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. For a full list of available versions, see the Directory of published versions

Logical Model: Procedure Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureNote Version: 3.0.0
Active as of 2024-05-18 Computable Name: ProcedureNote
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.1.6:2024-05-01

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient’s tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.

Document Sections

Although document templates may contain any section, the following sections are specifically called out by this template:

Required Sections

Additional Sections

Usage:

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

Formal Views of Template Content

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

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 USRealmHeader 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, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-componentOf: SHOULD contain componentOf
... templateId 2..* II
... Slices for templateId Content/Rules for all slices
.... templateId:procedure-note 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.6
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ProcedureNoteDocumentTypeCodes . (required)
.... participant:participant1 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).
..... @typeCode 1..1 cs Fixed Value: IND
..... functionCode 1..1 CE
...... @code 1..1 cs Required Pattern: PCP
...... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.5.88
..... associatedEntity
...... @classCode 1..1 cs Fixed Value: PROV
...... associatedPerson 1..1 Person
... documentationOf 1..* DocumentationOf A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
.... serviceEvent 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.
..... code C 0..1 CE Binding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

Additional BindingsPurposeDocumentation
Procedure . Preferred Binding
Allowed SNOMED Codes

1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low 1..1 IVXB_TS Low is required
...... (Choice of one) 1..1
....... width 0..1 PQ Represents the duration
....... high 0..1 IVXB_TS Equals low if only the date is known
..... Slices for performer 1..* 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.
Slice: Unordered, Open by value:typeCode
...... performer:primary 1..1 Performer1 This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1 cs Fixed Value: PPRF
....... assignedEntity C 1..1 AssignedEntity should-code: SHOULD contain code
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
...... performer:secondary 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 Fixed Value: SPRF
....... assignedEntity C 1..1 AssignedEntity should-code: SHOULD contain code
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
... authorization 0..1 Authorization Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... consent 1..1 Consent
..... @classCode 1..1 cs
..... @moodCode 1..1 cs
..... statusCode 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-id: SHOULD contain id
..... id 1..* II SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..1 CE
..... Slices for encounterParticipant 0..* EncounterParticipant Slice: Unordered, Open by value:typeCode
...... encounterParticipant:referrer 0..1 EncounterParticipant
....... @typeCode 1..1 cs Fixed Value: REF
..... location 1..1 InfrastructureRoot
...... healthCareFacility 1..1 HealthCareFacility
....... id 1..* II
... component 1..1 Component
.... structuredBody C 1..1 StructuredBody ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
..... Slices for component 5..* InfrastructureRoot Slice: Unordered, Open by profile:section
...... component:complications 1..1 InfrastructureRoot
....... section 1..1 ComplicationsSection Base for all types and resources
...... component:procedureDescription 1..1 InfrastructureRoot
....... section 1..1 ProcedureDescriptionSection Base for all types and resources
...... component:indications 1..1 InfrastructureRoot
....... section 1..1 ProcedureIndicationsSection Base for all types and resources
...... component:postProcedureDx 1..1 InfrastructureRoot
....... section 1..1 PostprocedureDiagnosisSection Base for all types and resources
...... component:assessment 0..1 InfrastructureRoot
....... section 1..1 AssessmentSection Base for all types and resources
...... component:assessmentAndPlan 0..1 InfrastructureRoot
....... section 1..1 AssessmentandPlanSection Base for all types and resources
...... component:planOfTreatment 0..1 InfrastructureRoot
....... section 1..1 PlanofTreatmentSection Base for all types and resources
...... component:allergies 0..1 InfrastructureRoot
....... section 1..1 AllergiesAndIntolerancesSection Base for all types and resources
...... component:anesthesia 0..1 InfrastructureRoot
....... section 1..1 AnesthesiaSection Base for all types and resources
...... component:chiefComplaint 0..1 InfrastructureRoot
....... section 1..1 ChiefComplaintSection Base for all types and resources
...... component:chiefComplaintRFV 0..1 InfrastructureRoot
....... section 1..1 ChiefComplaintandReasonforVisitSection Base for all types and resources
...... component:familyHistory 0..1 InfrastructureRoot
....... section 1..1 FamilyHistorySection Base for all types and resources
...... component:pastMedicalHistory 0..1 InfrastructureRoot
....... section 1..1 PastMedicalHistory Base for all types and resources
...... component:historyPresentIllness 0..1 InfrastructureRoot
....... section 1..1 HistoryofPresentIllnessSection Base for all types and resources
...... component:medicalHistory 0..1 InfrastructureRoot
....... section 1..1 MedicalGeneralHistorySection Base for all types and resources
...... component:medications 0..1 InfrastructureRoot
....... section 1..1 MedicationsSection Base for all types and resources
...... component:medsAdministered 0..1 InfrastructureRoot
....... section 1..1 MedicationsAdministeredSection Base for all types and resources
...... component:physicalExam 0..1 InfrastructureRoot
....... section 1..1 PhysicalExamSection Base for all types and resources
...... component:plannedProcedure 0..1 InfrastructureRoot
....... section 1..1 PlannedProcedureSection Base for all types and resources
...... component:procedureDisposition 0..1 InfrastructureRoot
....... section 1..1 ProcedureDispositionSection Base for all types and resources
...... component:estBloodLoss 0..1 InfrastructureRoot
....... section 1..1 ProcedureEstimatedBloodLossSection Base for all types and resources
...... component:findings 0..1 InfrastructureRoot
....... section 1..1 ProcedureFindingsSection Base for all types and resources
...... component:implants 0..1 InfrastructureRoot
....... section 1..1 ProcedureImplantsSection Base for all types and resources
...... component:specimensTaken 0..1 InfrastructureRoot
....... section 1..1 ProcedureSpecimensTakenSection Base for all types and resources
...... component:procedures 0..1 InfrastructureRoot
....... section 1..1 ProceduresSection Base for all types and resources
...... component:reasonForVisit 0..1 InfrastructureRoot
....... section 1..1 ReasonforVisitSection Base for all types and resources
...... component:reviewOfSystems 0..1 InfrastructureRoot
....... section 1..1 ReviewofSystemsSection Base for all types and resources
...... component:socialHistory 0..1 InfrastructureRoot
....... section 1..1 SocialHistorySection Base for all types and resources
...... component:advDirectives 0..1 InfrastructureRoot
....... section 1..1 AdvanceDirectivesSection Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClinicalDocument.coderequiredProcedureNoteDocumentTypeCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.6.1
ClinicalDocument.documentationOf.serviceEvent.coderequired
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.documentationOf.serviceEvent.performer:secondary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.285' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
cc-rfv-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-idwarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain id
: id.exists()
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 USRealmHeader 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, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
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
should-componentOf: SHOULD contain componentOf
... 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 2..* 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
.... templateId:procedure-note 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.6
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ProcedureNoteDocumentTypeCodes . (required)
.... @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)
... 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
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
... 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
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
..... 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)
... 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).
...... 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
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr C 1..1 USRealmAddress Base for all types and resources
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
... Slices for participant C 0..* Participant1 The participant element in the Procedure Note header follows the General Header Constraints for participants.
Slice: Unordered, Open by value:typeCode, value:functionCode.code
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).
.... participant:All Slices Content/Rules for all slices
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
..... associatedEntity 1..1 AssociatedEntity
.... participant:participant1 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)
Fixed Value: IND
..... functionCode 1..1 CE
...... @code 1..1 cs Required Pattern: PCP
...... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.5.88
..... associatedEntity 1..1 AssociatedEntity
...... @classCode 1..1 cs Binding: CDARoleClassAssociative (required)
Fixed Value: PROV
...... associatedPerson 1..1 Person
... documentationOf 1..* DocumentationOf A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
.... 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
..... code C 0..1 CE Binding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

Additional BindingsPurposeDocumentation
Procedure . Preferred Binding
Allowed SNOMED Codes

1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
..... 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.
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low C 1..1 IVXB_TS Low is required
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
...... (Choice of one) 1..1
....... width 0..1 PQ Represents the duration
....... high C 0..1 IVXB_TS Equals low if only the date is known
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
..... Slices for performer 1..* 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.
Slice: Unordered, Open by value:typeCode
...... performer:All Slices Content/Rules for all slices
....... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
....... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
........ id 1..* II
...... performer:primary 1..1 Performer1 This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
Fixed Value: PPRF
....... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
should-code: SHOULD contain code
........ id 1..* II
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
...... performer:secondary 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)
Fixed Value: SPRF
....... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
should-code: SHOULD contain code
........ id 1..* II
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
... authorization 0..1 Authorization Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... consent 1..1 Consent
..... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: CONS
..... @moodCode 1..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... 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
should-id: SHOULD contain id
..... id 1..* II SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..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.
..... Slices for encounterParticipant 0..* EncounterParticipant Slice: Unordered, Open by value:typeCode
...... encounterParticipant:referrer 0..1 EncounterParticipant
....... @typeCode 1..1 cs Binding: XEncounterParticipant (2.0.0) (required)
Fixed Value: REF
..... location 1..1 InfrastructureRoot
...... healthCareFacility 1..1 HealthCareFacility
....... id 1..* II
... component 1..1 Component
.... structuredBody C 1..1 StructuredBody ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
..... Slices for component 5..* InfrastructureRoot Slice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1 Section
...... component:complications 1..1 InfrastructureRoot
....... section 1..1 ComplicationsSection Base for all types and resources
...... component:procedureDescription 1..1 InfrastructureRoot
....... section 1..1 ProcedureDescriptionSection Base for all types and resources
...... component:indications 1..1 InfrastructureRoot
....... section 1..1 ProcedureIndicationsSection Base for all types and resources
...... component:postProcedureDx 1..1 InfrastructureRoot
....... section C 1..1 PostprocedureDiagnosisSection Base for all types and resources
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
...... component:assessment 0..1 InfrastructureRoot
....... section 1..1 AssessmentSection Base for all types and resources
...... component:assessmentAndPlan 0..1 InfrastructureRoot
....... section C 1..1 AssessmentandPlanSection Base for all types and resources
no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
...... component:planOfTreatment 0..1 InfrastructureRoot
....... section 1..1 PlanofTreatmentSection Base for all types and resources
...... component:allergies 0..1 InfrastructureRoot
....... section C 1..1 AllergiesAndIntolerancesSection Base for all types and resources
shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
...... component:anesthesia 0..1 InfrastructureRoot
....... section 1..1 AnesthesiaSection Base for all types and resources
...... component:chiefComplaint 0..1 InfrastructureRoot
....... section 1..1 ChiefComplaintSection Base for all types and resources
...... component:chiefComplaintRFV 0..1 InfrastructureRoot
....... section C 1..1 ChiefComplaintandReasonforVisitSection Base for all types and resources
no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
...... component:familyHistory 0..1 InfrastructureRoot
....... section 1..1 FamilyHistorySection Base for all types and resources
...... component:pastMedicalHistory 0..1 InfrastructureRoot
....... section 1..1 PastMedicalHistory Base for all types and resources
...... component:historyPresentIllness 0..1 InfrastructureRoot
....... section 1..1 HistoryofPresentIllnessSection Base for all types and resources
...... component:medicalHistory 0..1 InfrastructureRoot
....... section 1..1 MedicalGeneralHistorySection Base for all types and resources
...... component:medications 0..1 InfrastructureRoot
....... section C 1..1 MedicationsSection Base for all types and resources
shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity
...... component:medsAdministered 0..1 InfrastructureRoot
....... section 1..1 MedicationsAdministeredSection Base for all types and resources
...... component:physicalExam 0..1 InfrastructureRoot
....... section 1..1 PhysicalExamSection Base for all types and resources
...... component:plannedProcedure 0..1 InfrastructureRoot
....... section 1..1 PlannedProcedureSection Base for all types and resources
...... component:procedureDisposition 0..1 InfrastructureRoot
....... section 1..1 ProcedureDispositionSection Base for all types and resources
...... component:estBloodLoss 0..1 InfrastructureRoot
....... section 1..1 ProcedureEstimatedBloodLossSection Base for all types and resources
...... component:findings 0..1 InfrastructureRoot
....... section 1..1 ProcedureFindingsSection Base for all types and resources
...... component:implants 0..1 InfrastructureRoot
....... section 1..1 ProcedureImplantsSection Base for all types and resources
...... component:specimensTaken 0..1 InfrastructureRoot
....... section 1..1 ProcedureSpecimensTakenSection Base for all types and resources
...... component:procedures 0..1 InfrastructureRoot
....... section C 1..1 ProceduresSection Base for all types and resources
shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
...... component:reasonForVisit 0..1 InfrastructureRoot
....... section 1..1 ReasonforVisitSection Base for all types and resources
...... component:reviewOfSystems 0..1 InfrastructureRoot
....... section 1..1 ReviewofSystemsSection Base for all types and resources
...... component:socialHistory 0..1 InfrastructureRoot
....... section C 1..1 SocialHistorySection Base for all types and resources
should-smoking-status: SHOULD contain Smoking Status
...... component:advDirectives 0..1 InfrastructureRoot
....... section C 1..1 AdvanceDirectivesSection Base for all types and resources
shall-adv-directive-organizer: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.coderequiredProcedureNoteDocumentTypeCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.6.1
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.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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.participant:participant1.typeCoderequiredFixed Value: IND
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: PROV
http://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative
ClinicalDocument.documentationOf.serviceEvent.coderequired
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:primary.typeCoderequiredFixed Value: PPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.documentationOf.serviceEvent.performer:secondary.typeCoderequiredFixed Value: SPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.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.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
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer.typeCoderequiredFixed Value: REF
http://terminology.hl7.org/ValueSet/v3-xEncounterParticipant|2.0.0

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.285' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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, ClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1When 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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.informant:provider.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.informant:provider.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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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})?'))
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
cc-rfv-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
ivl-ts-centererrorClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.documentationOf.serviceEvent.effectiveTime, 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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
no-cc-rfverrorClinicalDocument.component.structuredBody.component:chiefComplaintRFV.sectionWhen using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.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-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:advDirectives.sectionIf section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer')).exists()
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergies.sectionIf section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists()
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionIf section/@nullFlavor is not present, SHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists()
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionIf section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists()
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-idwarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-post-procedure-dxwarningClinicalDocument.component.structuredBody.component:postProcedureDx.sectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
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-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
should-us-codewarningClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.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-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.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**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 USRealmHeader 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, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
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
should-componentOf: SHOULD contain componentOf
... @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 2..* 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
.... templateId:procedure-note 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: 2.16.840.1.113883.10.20.22.1.6
..... @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 The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ProcedureNoteDocumentTypeCodes . (required)
.... @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
... Slices for participant C 0..* Participant1 The participant element in the Procedure Note header follows the General Header Constraints for participants.
Slice: Unordered, Open by value:typeCode, value:functionCode.code
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).
.... participant:All Slices Content/Rules for all slices
..... @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
.... participant:participant1 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)
Fixed Value: IND
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... functionCode 1..1 CE
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @code 1..1 cs Required Pattern: PCP
...... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.5.88
...... @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.
..... associatedEntity 1..1 AssociatedEntity
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 1..1 cs Binding: CDARoleClassAssociative (required)
Fixed Value: PROV
...... id 0..* II
...... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1 CE Binding: CDARoleCode (example)
...... addr 0..* AD
...... telecom 0..* TEL
...... associatedPerson 1..1 Person
...... scopingOrganization 0..1 Organization
... 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 1..* DocumentationOf A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width 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: 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 C 0..1 CE Binding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

Additional BindingsPurposeDocumentation
Procedure . Preferred Binding
Allowed SNOMED Codes

1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
..... 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.
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... @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 Low is required
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
...... (Choice of one) 1..1
....... width 0..1 PQ Represents the duration
....... high C 0..1 IVXB_TS Equals low if only the date is known
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
..... Slices for performer 1..* 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.
Slice: Unordered, Open by value:typeCode
...... performer:All Slices Content/Rules for all slices
....... @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
...... performer:primary 1..1 Performer1 This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @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)
Fixed Value: PPRF
....... 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
should-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 . (required)
........ 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
...... performer:secondary 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)
Fixed Value: SPRF
....... 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
should-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 . (required)
........ 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..1 Authorization Authorization represents consent. Consent, if present, shall be represented by authorization/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
.... @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 1..1 cs Binding: CDAActClass (required)
Fixed Value: CONS
..... @moodCode 1..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
should-id: SHOULD contain id
..... @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 SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..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).
..... Slices for encounterParticipant 0..* EncounterParticipant Slice: Unordered, Open by value:typeCode
...... encounterParticipant:referrer 0..1 EncounterParticipant
....... @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: XEncounterParticipant (2.0.0) (required)
Fixed Value: REF
....... time 0..1 IVL_TS
....... assignedEntity 0..1 AssignedEntity
..... location 1..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
....... @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: RoleClassServiceDeliveryLocation (required)
....... id 1..* II
....... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1 CE Binding: ServiceDeliveryLocationRoleType (example)
....... location 0..1 Place
....... serviceProviderOrganization 0..1 Organization
... component 1..1 Component
.... @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
.... @contextConductionInd 0..1 bl Fixed Value: true
.... nonXMLBody 0..1 NonXMLBody
.... structuredBody C 1..1 StructuredBody ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
..... @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: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1 CE
..... languageCode 0..1 CS Binding: AllLanguages (required)
..... Slices for component 5..* InfrastructureRoot Slice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... @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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 Section
...... component:complications 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ComplicationsSection Base for all types and resources
...... component:procedureDescription 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureDescriptionSection Base for all types and resources
...... component:indications 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureIndicationsSection Base for all types and resources
...... component:postProcedureDx 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 PostprocedureDiagnosisSection Base for all types and resources
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
...... component:assessment 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 AssessmentSection Base for all types and resources
...... component:assessmentAndPlan 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 AssessmentandPlanSection Base for all types and resources
no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
...... component:planOfTreatment 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PlanofTreatmentSection Base for all types and resources
...... component:allergies 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 AllergiesAndIntolerancesSection Base for all types and resources
shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
...... component:anesthesia 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 AnesthesiaSection Base for all types and resources
...... component:chiefComplaint 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ChiefComplaintSection Base for all types and resources
...... component:chiefComplaintRFV 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 ChiefComplaintandReasonforVisitSection Base for all types and resources
no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
...... component:familyHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 FamilyHistorySection Base for all types and resources
...... component:pastMedicalHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PastMedicalHistory Base for all types and resources
...... component:historyPresentIllness 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 HistoryofPresentIllnessSection Base for all types and resources
...... component:medicalHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 MedicalGeneralHistorySection Base for all types and resources
...... component:medications 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 MedicationsSection Base for all types and resources
shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity
...... component:medsAdministered 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 MedicationsAdministeredSection Base for all types and resources
...... component:physicalExam 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PhysicalExamSection Base for all types and resources
...... component:plannedProcedure 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PlannedProcedureSection Base for all types and resources
...... component:procedureDisposition 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureDispositionSection Base for all types and resources
...... component:estBloodLoss 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureEstimatedBloodLossSection Base for all types and resources
...... component:findings 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureFindingsSection Base for all types and resources
...... component:implants 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureImplantsSection Base for all types and resources
...... component:specimensTaken 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureSpecimensTakenSection Base for all types and resources
...... component:procedures 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 ProceduresSection Base for all types and resources
shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
...... component:reasonForVisit 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ReasonforVisitSection Base for all types and resources
...... component:reviewOfSystems 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ReviewofSystemsSection Base for all types and resources
...... component:socialHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 SocialHistorySection Base for all types and resources
should-smoking-status: SHOULD contain Smoking Status
...... component:advDirectives 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 AdvanceDirectivesSection Base for all types and resources
shall-adv-directive-organizer: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer

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.templateId:procedure-note.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.coderequiredProcedureNoteDocumentTypeCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.6.1
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.participant:participant1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: IND
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.participant:participant1.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: PROV
http://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative
ClinicalDocument.participant:participant1.associatedEntity.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
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.coderequired
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.documentationOf.serviceEvent.performer:primary.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.typeCoderequiredFixed Value: PPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:primary.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.documentationOf.serviceEvent.performer:secondary.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.typeCoderequiredFixed Value: SPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.encounterParticipant:referrer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer.typeCoderequiredFixed Value: REF
http://terminology.hl7.org/ValueSet/v3-xEncounterParticipant|2.0.0
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
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCoderequiredRoleClassServiceDeliveryLocation
http://terminology.hl7.org/ValueSet/v3-RoleClassServiceDeliveryLocation
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.codeexampleServiceDeliveryLocationRoleType
http://terminology.hl7.org/ValueSet/v3-ServiceDeliveryLocationRoleType
ClinicalDocument.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent
ClinicalDocument.component.structuredBody.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.component.structuredBody.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
ClinicalDocument.component.structuredBody.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:complications.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:complications.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDescription.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDescription.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:indications.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:indications.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:postProcedureDx.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:postProcedureDx.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:planOfTreatment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:planOfTreatment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:allergies.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:allergies.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:anesthesia.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:anesthesia.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaint.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaint.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:pastMedicalHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:pastMedicalHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:historyPresentIllness.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:historyPresentIllness.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medsAdministered.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medsAdministered.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:plannedProcedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:plannedProcedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDisposition.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDisposition.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:estBloodLoss.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:estBloodLoss.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:findings.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:findings.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:implants.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:implants.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:specimensTaken.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:specimensTaken.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForVisit.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForVisit.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:advDirectives.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:advDirectives.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.285' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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, ClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1When 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
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
cc-rfv-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
ivl-ts-centererrorClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:primary.time, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.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.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:primary.time, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.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.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:primary.time, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
no-cc-rfverrorClinicalDocument.component.structuredBody.component:chiefComplaintRFV.sectionWhen using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
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-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:advDirectives.sectionIf section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer')).exists()
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergies.sectionIf section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists()
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-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionIf section/@nullFlavor is not present, SHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists()
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionIf section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists()
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-code-attrwarningClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:primary.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.functionCodeSHOULD contain @code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-idwarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-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.root, ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.id.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-post-procedure-dxwarningClinicalDocument.component.structuredBody.component:postProcedureDx.sectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
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-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
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.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-us-telecomwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain telecom
: telecom.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
text-nullerrorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinctxmlText and nullFlavor are mutually exclusive (one must be present)
: (xmlText | nullFlavor).count() = 1
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

This structure is derived from USRealmHeader

Summary

Mandatory: 11 elements(9 nested mandatory elements)
Fixed: 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.participant
  • The element 1 is sliced based on the value of ClinicalDocument.documentationOf.serviceEvent.performer
  • The element 1 is sliced based on the value of ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant
  • The element 1 is sliced based on the value of ClinicalDocument.component.structuredBody.component

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 USRealmHeader 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, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-componentOf: SHOULD contain componentOf
... templateId 2..* II
... Slices for templateId Content/Rules for all slices
.... templateId:procedure-note 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.6
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ProcedureNoteDocumentTypeCodes . (required)
.... participant:participant1 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).
..... @typeCode 1..1 cs Fixed Value: IND
..... functionCode 1..1 CE
...... @code 1..1 cs Required Pattern: PCP
...... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.5.88
..... associatedEntity
...... @classCode 1..1 cs Fixed Value: PROV
...... associatedPerson 1..1 Person
... documentationOf 1..* DocumentationOf A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
.... serviceEvent 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.
..... code C 0..1 CE Binding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

Additional BindingsPurposeDocumentation
Procedure . Preferred Binding
Allowed SNOMED Codes

1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
..... effectiveTime C 1..1 USRealmDateTimeInterval Base for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low 1..1 IVXB_TS Low is required
...... (Choice of one) 1..1
....... width 0..1 PQ Represents the duration
....... high 0..1 IVXB_TS Equals low if only the date is known
..... Slices for performer 1..* 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.
Slice: Unordered, Open by value:typeCode
...... performer:primary 1..1 Performer1 This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1 cs Fixed Value: PPRF
....... assignedEntity C 1..1 AssignedEntity should-code: SHOULD contain code
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
...... performer:secondary 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 Fixed Value: SPRF
....... assignedEntity C 1..1 AssignedEntity should-code: SHOULD contain code
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
... authorization 0..1 Authorization Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... consent 1..1 Consent
..... @classCode 1..1 cs
..... @moodCode 1..1 cs
..... statusCode 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-id: SHOULD contain id
..... id 1..* II SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..1 CE
..... Slices for encounterParticipant 0..* EncounterParticipant Slice: Unordered, Open by value:typeCode
...... encounterParticipant:referrer 0..1 EncounterParticipant
....... @typeCode 1..1 cs Fixed Value: REF
..... location 1..1 InfrastructureRoot
...... healthCareFacility 1..1 HealthCareFacility
....... id 1..* II
... component 1..1 Component
.... structuredBody C 1..1 StructuredBody ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
..... Slices for component 5..* InfrastructureRoot Slice: Unordered, Open by profile:section
...... component:complications 1..1 InfrastructureRoot
....... section 1..1 ComplicationsSection Base for all types and resources
...... component:procedureDescription 1..1 InfrastructureRoot
....... section 1..1 ProcedureDescriptionSection Base for all types and resources
...... component:indications 1..1 InfrastructureRoot
....... section 1..1 ProcedureIndicationsSection Base for all types and resources
...... component:postProcedureDx 1..1 InfrastructureRoot
....... section 1..1 PostprocedureDiagnosisSection Base for all types and resources
...... component:assessment 0..1 InfrastructureRoot
....... section 1..1 AssessmentSection Base for all types and resources
...... component:assessmentAndPlan 0..1 InfrastructureRoot
....... section 1..1 AssessmentandPlanSection Base for all types and resources
...... component:planOfTreatment 0..1 InfrastructureRoot
....... section 1..1 PlanofTreatmentSection Base for all types and resources
...... component:allergies 0..1 InfrastructureRoot
....... section 1..1 AllergiesAndIntolerancesSection Base for all types and resources
...... component:anesthesia 0..1 InfrastructureRoot
....... section 1..1 AnesthesiaSection Base for all types and resources
...... component:chiefComplaint 0..1 InfrastructureRoot
....... section 1..1 ChiefComplaintSection Base for all types and resources
...... component:chiefComplaintRFV 0..1 InfrastructureRoot
....... section 1..1 ChiefComplaintandReasonforVisitSection Base for all types and resources
...... component:familyHistory 0..1 InfrastructureRoot
....... section 1..1 FamilyHistorySection Base for all types and resources
...... component:pastMedicalHistory 0..1 InfrastructureRoot
....... section 1..1 PastMedicalHistory Base for all types and resources
...... component:historyPresentIllness 0..1 InfrastructureRoot
....... section 1..1 HistoryofPresentIllnessSection Base for all types and resources
...... component:medicalHistory 0..1 InfrastructureRoot
....... section 1..1 MedicalGeneralHistorySection Base for all types and resources
...... component:medications 0..1 InfrastructureRoot
....... section 1..1 MedicationsSection Base for all types and resources
...... component:medsAdministered 0..1 InfrastructureRoot
....... section 1..1 MedicationsAdministeredSection Base for all types and resources
...... component:physicalExam 0..1 InfrastructureRoot
....... section 1..1 PhysicalExamSection Base for all types and resources
...... component:plannedProcedure 0..1 InfrastructureRoot
....... section 1..1 PlannedProcedureSection Base for all types and resources
...... component:procedureDisposition 0..1 InfrastructureRoot
....... section 1..1 ProcedureDispositionSection Base for all types and resources
...... component:estBloodLoss 0..1 InfrastructureRoot
....... section 1..1 ProcedureEstimatedBloodLossSection Base for all types and resources
...... component:findings 0..1 InfrastructureRoot
....... section 1..1 ProcedureFindingsSection Base for all types and resources
...... component:implants 0..1 InfrastructureRoot
....... section 1..1 ProcedureImplantsSection Base for all types and resources
...... component:specimensTaken 0..1 InfrastructureRoot
....... section 1..1 ProcedureSpecimensTakenSection Base for all types and resources
...... component:procedures 0..1 InfrastructureRoot
....... section 1..1 ProceduresSection Base for all types and resources
...... component:reasonForVisit 0..1 InfrastructureRoot
....... section 1..1 ReasonforVisitSection Base for all types and resources
...... component:reviewOfSystems 0..1 InfrastructureRoot
....... section 1..1 ReviewofSystemsSection Base for all types and resources
...... component:socialHistory 0..1 InfrastructureRoot
....... section 1..1 SocialHistorySection Base for all types and resources
...... component:advDirectives 0..1 InfrastructureRoot
....... section 1..1 AdvanceDirectivesSection Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClinicalDocument.coderequiredProcedureNoteDocumentTypeCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.6.1
ClinicalDocument.documentationOf.serviceEvent.coderequired
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.documentationOf.serviceEvent.performer:secondary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.285' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
cc-rfv-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-idwarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain id
: id.exists()
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 USRealmHeader 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, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
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
should-componentOf: SHOULD contain componentOf
... 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 2..* 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
.... templateId:procedure-note 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.1.6
..... @extension 1..1 st Required Pattern: 2024-05-01
... code 1..1 CE The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ProcedureNoteDocumentTypeCodes . (required)
.... @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)
... 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
...... raceCode 1..1 CE (USCDI) Race
Binding: Race Category Excluding Nulls . (required)
...... ethnicGroupCode 1..1 CE (USCDI) Ethnicity
Binding: Ethnicity . (required)
... 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
....... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.4.6
..... 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)
... 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).
...... 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
...... name 1..1 ON
...... telecom C 1..1 TEL should-use: SHOULD contain @use
....... @use 0..1 cs Binding: Telecom Use (US Realm Header) . (required)
...... addr C 1..1 USRealmAddress Base for all types and resources
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
... Slices for participant C 0..* Participant1 The participant element in the Procedure Note header follows the General Header Constraints for participants.
Slice: Unordered, Open by value:typeCode, value:functionCode.code
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).
.... participant:All Slices Content/Rules for all slices
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
..... associatedEntity 1..1 AssociatedEntity
.... participant:participant1 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)
Fixed Value: IND
..... functionCode 1..1 CE
...... @code 1..1 cs Required Pattern: PCP
...... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.5.88
..... associatedEntity 1..1 AssociatedEntity
...... @classCode 1..1 cs Binding: CDARoleClassAssociative (required)
Fixed Value: PROV
...... associatedPerson 1..1 Person
... documentationOf 1..* DocumentationOf A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
.... 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
..... code C 0..1 CE Binding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

Additional BindingsPurposeDocumentation
Procedure . Preferred Binding
Allowed SNOMED Codes

1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
..... 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.
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... low C 1..1 IVXB_TS Low is required
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
...... (Choice of one) 1..1
....... width 0..1 PQ Represents the duration
....... high C 0..1 IVXB_TS Equals low if only the date is known
ts-shall-day: **SHALL** be precise to at least the day
ts-should-minute: **SHOULD** be precise to at least the minute
..... Slices for performer 1..* 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.
Slice: Unordered, Open by value:typeCode
...... performer:All Slices Content/Rules for all slices
....... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
....... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
........ id 1..* II
...... performer:primary 1..1 Performer1 This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @typeCode 1..1 cs Binding: x_ServiceEventPerformer . (required)
Fixed Value: PPRF
....... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
should-code: SHOULD contain code
........ id 1..* II
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
...... performer:secondary 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)
Fixed Value: SPRF
....... assignedEntity C 1..1 AssignedEntity should-us-code: SHOULD contain code
should-code: SHOULD contain code
........ id 1..* II
........ code 0..1 CE Binding: Healthcare Provider Taxonomy . (required)
... authorization 0..1 Authorization Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... consent 1..1 Consent
..... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: CONS
..... @moodCode 1..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... 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
should-id: SHOULD contain id
..... id 1..* II SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..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.
..... Slices for encounterParticipant 0..* EncounterParticipant Slice: Unordered, Open by value:typeCode
...... encounterParticipant:referrer 0..1 EncounterParticipant
....... @typeCode 1..1 cs Binding: XEncounterParticipant (2.0.0) (required)
Fixed Value: REF
..... location 1..1 InfrastructureRoot
...... healthCareFacility 1..1 HealthCareFacility
....... id 1..* II
... component 1..1 Component
.... structuredBody C 1..1 StructuredBody ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
..... Slices for component 5..* InfrastructureRoot Slice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1 Section
...... component:complications 1..1 InfrastructureRoot
....... section 1..1 ComplicationsSection Base for all types and resources
...... component:procedureDescription 1..1 InfrastructureRoot
....... section 1..1 ProcedureDescriptionSection Base for all types and resources
...... component:indications 1..1 InfrastructureRoot
....... section 1..1 ProcedureIndicationsSection Base for all types and resources
...... component:postProcedureDx 1..1 InfrastructureRoot
....... section C 1..1 PostprocedureDiagnosisSection Base for all types and resources
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
...... component:assessment 0..1 InfrastructureRoot
....... section 1..1 AssessmentSection Base for all types and resources
...... component:assessmentAndPlan 0..1 InfrastructureRoot
....... section C 1..1 AssessmentandPlanSection Base for all types and resources
no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
...... component:planOfTreatment 0..1 InfrastructureRoot
....... section 1..1 PlanofTreatmentSection Base for all types and resources
...... component:allergies 0..1 InfrastructureRoot
....... section C 1..1 AllergiesAndIntolerancesSection Base for all types and resources
shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
...... component:anesthesia 0..1 InfrastructureRoot
....... section 1..1 AnesthesiaSection Base for all types and resources
...... component:chiefComplaint 0..1 InfrastructureRoot
....... section 1..1 ChiefComplaintSection Base for all types and resources
...... component:chiefComplaintRFV 0..1 InfrastructureRoot
....... section C 1..1 ChiefComplaintandReasonforVisitSection Base for all types and resources
no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
...... component:familyHistory 0..1 InfrastructureRoot
....... section 1..1 FamilyHistorySection Base for all types and resources
...... component:pastMedicalHistory 0..1 InfrastructureRoot
....... section 1..1 PastMedicalHistory Base for all types and resources
...... component:historyPresentIllness 0..1 InfrastructureRoot
....... section 1..1 HistoryofPresentIllnessSection Base for all types and resources
...... component:medicalHistory 0..1 InfrastructureRoot
....... section 1..1 MedicalGeneralHistorySection Base for all types and resources
...... component:medications 0..1 InfrastructureRoot
....... section C 1..1 MedicationsSection Base for all types and resources
shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity
...... component:medsAdministered 0..1 InfrastructureRoot
....... section 1..1 MedicationsAdministeredSection Base for all types and resources
...... component:physicalExam 0..1 InfrastructureRoot
....... section 1..1 PhysicalExamSection Base for all types and resources
...... component:plannedProcedure 0..1 InfrastructureRoot
....... section 1..1 PlannedProcedureSection Base for all types and resources
...... component:procedureDisposition 0..1 InfrastructureRoot
....... section 1..1 ProcedureDispositionSection Base for all types and resources
...... component:estBloodLoss 0..1 InfrastructureRoot
....... section 1..1 ProcedureEstimatedBloodLossSection Base for all types and resources
...... component:findings 0..1 InfrastructureRoot
....... section 1..1 ProcedureFindingsSection Base for all types and resources
...... component:implants 0..1 InfrastructureRoot
....... section 1..1 ProcedureImplantsSection Base for all types and resources
...... component:specimensTaken 0..1 InfrastructureRoot
....... section 1..1 ProcedureSpecimensTakenSection Base for all types and resources
...... component:procedures 0..1 InfrastructureRoot
....... section C 1..1 ProceduresSection Base for all types and resources
shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
...... component:reasonForVisit 0..1 InfrastructureRoot
....... section 1..1 ReasonforVisitSection Base for all types and resources
...... component:reviewOfSystems 0..1 InfrastructureRoot
....... section 1..1 ReviewofSystemsSection Base for all types and resources
...... component:socialHistory 0..1 InfrastructureRoot
....... section C 1..1 SocialHistorySection Base for all types and resources
should-smoking-status: SHOULD contain Smoking Status
...... component:advDirectives 0..1 InfrastructureRoot
....... section C 1..1 AdvanceDirectivesSection Base for all types and resources
shall-adv-directive-organizer: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClinicalDocument.coderequiredProcedureNoteDocumentTypeCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.6.1
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.raceCoderequiredRaceCategoryExcludingNulls .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecomUseUSRealmHeader .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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.participant:participant1.typeCoderequiredFixed Value: IND
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: PROV
http://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative
ClinicalDocument.documentationOf.serviceEvent.coderequired
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:primary.typeCoderequiredFixed Value: PPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.documentationOf.serviceEvent.performer:secondary.typeCoderequiredFixed Value: SPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.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.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
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer.typeCoderequiredFixed Value: REF
http://terminology.hl7.org/ValueSet/v3-xEncounterParticipant|2.0.0

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.285' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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, ClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1When 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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296)
: item.xmlText.empty()
81-9371errorClinicalDocument.informant:provider.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.informant:provider.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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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})?'))
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
cc-rfv-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
ivl-ts-centererrorClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
ivl-value-shallerrorClinicalDocument.documentationOf.serviceEvent.effectiveTime, 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.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
no-cc-rfverrorClinicalDocument.component.structuredBody.component:chiefComplaintRFV.sectionWhen using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:provider.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-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:advDirectives.sectionIf section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer')).exists()
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergies.sectionIf section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists()
shall-cityerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.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-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionIf section/@nullFlavor is not present, SHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists()
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionIf section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists()
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-idwarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-legalAuthenticatorwarningClinicalDocumentSHOULD contain legalAuthenticator
: legalAuthenticator.exists()
should-maritalStatusCodewarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain maritalStatusCode
: maritalStatusCode.exists()
should-post-procedure-dxwarningClinicalDocument.component.structuredBody.component:postProcedureDx.sectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
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-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
should-us-codewarningClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.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-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addrSHOULD contain @use
: nullFlavor.exists() or use.exists()
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.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**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument C 1..1 USRealmHeader 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, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
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
should-componentOf: SHOULD contain componentOf
... @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 2..* 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
.... templateId:procedure-note 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: 2.16.840.1.113883.10.20.22.1.6
..... @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 The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ProcedureNoteDocumentTypeCodes . (required)
.... @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
... Slices for participant C 0..* Participant1 The participant element in the Procedure Note header follows the General Header Constraints for participants.
Slice: Unordered, Open by value:typeCode, value:functionCode.code
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).
.... participant:All Slices Content/Rules for all slices
..... @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
.... participant:participant1 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)
Fixed Value: IND
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... functionCode 1..1 CE
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @code 1..1 cs Required Pattern: PCP
...... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.5.88
...... @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.
..... associatedEntity 1..1 AssociatedEntity
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 1..1 cs Binding: CDARoleClassAssociative (required)
Fixed Value: PROV
...... id 0..* II
...... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1 CE Binding: CDARoleCode (example)
...... addr 0..* AD
...... telecom 0..* TEL
...... associatedPerson 1..1 Person
...... scopingOrganization 0..1 Organization
... 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 1..* DocumentationOf A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width 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: 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 C 0..1 CE Binding: (unbound) (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

Additional BindingsPurposeDocumentation
Procedure . Preferred Binding
Allowed SNOMED Codes

1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
..... 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.
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
...... @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 Low is required
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
...... (Choice of one) 1..1
....... width 0..1 PQ Represents the duration
....... high C 0..1 IVXB_TS Equals low if only the date is known
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
..... Slices for performer 1..* 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.
Slice: Unordered, Open by value:typeCode
...... performer:All Slices Content/Rules for all slices
....... @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
...... performer:primary 1..1 Performer1 This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... @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)
Fixed Value: PPRF
....... 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
should-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 . (required)
........ 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
...... performer:secondary 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)
Fixed Value: SPRF
....... 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
should-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 . (required)
........ 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..1 Authorization Authorization represents consent. Consent, if present, shall be represented by authorization/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
.... @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 1..1 cs Binding: CDAActClass (required)
Fixed Value: CONS
..... @moodCode 1..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
should-id: SHOULD contain id
..... @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 SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..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).
..... Slices for encounterParticipant 0..* EncounterParticipant Slice: Unordered, Open by value:typeCode
...... encounterParticipant:referrer 0..1 EncounterParticipant
....... @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: XEncounterParticipant (2.0.0) (required)
Fixed Value: REF
....... time 0..1 IVL_TS
....... assignedEntity 0..1 AssignedEntity
..... location 1..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
....... @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: RoleClassServiceDeliveryLocation (required)
....... id 1..* II
....... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1 CE Binding: ServiceDeliveryLocationRoleType (example)
....... location 0..1 Place
....... serviceProviderOrganization 0..1 Organization
... component 1..1 Component
.... @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
.... @contextConductionInd 0..1 bl Fixed Value: true
.... nonXMLBody 0..1 NonXMLBody
.... structuredBody C 1..1 StructuredBody ap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
..... @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: ActClassRecordOrganizer (required)
Fixed Value: DOCBODY
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1 CE
..... languageCode 0..1 CS Binding: AllLanguages (required)
..... Slices for component 5..* InfrastructureRoot Slice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... @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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 Section
...... component:complications 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ComplicationsSection Base for all types and resources
...... component:procedureDescription 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureDescriptionSection Base for all types and resources
...... component:indications 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureIndicationsSection Base for all types and resources
...... component:postProcedureDx 1..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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 PostprocedureDiagnosisSection Base for all types and resources
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
...... component:assessment 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 AssessmentSection Base for all types and resources
...... component:assessmentAndPlan 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 AssessmentandPlanSection Base for all types and resources
no-a-p: When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
...... component:planOfTreatment 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PlanofTreatmentSection Base for all types and resources
...... component:allergies 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 AllergiesAndIntolerancesSection Base for all types and resources
shall-allergy-concern: If section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
...... component:anesthesia 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 AnesthesiaSection Base for all types and resources
...... component:chiefComplaint 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ChiefComplaintSection Base for all types and resources
...... component:chiefComplaintRFV 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 ChiefComplaintandReasonforVisitSection Base for all types and resources
no-cc-rfv: When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
...... component:familyHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 FamilyHistorySection Base for all types and resources
...... component:pastMedicalHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PastMedicalHistory Base for all types and resources
...... component:historyPresentIllness 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 HistoryofPresentIllnessSection Base for all types and resources
...... component:medicalHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 MedicalGeneralHistorySection Base for all types and resources
...... component:medications 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 MedicationsSection Base for all types and resources
shall-med-activity: If section/@nullFlavor is not present, SHALL contain at least one Medication Activity
...... component:medsAdministered 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 MedicationsAdministeredSection Base for all types and resources
...... component:physicalExam 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PhysicalExamSection Base for all types and resources
...... component:plannedProcedure 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 PlannedProcedureSection Base for all types and resources
...... component:procedureDisposition 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureDispositionSection Base for all types and resources
...... component:estBloodLoss 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureEstimatedBloodLossSection Base for all types and resources
...... component:findings 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureFindingsSection Base for all types and resources
...... component:implants 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureImplantsSection Base for all types and resources
...... component:specimensTaken 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ProcedureSpecimensTakenSection Base for all types and resources
...... component:procedures 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 ProceduresSection Base for all types and resources
shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
...... component:reasonForVisit 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ReasonforVisitSection Base for all types and resources
...... component:reviewOfSystems 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section 1..1 ReviewofSystemsSection Base for all types and resources
...... component:socialHistory 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 SocialHistorySection Base for all types and resources
should-smoking-status: SHOULD contain Smoking Status
...... component:advDirectives 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 Fixed Value: COMP
....... @contextConductionInd 0..1 bl Fixed Value: true
....... section C 1..1 AdvanceDirectivesSection Base for all types and resources
shall-adv-directive-organizer: If section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer

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.templateId:procedure-note.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.coderequiredProcedureNoteDocumentTypeCodes .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.6.1
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.participant:participant1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: IND
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
ClinicalDocument.participant:participant1.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: PROV
http://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative
ClinicalDocument.participant:participant1.associatedEntity.codeexampleCDARoleCode
http://hl7.org/cda/stds/core/ValueSet/CDARoleCode
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.coderequired
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.documentationOf.serviceEvent.performer:primary.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.typeCoderequiredFixed Value: PPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:primary.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.documentationOf.serviceEvent.performer:secondary.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.typeCoderequiredFixed Value: SPRF
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.functionCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.functionCode.codepreferredCareTeamMemberFunction .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.id.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.coderequiredHealthcareProviderTaxonomy . (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.encounterParticipant:referrer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer.typeCoderequiredFixed Value: REF
http://terminology.hl7.org/ValueSet/v3-xEncounterParticipant|2.0.0
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
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCoderequiredRoleClassServiceDeliveryLocation
http://terminology.hl7.org/ValueSet/v3-RoleClassServiceDeliveryLocation
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.codeexampleServiceDeliveryLocationRoleType
http://terminology.hl7.org/ValueSet/v3-ServiceDeliveryLocationRoleType
ClinicalDocument.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent
ClinicalDocument.component.structuredBody.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
ClinicalDocument.component.structuredBody.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
ClinicalDocument.component.structuredBody.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:complications.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:complications.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDescription.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDescription.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:indications.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:indications.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:postProcedureDx.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:postProcedureDx.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:assessmentAndPlan.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:planOfTreatment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:planOfTreatment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:allergies.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:allergies.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:anesthesia.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:anesthesia.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaint.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaint.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:familyHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:pastMedicalHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:pastMedicalHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:historyPresentIllness.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:historyPresentIllness.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medicalHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medications.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medsAdministered.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:medsAdministered.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:physicalExam.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:plannedProcedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:plannedProcedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDisposition.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedureDisposition.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:estBloodLoss.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:estBloodLoss.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:findings.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:findings.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:implants.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:implants.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:specimensTaken.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:specimensTaken.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:procedures.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForVisit.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reasonForVisit.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:reviewOfSystems.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:advDirectives.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
ClinicalDocument.component.structuredBody.component:advDirectives.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf.serviceEvent.codeThe value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
: codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.285' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28'))
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, ClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
: associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists()
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1When 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
ap-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
ap-or-a-and-perrorClinicalDocument.component.structuredBody**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2)
cc-rfv-comboerrorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present.
: component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
ivl-ts-centererrorClinicalDocument.participant.time, ClinicalDocument.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:primary.time, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.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.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:primary.time, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.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.participant:participant1.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.documentationOf.serviceEvent.performer:primary.time, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf a time interval contains @value, then it SHOULD contain a time component.
: value.exists() implies value.toString().length() > 10
no-a-perrorClinicalDocument.component.structuredBody.component:assessmentAndPlan.sectionWhen using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
no-cc-rfverrorClinicalDocument.component.structuredBody.component:chiefComplaintRFV.sectionWhen using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.
: %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()
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-adv-directive-organizererrorClinicalDocument.component.structuredBody.component:advDirectives.sectionIf section/@nullFlavor is not present, SHALL contain at least one Advance Directive Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectiveOrganizer')).exists()
shall-allergy-concernerrorClinicalDocument.component.structuredBody.component:allergies.sectionIf section/@nullFlavor is not present, SHALL contain at least one Allergy Concern Act
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AllergyConcernAct')).exists()
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-med-activityerrorClinicalDocument.component.structuredBody.component:medications.sectionIf section/@nullFlavor is not present, SHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity')).exists()
shall-procedure-act-procedureerrorClinicalDocument.component.structuredBody.component:procedures.sectionIf section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists()
shall-streetAddressLineerrorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).
: nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4)
should-codewarningClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-code-attrwarningClinicalDocument.documentationOf.serviceEvent.performer.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:primary.functionCode, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.functionCodeSHOULD contain @code
: code.exists()
should-componentOfwarningClinicalDocumentSHOULD contain componentOf
: componentOf.exists()
should-countrywarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addrSHOULD contain country
: nullFlavor.exists() or item.country.exists()
should-extensionwarningClinicalDocument.author.assignedAuthor.id:npiSHOULD contain extension
: extension.exists()
should-idwarningClinicalDocument.componentOf.encompassingEncounterSHOULD contain id
: id.exists()
should-id-npiwarningClinicalDocument.author.assignedAuthorSHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI)
: id.where(root = '2.16.840.1.113883.4.6')
should-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.root, ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.id.root, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.id.rootSHOULD be NPI
: $this = '2.16.840.1.113883.4.6'
should-post-procedure-dxwarningClinicalDocument.component.structuredBody.component:postProcedureDx.sectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
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-smoking-statuswarningClinicalDocument.component.structuredBody.component:socialHistory.sectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
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.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity, ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntitySHOULD contain code
: code.exists()
should-us-languageCommunicationwarningClinicalDocument.recordTarget.patientRole.patientSHOULD contain languageCommunication
: languageCommunication.exists()
should-us-performerwarningClinicalDocument.documentationOf.serviceEventSHOULD contain performer
: performer.exists()
should-us-telecomwarningClinicalDocument.recordTarget.patientRole.patient.guardianSHOULD contain telecom
: telecom.exists()
should-usewarningClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecomSHOULD contain @use
: nullFlavor.exists() or use.exists()
should-value-attwarningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTimeSHOULD contain @value
: value.exists()
signaturewarningClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCodeCDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
: code.exists() implies code != 'X'
text-nullerrorClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox, ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinctxmlText and nullFlavor are mutually exclusive (one must be present)
: (xmlText | nullFlavor).count() = 1
ts-shall-dayerrorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHALL** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-shall-yearerrorClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHALL** be precise to at least the year
: nullFlavor.exists() or value.toString().length() >= 4
ts-should-daywarningClinicalDocument.recordTarget.patientRole.patient.birthTime, ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime**SHOULD** be precise to at least the day
: nullFlavor.exists() or value.toString().length() >= 10
ts-should-minutewarningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high**SHOULD** be precise to at least the minute
: nullFlavor.exists() or value.toString().length() > 10
width-or-higherrorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWidth and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.
: (width | high).count() = 1

This structure is derived from USRealmHeader

Summary

Mandatory: 11 elements(9 nested mandatory elements)
Fixed: 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.participant
  • The element 1 is sliced based on the value of ClinicalDocument.documentationOf.serviceEvent.performer
  • The element 1 is sliced based on the value of ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant
  • The element 1 is sliced based on the value of ClinicalDocument.component.structuredBody.component

 

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