1 OrganizationPartOf
... author 1..* Author The author element represents the creator of the clinical document. The author may be a device or a person.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... functionCode 0..1 CE
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedAuthor C 1..1 AssignedAuthor 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
should-us-code: SHOULD contain code
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... Slices for id 1..* II Slice: Unordered, Open by value:root
...... id:npi C 0..1 II should-extension: SHOULD contain extension
....... @nullFlavor 0..1 cs If NPI is unknown, set @nullFlavor to UNK
Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: CDARoleCode (example)
...... @code 1..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
...... @codeSystem 0..1 oid, uuid, ruid
...... @codeSystemName 0..1 st
...... @codeSystemVersion 0..1 st
...... @displayName 0..1 st
...... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1 ED
...... translation 0..* CD
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... (Choice of one) 1..1
...... assignedPerson 0..1 Person
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
....... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 1..1 cs Fixed Value: PRS
........ @determinerCode 0..1 cs Fixed Value: INSTANCE
........ code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... assignedAuthoringDevice 0..1 AuthoringDevice
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: EntityClassDevice (required)
Fixed Value: DEV
....... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 0..1 CE Binding: CDAEntityCode (example)
....... manufacturerModelName 1..1 SC Binding: Manufacturer Model Name Example (example)
....... softwareName 1..1 SC Binding: Software Name Example (example)
....... asMaintainedEntity 0..* MaintainedEntity
..... representedOrganization 0..1 Organization
... dataEnterer 0..1 DataEnterer The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: ENT
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... time C 0..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1 Organization
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... Slices for informant 0..* Informant Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity
.... informant:provider 0..* Informant The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... assignedEntity 1..1 AssignedEntity
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... id 1..* II If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
...... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
...... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
...... telecom 0..* TEL
...... assignedPerson 1..1 Person
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
....... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
....... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @classCode 1..1 cs Fixed Value: PRS
........ @determinerCode 0..1 cs Fixed Value: INSTANCE
........ code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
...... representedOrganization 0..1 Organization
...... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
....... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
.... informant:non-provider 0..* Informant The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: INF
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... relatedEntity 1..1 RelatedEntity
... custodian 1..1 Custodian The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: CST
.... assignedCustodian 1..1 AssignedCustodian
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... representedCustodianOrganization 1..1 CustodianOrganization
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 1..* II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
....... @extension 0..1 st
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 url
....... useablePeriod 0..*
........ useablePeriod IVL_TS
........ useablePeriod EIVL_TS
........ useablePeriod PIVL_TS
........ useablePeriod SXPR_TS
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... sdtcTelecom 0..* TEL XML Namespace: urn:hl7-org:sdtc
The stdc:telecom extension can be used to provide additional telecom elements for the custodian organization.
XML: telecom (urn:hl7-org:sdtc)
...... addr C 1..1 USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
... informationRecipient 0..* InformationRecipient The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: XInformationRecipient (2.0.0) (required)
.... intendedRecipient 1..1 IntendedRecipient
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAInformationRecipientRole (required)
..... id 0..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..* AD
..... telecom 0..* TEL
..... informationRecipient 0..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... receivedOrganization 0..1 Organization
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... id 0..* II
...... name 1..1 ON
...... telecom 0..* TEL
...... addr 0..* AD
...... standardIndustryClassCode 0..1 CE Binding: OrganizationIndustryClassNAICS (example)
...... asOrganizationPartOf 0..1 OrganizationPartOf
... legalAuthenticator 0..1 LegalAuthenticator The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: LA
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @code 1..1 cs Required Pattern: S
..... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 0..1 oid, uuid, ruid MAY contain '2.16.840.1.113883.4.6' (NPI)
...... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1 Organization
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... authenticator 0..* Authenticator The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: AUTHEN
.... time C 1..1 USRealmDateTime Base for all types and resources
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
.... signatureCode C 1..1 CS Binding: CDASignatureCode (required)
signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @code 1..1 cs Required Pattern: S
..... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1 ED XML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
...... @extension 0..1 st
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1 CE Binding: CDARoleCode (example)
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @code 0..1 cs Binding: Healthcare Provider Taxonomy . (preferred)
...... @codeSystem 0..1 oid, uuid, ruid
...... @codeSystemName 0..1 st
...... @codeSystemVersion 0..1 st
...... @displayName 0..1 st
...... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1 ED
...... translation 0..* CD
..... addr C 1..* USRealmAddress Base for all types and resources
shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292).
shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
should-use: SHOULD contain @use
should-country: SHOULD contain country
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296)
81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).
81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).
shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country
..... telecom C 1..* TEL should-use: SHOULD contain @use
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 url
...... useablePeriod 0..*
....... useablePeriod IVL_TS
....... useablePeriod EIVL_TS
....... useablePeriod PIVL_TS
....... useablePeriod SXPR_TS
...... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
..... assignedPerson 1..1 Person
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1 cs Binding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... name C 1..* USRealmPersonNamePNUSFIELDED Base for all types and resources
pn-no-ls: No PN name part may have a qualifier of LS.
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372).
...... sdtcDesc 0..1 ED XML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... sdtcAsPatientRelationship 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 1..1 cs Fixed Value: PRS
....... @determinerCode 0..1 cs Fixed Value: INSTANCE
....... code 1..1 CE XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
..... representedOrganization 0..1 Organization
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... participant C 0..* Participant1 The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 1..1 cs Binding: CDAParticipationType (required)
.... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
.... functionCode 0..1 CE
.... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
.... associatedEntity 1..1 AssociatedEntity
... inFulfillmentOf 0..* InFulfillmentOf The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ActRelationshipFulfills (2.0.0) (required)
Fixed Value: FLFS
.... order 1..1 Order
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
..... @moodCode 0..1 cs Binding: CDAActMoodIntent (required)
Fixed Value: RQO
..... id 1..* II
..... code 0..1 CE Binding: v3 Code System ActCode (example)
..... priorityCode 0..1 CE Binding: ActPriority (example)
... documentationOf 0..* DocumentationOf
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: DOC
.... serviceEvent C 1..1 ServiceEvent A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
should-us-performer: SHOULD contain performer
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..* II
..... code 0..1 CE
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @value 0..1 ts Either @value or low/high should be present, but not both
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... @operator 0..1 cs Binding: CDASetOperator (required)
...... low C 1..1 IVXB_TS **MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1 bl
...... center 0..1 TS
...... width 0..1 PQ
...... high C 0..1 IVXB_TS **MAY** be precise to at least the second
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @inclusive 0..1 bl
..... performer 0..* Performer1 The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
...... functionCode C 0..1 CE should-code-attr: SHOULD contain @code
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 0..1 cs Binding: Care Team Member Function . (preferred)
....... @codeSystem 0..1 oid, uuid, ruid
....... @codeSystemName 0..1 st
....... @codeSystemVersion 0..1 st
....... @displayName 0..1 st
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1 ED
....... translation 0..* CD
...... time C 0..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
...... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
....... id 1..* II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root C 0..1 oid, uuid, ruid should-npi: SHOULD be NPI
........ @extension 0..1 st
....... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
....... addr 0..* AD
....... telecom 0..* TEL
....... assignedPerson 0..1 Person
....... representedOrganization 0..1 Organization
....... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
........ id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... relatedDocument 0..* RelatedDocument
... authorization 0..* Authorization The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ActRelationshipAuthorizedBy (required)
Fixed Value: AUTH
.... consent 1..1 Consent
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
Fixed Value: CONS
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..* II
..... code 0..1 CE The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (example)
..... statusCode 1..1 CS Binding: ActStatus (required)
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @code 1..1 cs Fixed Value: completed
...... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... componentOf 0..1 ComponentOf The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ActRelationshipHasComponent (required)
Fixed Value: COMP
.... encompassingEncounter C 1..1 EncompassingEncounter should-responsibleParty: SHOULD contain responsibleParty
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: CDAActClass (required)
Fixed Value: ENC
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 1..* II
..... code 0..1 CE Binding: Act Encounter Codes . (preferred)
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
ivl-ts-center: Center cannot co-exist with low or high
ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day.
ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component.
..... sdtcAdmissionReferralSourceCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1 CE Binding: USEncounterDischargeDisposition (example)
..... responsibleParty 0..1 InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: RESP
...... assignedEntity C 1..1 AssignedEntity 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
..... encounterParticipant 0..* EncounterParticipant
..... location 0..1 InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Binding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1 HealthCareFacility
... component 1..1 Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.classCodeexampleFixed Value: DOCCLIN
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.realmCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.templateId:us-realm.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.codeexampleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
ClinicalDocument.sdtcStatusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.confidentialityCode.codepreferredHL7BasicConfidentialityKind .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926
ClinicalDocument.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
ClinicalDocument.recordTarget.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.recordTarget.patientRole.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
http://terminology.hl7.org/ValueSet/v3-RoleClassRelationshipFormal
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrativeGenderHL7V3 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligiousAffiliation .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRaceValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailedEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877
ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
http://terminology.hl7.org/ValueSet/v3-RoleClassAgent
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonalAndLegalRelationshipRoleType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
http://terminology.hl7.org/ValueSet/v3-RoleClassPassive
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
http://terminology.hl7.org/ValueSet/v3-EntityClassPlace
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.userequiredCDAPostalAddressUse
http://hl7.org/cda/stds/core/ValueSet/CDAPostalAddressUse
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredLanguageCodesWithLanguageAndOptionallyARegionModifier
http://hl7.org/fhir/us/core/ValueSet/simple-language
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCoderequiredFixed Value: ORG
http://terminology.hl7.org/ValueSet/v3-EntityClassOrganization
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
http://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.author.assignedAuthor.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
http://terminology.hl7.org/ValueSet/v3-EntityClassDevice
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeexampleCDAEntityCode
http://hl7.org/cda/stds/core/ValueSet/CDAEntityCode
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelNameexampleManufacturerModelNameExample
http://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareNameexampleSoftwareNameExample
http://terminology.hl7.org/ValueSet/v3-SoftwareNameExample
ClinicalDocument.dataEnterer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.dataEnterer.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.typeCoderequiredFixed Value: INF
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.informant:provider.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.informant:provider.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.informant:provider.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:non-provider.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:non-provider.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informant:non-provider.typeCoderequiredFixed Value: INF
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.informant:non-provider.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.custodian.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: CST
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.custodian.assignedCustodian.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
http://terminology.hl7.org/ValueSet/v3-EntityClassOrganization
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.informationRecipient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredXInformationRecipient
http://terminology.hl7.org/ValueSet/v3-xInformationRecipient|2.0.0
ClinicalDocument.informationRecipient.intendedRecipient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.classCoderequiredCDAInformationRecipientRole
http://hl7.org/cda/stds/core/ValueSet/CDAInformationRecipientRole
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
http://terminology.hl7.org/ValueSet/v3-EntityClassOrganization
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCodeexampleOrganizationIndustryClassNAICS
http://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.legalAuthenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.typeCoderequiredFixed Value: AUTHEN
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.authenticator.signatureCoderequiredCDASignatureCode
http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode
ClinicalDocument.authenticator.signatureCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.authenticator.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
ClinicalDocument.authenticator.assignedEntity.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.code.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authenticator.assignedEntity.telecom.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
http://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject
ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
http://terminology.hl7.org/ValueSet/v3-EntityDeterminer
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant.typeCoderequiredCDAParticipationType
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.participant.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
http://terminology.hl7.org/ValueSet/v3-ActRelationshipFulfills|2.0.0
ClinicalDocument.inFulfillmentOf.order.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.inFulfillmentOf.order.classCoderequiredCDAActClass
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
http://hl7.org/cda/stds/core/ValueSet/CDAActMoodIntent
ClinicalDocument.inFulfillmentOf.order.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
ClinicalDocument.documentationOf.serviceEvent.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredCDAActClass
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredX_ServiceEventPerformer .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ClinicalDocument.authorization.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUTH
http://terminology.hl7.org/ValueSet/v3-ActRelationshipAuthorizedBy
ClinicalDocument.authorization.consent.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.consent.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.authorization.consent.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
ClinicalDocument.authorization.consent.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent
ClinicalDocument.componentOf.encompassingEncounter.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.componentOf.encompassingEncounter.codepreferredActEncounterCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeexampleUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

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')
4537-32993errorClinicalDocument.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-code-attrwarningClinicalDocument.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.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-countrywarningClinicalDocument.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-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-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-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-us-addrwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain addr
: addr.exists()
should-us-codewarningClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, 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.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-usewarningClinicalDocument.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.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
text-nullerrorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinctxmlText and nullFlavor are mutually exclusive (one must be present)
: (xmlText | nullFlavor).count() = 1
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10

This structure is derived from ClinicalDocument

Summary

Mandatory: 25 elements(37 nested mandatory elements)
Prohibited: 5 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of ClinicalDocument.templateId
  • The element 1 is sliced based on the value of ClinicalDocument.author.assignedAuthor.id
  • The element 2 is sliced based on the values of ClinicalDocument.informant

 

Other representations of profile: CSV, Excel