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
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeaderforPatientGeneratedDocument | Version: 3.0.0 | |||
Active as of 2024-05-18 | Computable Name: USRealmHeaderforPatientGeneratedDocument | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.29.1:2024-05-01 |
This template focuses on the patient or related person in the roles of author and other participants and is designed to be used in conjunction with the US Realm Header. It includes additional conformances which further constrain the US Realm Header. The Patient Generated Document Header template is not a separate document type. The document body may contain any structured or unstructured content from C-CDA.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 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) | |
templateId | 2..* | II | ||
Slices for templateId | Content/Rules for all slices | |||
templateId:us-patient-gen-doc | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |
recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
patientRole | 1..1 | PatientRole | ||
id | 1..* | II | ||
patient | C | 1..1 | Patient | should-languageCommunication: SHOULD contain languageCommunication |
guardian | C | 0..* | Guardian | should-id: SHOULD contain id should-code: SHOULD contain code |
id | 0..* | II | ||
code | 0..1 | CE | ||
languageCommunication | 0..* | LanguageCommunication | (USCDI) Preferred Language | |
languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. | |
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate. | |
assignedAuthor | C | 1..1 | AssignedAuthor | should-code: SHOULD contain code |
id | 1..* | II | ||
code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. | |
@code | 1..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
assignedEntity | 1..1 | AssignedEntity | ||
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
Slices for informant | Content/Rules for all slices | |||
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 | ||
code | C | 0..1 | CE | should-us-code-attr: SHOULD contain @code |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
assignedCustodian | 1..1 | AssignedCustodian | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
id | 1..* | II | The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way. | |
informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
intendedRecipient | C | 1..1 | IntendedRecipient | should-id: SHOULD contain id |
id | C | 0..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. should-root: SHOULD contain @root |
@root | 0..1 | oid, uuid, ruid | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | ||
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
assignedEntity | C | 1..1 | AssignedEntity | should-code: SHOULD contain code |
id | 1..* | II | The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
participant | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin) | |
@typeCode | 1..1 | cs | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 | |
associatedEntity | C | 1..1 | AssociatedEntity | should-code: SHOULD contain code |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
order | 1..1 | Order | ||
id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
documentationOf | 0..* | DocumentationOf | ||
serviceEvent | C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-code: SHOULD contain code should-performer: SHOULD contain performer |
code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
functionCode | 0..1 | CE | When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode | |
@code | 0..1 | cs | Binding: ParticipationFunction (required) | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.author.assignedAuthor.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.informant:non-provider.relatedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.legalAuthenticator.assignedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authenticator.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.participant.associatedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | required | ParticipationFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.10267 | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 |
Id | Grade | Path(s) | Details | Requirements |
should-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEvent | SHOULD contain code : code.exists() | |
should-id | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipient | SHOULD contain id : id.exists() | |
should-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-root | warning | ClinicalDocument.informationRecipient.intendedRecipient.id | SHOULD contain @root : root.exists() | |
should-us-code-attr | warning | ClinicalDocument.informant:non-provider.relatedEntity.code | SHOULD contain @code : code.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
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:us-patient-gen-doc | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |
id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
code | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) | |
@code | 1..1 | cs | ||
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA.
HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
patientRole | 1..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 should-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) | |
guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom should-id: SHOULD contain id should-code: SHOULD contain code |
id | 0..* | II | ||
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
guardianPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
languageCommunication | C | 0..* | LanguageCommunication | (USCDI) Preferred Language should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. | |
id | 1..* | II | ||
name | 1..* | ON | ||
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate. | |
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 should-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 | |
code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. Binding: CDARoleCode (example) | |
@code | 1..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
informant:provider | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). | |
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 | ||
@classCode | 1..1 | cs | Binding: CDARoleClassMutualRelationship (required) | |
code | C | 0..1 | CE | Binding: PersonalRelationshipRoleType (example) should-us-code-attr: SHOULD contain @code |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
assignedCustodian | 1..1 | AssignedCustodian | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
id | 1..* | II | The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way. | |
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 |
informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
intendedRecipient | C | 1..1 | IntendedRecipient | should-id: SHOULD contain id |
id | C | 0..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. should-root: SHOULD contain @root |
@root | 0..1 | oid, uuid, ruid | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
time | C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
@code | 1..1 | cs | Required Pattern: S | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
time | C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
@code | 1..1 | cs | Required Pattern: S | |
assignedEntity | C | 1..1 | AssignedEntity | should-code: SHOULD contain code |
id | 1..* | II | The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
participant | C | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin) 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 | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 Binding: CDAParticipationType (required) | |
associatedEntity | C | 1..1 | AssociatedEntity | should-code: SHOULD contain code |
@classCode | 1..1 | cs | Binding: CDARoleClassAssociative (required) | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
order | 1..1 | Order | ||
id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
documentationOf | 0..* | DocumentationOf | ||
serviceEvent | C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-us-performer: SHOULD contain performer should-code: SHOULD contain code should-performer: SHOULD contain performer |
code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
@typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
functionCode | C | 0..1 | CE | When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode should-code-attr: SHOULD contain @code |
@code | 0..1 | cs | Binding: ParticipationFunction (required) | |
assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
id | 1..* | II | The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
component | 1..1 | Component | ||
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClinicalDocument.code | example | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.author.assignedAuthor.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
ClinicalDocument.author.assignedAuthor.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.informant:non-provider.relatedEntity.classCode | required | CDARoleClassMutualRelationshiphttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassMutualRelationship | |
ClinicalDocument.informant:non-provider.relatedEntity.code | example | PersonalRelationshipRoleTypehttp://terminology.hl7.org/ValueSet/v3-PersonalRelationshipRoleType | |
ClinicalDocument.informant:non-provider.relatedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (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.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.authenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.authenticator.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.participant.associatedEntity.classCode | required | CDARoleClassAssociativehttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative | |
ClinicalDocument.participant.associatedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601 | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | required | ParticipationFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.10267 | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 |
Id | Grade | Path(s) | Details | Requirements |
4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
4537-10007 | warning | ClinicalDocument.participant | 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 = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The 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() | |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | 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). : 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')) | |
81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | 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). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
ivl-ts-center | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
ivl-value-shall | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
ivl-value-should | warning | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | No 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-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
should-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEvent | SHOULD contain code : code.exists() | |
should-code-attr | warning | ClinicalDocument.documentationOf.serviceEvent.performer.functionCode | SHOULD contain @code : code.exists() | |
should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
should-id | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipient | SHOULD contain id : id.exists() | |
should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
should-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
should-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
should-root | warning | ClinicalDocument.informationRecipient.intendedRecipient.id | SHOULD contain @root : root.exists() | |
should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
should-us-code-attr | warning | ClinicalDocument.informant:non-provider.relatedEntity.code | SHOULD contain @code : code.exists() | |
should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X' | |
ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
ts-shall-year | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to at least the year : nullFlavor.exists() or value.toString().length() >= 4 | |
ts-should-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
ts-should-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
@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:us-patient-gen-doc | 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: 2.16.840.1.113883.10.20.29.1 | |
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |
id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
code | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) | |
@code | 1..1 | cs | ||
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | ||
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
sdtcStatusCode | 0..1 | CS | XML Namespace: urn:hl7-org:sdtc XML: statusCode (urn:hl7-org:sdtc) Binding: ActStatus (required) | |
effectiveTime | C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
confidentialityCode | 1..1 | CE | ||
@code | 1..1 | cs | Binding: HL7 BasicConfidentialityKind (preferred) | |
@codeSystem | 0..1 | oid, uuid, ruid | ||
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | ||
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
setId | 0..1 | II | ||
versionNumber | 0..1 | INT | ||
copyTime | 0..1 | TS | ||
recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA.
HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 should-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 should-id: SHOULD contain id 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: 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: AllLanguages (required) | |
modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a 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 | ||
@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. The person is the patient or the patient's advocate. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 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 | |
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 | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. Binding: CDARoleCode (example) | |
@code | 1..1 | cs | Binding: Personal And Legal Relationship Role Type (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 by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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: Personal And Legal Relationship Role Type (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 | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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: CDARoleClassMutualRelationship (required) | |
code | C | 0..1 | CE | Binding: PersonalRelationshipRoleType (example) should-us-code-attr: SHOULD contain @code |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (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 | 0..* | AD | ||
telecom | 0..* | TEL | ||
effectiveTime | 0..1 | IVL_TS | ||
relatedPerson | 0..1 | Person | ||
custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 | The representedCustodianOrganization may be the person when the document is not maintained by an 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 | The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way. | |
@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 is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 | C | 1..1 | IntendedRecipient | 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: CDAInformationRecipientRole (required) | |
id | C | 0..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. should-root: SHOULD contain @root |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 0..1 | oid, uuid, ruid | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
@extension | 0..1 | st | ||
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 | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. | |
@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) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (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 | |
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 | C | 1..1 | AssignedEntity | 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 | The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way. | |
@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: Personal And Legal Relationship Role Type (preferred) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
@codeSystem | 0..1 | oid, uuid, ruid | ||
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | ||
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | url | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
@determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 1..1 | cs | Fixed Value: PRS | |
@determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
representedOrganization | 0..1 | Organization | ||
sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
participant | C | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin) 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 | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 Binding: 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 | C | 1..1 | AssociatedEntity | 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 | 1..1 | cs | Binding: CDARoleClassAssociative (required) | |
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 (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 0..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 | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
code | 0..1 | CE | Binding: v3 Code System ActCode (example) | |
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
documentationOf | 0..* | DocumentationOf | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: DOC | |
serviceEvent | C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-us-performer: SHOULD contain performer should-code: SHOULD contain code should-performer: SHOULD contain performer |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: CDAActClass (required) | |
@moodCode | 0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
id | 0..* | II | ||
code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | Either @value or low/high should be present, but not both Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |
low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@inclusive | 0..1 | bl | ||
center | 0..1 | TS | ||
width | 0..1 | PQ | ||
high | C | 0..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@inclusive | 0..1 | bl | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
functionCode | C | 0..1 | CE | When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode should-code-attr: SHOULD contain @code |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: ParticipationFunction (required) | |
@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 | The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way. | |
@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 | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
relatedDocument | 0..* | RelatedDocument | ||
authorization | 0..* | Authorization | The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: ActRelationshipAuthorizedBy (required) Fixed Value: AUTH | |
consent | 1..1 | Consent | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: CDAActClass (required) Fixed Value: CONS | |
@moodCode | 0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
id | 0..* | II | ||
code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (example) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: CDAActClass (required) Fixed Value: ENC | |
@moodCode | 0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
id | 1..* | II | ||
code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (example) | |
responsibleParty | 0..1 | InfrastructureRoot | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: RESP | |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
encounterParticipant | 0..* | EncounterParticipant | ||
location | 0..1 | InfrastructureRoot | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
component | 1..1 | Component | ||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
ClinicalDocument.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.classCode | example | Fixed Value: DOCCLINhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.realmCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.templateId:us-realm.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.templateId:us-patient-gen-doc.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.code | example | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
ClinicalDocument.sdtcStatusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.recordTarget.patientRole.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAThttp://terminology.hl7.org/ValueSet/v3-RoleClassRelationshipFormal | |
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.patient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212 | |
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185 | |
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914 | |
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAgent | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPLhttp://terminology.hl7.org/ValueSet/v3-RoleClassPassive | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLChttp://terminology.hl7.org/ValueSet/v3-EntityClassPlace | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.use | required | CDAPostalAddressUsehttp://hl7.org/cda/stds/core/ValueSet/CDAPostalAddressUse | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249 | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199 | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
ClinicalDocument.author.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.typeCode | required | Fixed Value: AUThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.author.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.author.assignedAuthor.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
ClinicalDocument.author.assignedAuthor.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEVhttp://terminology.hl7.org/ValueSet/v3-EntityClassDevice | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | example | CDAEntityCodehttp://hl7.org/cda/stds/core/ValueSet/CDAEntityCode | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExamplehttp://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExamplehttp://terminology.hl7.org/ValueSet/v3-SoftwareNameExample | |
ClinicalDocument.dataEnterer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.dataEnterer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.informant:provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.informant:provider.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.informant:non-provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.informant:non-provider.relatedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.relatedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.relatedEntity.classCode | required | CDARoleClassMutualRelationshiphttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassMutualRelationship | |
ClinicalDocument.informant:non-provider.relatedEntity.code | example | PersonalRelationshipRoleTypehttp://terminology.hl7.org/ValueSet/v3-PersonalRelationshipRoleType | |
ClinicalDocument.informant:non-provider.relatedEntity.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.relatedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.custodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.typeCode | required | Fixed Value: CSThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.custodian.assignedCustodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.typeCode | required | XInformationRecipienthttp://terminology.hl7.org/ValueSet/v3-xInformationRecipient|2.0.0 | |
ClinicalDocument.informationRecipient.intendedRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.classCode | required | CDAInformationRecipientRolehttp://hl7.org/cda/stds/core/ValueSet/CDAInformationRecipientRole | |
ClinicalDocument.informationRecipient.intendedRecipient.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
ClinicalDocument.legalAuthenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LAhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (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.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.typeCode | required | Fixed Value: AUTHENhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.authenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.authenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.authenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authenticator.assignedEntity.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.participant.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.participant.associatedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.associatedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.associatedEntity.classCode | required | CDARoleClassAssociativehttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative | |
ClinicalDocument.participant.associatedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.inFulfillmentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFShttp://terminology.hl7.org/ValueSet/v3-ActRelationshipFulfills|2.0.0 | |
ClinicalDocument.inFulfillmentOf.order.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.order.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQOhttp://hl7.org/cda/stds/core/ValueSet/CDAActMoodIntent | |
ClinicalDocument.inFulfillmentOf.order.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
ClinicalDocument.inFulfillmentOf.order.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
ClinicalDocument.documentationOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOChttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
ClinicalDocument.documentationOf.serviceEvent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601 | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | required | ParticipationFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.10267 | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authorization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTHhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipAuthorizedBy | |
ClinicalDocument.authorization.consent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.consent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONShttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.authorization.consent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
ClinicalDocument.authorization.consent.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
ClinicalDocument.authorization.consent.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent | |
ClinicalDocument.componentOf.encompassingEncounter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENChttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5 | |
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | example | USEncounterDischargeDispositionhttp://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition | |
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESPhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOChttp://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation |
Id | Grade | Path(s) | Details | Requirements |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | 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). : 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')) | |
4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | 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). : 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})?')) | |
4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
4537-10007 | warning | ClinicalDocument.participant | 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 = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
81-7296 | error | ClinicalDocument.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() | |
81-9371 | error | 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.name | The 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() | |
81-9372 | error | 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.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
81-10024 | error | ClinicalDocument.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 | 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). : 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')) | |
81-10025 | error | ClinicalDocument.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 | 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). : 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-1 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item | Can only have only one of the possible item elements in each choice : (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1 | |
ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
pn-no-ls | error | ClinicalDocument.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.name | No 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-city | error | ClinicalDocument.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 contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
shall-max-ad-parts | error | ClinicalDocument.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 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
shall-streetAddressLine | error | ClinicalDocument.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 contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
should-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEvent | SHOULD contain code : code.exists() | |
should-code-attr | warning | ClinicalDocument.documentationOf.serviceEvent.performer.functionCode | SHOULD contain @code : code.exists() | |
should-country | warning | ClinicalDocument.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.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
should-id | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipient | SHOULD contain id : id.exists() | |
should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
should-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
should-npi | warning | ClinicalDocument.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 | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
should-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
should-root | warning | ClinicalDocument.informationRecipient.intendedRecipient.id | SHOULD contain @root : root.exists() | |
should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
should-us-code-attr | warning | ClinicalDocument.informant:non-provider.relatedEntity.code | SHOULD contain @code : code.exists() | |
should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
should-use | warning | ClinicalDocument.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.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X' | |
text-null | error | ClinicalDocument.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.precinct | xmlText and nullFlavor are mutually exclusive (one must be present) : (xmlText | nullFlavor).count() = 1 | |
ts-shall-day | error | ClinicalDocument.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-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.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-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
This structure is derived from USRealmHeader
Differential View
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 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) | |
templateId | 2..* | II | ||
Slices for templateId | Content/Rules for all slices | |||
templateId:us-patient-gen-doc | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |
recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
patientRole | 1..1 | PatientRole | ||
id | 1..* | II | ||
patient | C | 1..1 | Patient | should-languageCommunication: SHOULD contain languageCommunication |
guardian | C | 0..* | Guardian | should-id: SHOULD contain id should-code: SHOULD contain code |
id | 0..* | II | ||
code | 0..1 | CE | ||
languageCommunication | 0..* | LanguageCommunication | (USCDI) Preferred Language | |
languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. | |
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate. | |
assignedAuthor | C | 1..1 | AssignedAuthor | should-code: SHOULD contain code |
id | 1..* | II | ||
code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. | |
@code | 1..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
assignedEntity | 1..1 | AssignedEntity | ||
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
Slices for informant | Content/Rules for all slices | |||
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 | ||
code | C | 0..1 | CE | should-us-code-attr: SHOULD contain @code |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
assignedCustodian | 1..1 | AssignedCustodian | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
id | 1..* | II | The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way. | |
informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
intendedRecipient | C | 1..1 | IntendedRecipient | should-id: SHOULD contain id |
id | C | 0..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. should-root: SHOULD contain @root |
@root | 0..1 | oid, uuid, ruid | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | ||
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
assignedEntity | C | 1..1 | AssignedEntity | should-code: SHOULD contain code |
id | 1..* | II | The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
participant | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin) | |
@typeCode | 1..1 | cs | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 | |
associatedEntity | C | 1..1 | AssociatedEntity | should-code: SHOULD contain code |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
order | 1..1 | Order | ||
id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
documentationOf | 0..* | DocumentationOf | ||
serviceEvent | C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-code: SHOULD contain code should-performer: SHOULD contain performer |
code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
functionCode | 0..1 | CE | When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode | |
@code | 0..1 | cs | Binding: ParticipationFunction (required) | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.author.assignedAuthor.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.informant:non-provider.relatedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.legalAuthenticator.assignedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authenticator.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.participant.associatedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | required | ParticipationFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.10267 | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 |
Id | Grade | Path(s) | Details | Requirements |
should-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEvent | SHOULD contain code : code.exists() | |
should-id | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipient | SHOULD contain id : id.exists() | |
should-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-root | warning | ClinicalDocument.informationRecipient.intendedRecipient.id | SHOULD contain @root : root.exists() | |
should-us-code-attr | warning | ClinicalDocument.informant:non-provider.relatedEntity.code | SHOULD contain @code : code.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
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:us-patient-gen-doc | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |
id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
code | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) | |
@code | 1..1 | cs | ||
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA.
HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
patientRole | 1..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 should-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) | |
guardian | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom should-id: SHOULD contain id should-code: SHOULD contain code |
id | 0..* | II | ||
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
guardianPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
languageCommunication | C | 0..* | LanguageCommunication | (USCDI) Preferred Language should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. | |
id | 1..* | II | ||
name | 1..* | ON | ||
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient's advocate. | |
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 should-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 | |
code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. Binding: CDARoleCode (example) | |
@code | 1..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
Slices for informant | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
informant:provider | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). | |
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 | ||
@classCode | 1..1 | cs | Binding: CDARoleClassMutualRelationship (required) | |
code | C | 0..1 | CE | Binding: PersonalRelationshipRoleType (example) should-us-code-attr: SHOULD contain @code |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
assignedCustodian | 1..1 | AssignedCustodian | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
id | 1..* | II | The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way. | |
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 |
informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
intendedRecipient | C | 1..1 | IntendedRecipient | should-id: SHOULD contain id |
id | C | 0..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. should-root: SHOULD contain @root |
@root | 0..1 | oid, uuid, ruid | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
time | C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
@code | 1..1 | cs | Required Pattern: S | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
time | C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
signatureCode | C | 1..1 | CS | Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. |
@code | 1..1 | cs | Required Pattern: S | |
assignedEntity | C | 1..1 | AssignedEntity | should-code: SHOULD contain code |
id | 1..* | II | The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
participant | C | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin) 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 | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 Binding: CDAParticipationType (required) | |
associatedEntity | C | 1..1 | AssociatedEntity | should-code: SHOULD contain code |
@classCode | 1..1 | cs | Binding: CDARoleClassAssociative (required) | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists' report of an x-ray. | |
order | 1..1 | Order | ||
id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
documentationOf | 0..* | DocumentationOf | ||
serviceEvent | C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-us-performer: SHOULD contain performer should-code: SHOULD contain code should-performer: SHOULD contain performer |
code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
@typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
functionCode | C | 0..1 | CE | When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode should-code-attr: SHOULD contain @code |
@code | 0..1 | cs | Binding: ParticipationFunction (required) | |
assignedEntity | C | 1..1 | AssignedEntity | should-us-code: SHOULD contain code |
id | 1..* | II | The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way. | |
code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
component | 1..1 | Component | ||
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClinicalDocument.code | example | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.author.assignedAuthor.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
ClinicalDocument.author.assignedAuthor.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.informant:non-provider.relatedEntity.classCode | required | CDARoleClassMutualRelationshiphttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassMutualRelationship | |
ClinicalDocument.informant:non-provider.relatedEntity.code | example | PersonalRelationshipRoleTypehttp://terminology.hl7.org/ValueSet/v3-PersonalRelationshipRoleType | |
ClinicalDocument.informant:non-provider.relatedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (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.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.authenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.authenticator.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.participant.associatedEntity.classCode | required | CDARoleClassAssociativehttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative | |
ClinicalDocument.participant.associatedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601 | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | required | ParticipationFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.10267 | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 |
Id | Grade | Path(s) | Details | Requirements |
4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
4537-10007 | warning | ClinicalDocument.participant | 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 = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296) : item.xmlText.empty() | |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The 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() | |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
81-10024 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | 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). : 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')) | |
81-10025 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | 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). : nullFlavor.exists() or (item.country.exists() and item.country.xmlText != 'US' and item.country.xmlText != 'USA') or item.postalCode.exists(nullFlavor.exists() or xmlText.matches('[0-9]{5}(-[0-9]{4})?')) | |
ivl-ts-center | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
ivl-value-shall | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
ivl-value-should | warning | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:provider.assignedEntity.assignedPerson.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator.assignedEntity.assignedPerson.name | No 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-city | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
shall-max-ad-parts | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
shall-streetAddressLine | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
should-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEvent | SHOULD contain code : code.exists() | |
should-code-attr | warning | ClinicalDocument.documentationOf.serviceEvent.performer.functionCode | SHOULD contain @code : code.exists() | |
should-country | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
should-id | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipient | SHOULD contain id : id.exists() | |
should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
should-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
should-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
should-root | warning | ClinicalDocument.informationRecipient.intendedRecipient.id | SHOULD contain @root : root.exists() | |
should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
should-us-code-attr | warning | ClinicalDocument.informant:non-provider.relatedEntity.code | SHOULD contain @code : code.exists() | |
should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
should-use | warning | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.author.assignedAuthor.telecom, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.dataEnterer.assignedEntity.telecom, ClinicalDocument.informant:provider.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.legalAuthenticator.assignedEntity.telecom, ClinicalDocument.authenticator.assignedEntity.addr, ClinicalDocument.authenticator.assignedEntity.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X' | |
ts-shall-day | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHALL** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
ts-shall-year | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to at least the year : nullFlavor.exists() or value.toString().length() >= 4 | |
ts-should-day | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to at least the day : nullFlavor.exists() or value.toString().length() >= 10 | |
ts-should-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
@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:us-patient-gen-doc | 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: 2.16.840.1.113883.10.20.29.1 | |
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |
id | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
code | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). Binding: FHIRDocumentTypeCodes (example) | |
@code | 1..1 | cs | ||
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | ||
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
sdtcStatusCode | 0..1 | CS | XML Namespace: urn:hl7-org:sdtc XML: statusCode (urn:hl7-org:sdtc) Binding: ActStatus (required) | |
effectiveTime | C | 1..1 | USRealmDateTime | Base for all types and resources ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
confidentialityCode | 1..1 | CE | ||
@code | 1..1 | cs | Binding: HL7 BasicConfidentialityKind (preferred) | |
@codeSystem | 0..1 | oid, uuid, ruid | ||
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | ||
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
languageCode | 1..1 | CS | Binding: AllLanguages (required) | |
setId | 0..1 | II | ||
versionNumber | 0..1 | INT | ||
copyTime | 0..1 | TS | ||
recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient's language of preference and the predominant language used by the organization receiving the CDA.
HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child's parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child's mom or "father" for the child's dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 should-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 should-id: SHOULD contain id 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: 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: AllLanguages (required) | |
modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a 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 | ||
@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. The person is the patient or the patient's advocate. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 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 | |
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 | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. Binding: CDARoleCode (example) | |
@code | 1..1 | cs | Binding: Personal And Legal Relationship Role Type (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 by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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: Personal And Legal Relationship Role Type (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 | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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: CDARoleClassMutualRelationship (required) | |
code | C | 0..1 | CE | Binding: PersonalRelationshipRoleType (example) should-us-code-attr: SHOULD contain @code |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (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 | 0..* | AD | ||
telecom | 0..* | TEL | ||
effectiveTime | 0..1 | IVL_TS | ||
relatedPerson | 0..1 | Person | ||
custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 | The representedCustodianOrganization may be the person when the document is not maintained by an 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 | The combined @root and @extension attributes record the custodian organization's identity in a secure, trusted, and unique way. | |
@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 is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 | C | 1..1 | IntendedRecipient | 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: CDAInformationRecipientRole (required) | |
id | C | 0..* | II | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. should-root: SHOULD contain @root |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 0..1 | oid, uuid, ruid | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
@extension | 0..1 | st | ||
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 | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..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 | The combined @root and @extension attributes to record the information recipient's identity in a secure, trusted, and unique way. | |
@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) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Personal And Legal Relationship Role Type (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 | |
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 | C | 1..1 | AssignedEntity | 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 | The combined @root and @extension attributes to record the authenticator's identity in a secure, trusted, and unique way. | |
@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: Personal And Legal Relationship Role Type (preferred) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
@codeSystem | 0..1 | oid, uuid, ruid | ||
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | ||
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | C | 1..* | USRealmAddress | Base for all types and resources shall-city: SHALL contain exactly one [1..1] city (CONF:81-7292). shall-streetAddressLine: SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291). should-use: SHOULD contain @use should-country: SHOULD contain country 81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296) 81-10024: If the country is US, the state element is required and SHALL be selected from ValueSet StateValueSet but SHOULD have @nullFlavor if the state is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 81-10025: If the country is US, the postalCode element is required but SHOULD have @nullFlavor if the postalCode is unknown. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). shall-max-ad-parts: SHALL have at most one of each: state, city, postalCode, and country |
telecom | C | 1..* | TEL | should-use: SHOULD contain @use |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | url | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
@use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
@determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources pn-no-ls: No PN name part may have a qualifier of LS. 81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). 81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). |
sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
sdtcAsPatientRelationship | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 1..1 | cs | Fixed Value: PRS | |
@determinerCode | 0..1 | cs | Fixed Value: INSTANCE | |
code | 1..1 | CE | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
representedOrganization | 0..1 | Organization | ||
sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
participant | C | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin) 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 | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 Binding: 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 | C | 1..1 | AssociatedEntity | 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 | 1..1 | cs | Binding: CDARoleClassAssociative (required) | |
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 (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 0..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 | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
code | 0..1 | CE | Binding: v3 Code System ActCode (example) | |
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
documentationOf | 0..* | DocumentationOf | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: DOC | |
serviceEvent | C | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. should-us-performer: SHOULD contain performer should-code: SHOULD contain code should-performer: SHOULD contain performer |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: CDAActClass (required) | |
@moodCode | 0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
id | 0..* | II | ||
code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | Either @value or low/high should be present, but not both Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |
low | C | 1..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@inclusive | 0..1 | bl | ||
center | 0..1 | TS | ||
width | 0..1 | PQ | ||
high | C | 0..1 | IVXB_TS | **MAY** be precise to at least the second ts-shall-day: **SHALL** be precise to at least the day ts-should-minute: **SHOULD** be precise to at least the minute |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@inclusive | 0..1 | bl | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
functionCode | C | 0..1 | CE | When indicating the performer was the primary care physician, implementers should indicate "PCP" as the functionCode should-code-attr: SHOULD contain @code |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: ParticipationFunction (required) | |
@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 | The combined @root and @extension attributes record the performer's identity in a secure, trusted, and unique way. | |
@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 | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
sdtcPatient | 0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
id | 1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
relatedDocument | 0..* | RelatedDocument | ||
authorization | 0..* | Authorization | The authorization element represents information about the patient's consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of 'Privacy Consent'. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: ActRelationshipAuthorizedBy (required) Fixed Value: AUTH | |
consent | 1..1 | Consent | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: CDAActClass (required) Fixed Value: CONS | |
@moodCode | 0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
id | 0..* | II | ||
code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (example) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
encompassingEncounter | C | 1..1 | EncompassingEncounter | should-responsibleParty: SHOULD contain responsibleParty |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@classCode | 0..1 | cs | Binding: CDAActClass (required) Fixed Value: ENC | |
@moodCode | 0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
id | 1..* | II | ||
code | 0..1 | CE | Binding: Act Encounter Codes (preferred) | |
effectiveTime | C | 1..1 | USRealmDateTimeInterval | Base for all types and resources ivl-ts-center: Center cannot co-exist with low or high ivl-value-shall: If a time interval contains @value, then it shall be precise to at least the day. ivl-value-should: If a time interval contains @value, then it SHOULD contain a time component. |
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (example) | |
responsibleParty | 0..1 | InfrastructureRoot | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: RESP | |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
encounterParticipant | 0..* | EncounterParticipant | ||
location | 0..1 | InfrastructureRoot | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@assigningAuthorityName | 0..1 | st | ||
@displayable | 0..1 | bl | ||
@root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
@extension | 1..1 | st | ||
templateId | 0..* | II | ||
@typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
component | 1..1 | Component | ||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
ClinicalDocument.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.classCode | example | Fixed Value: DOCCLINhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.realmCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.templateId:us-realm.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.templateId:us-patient-gen-doc.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.code | example | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
ClinicalDocument.sdtcStatusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
ClinicalDocument.confidentialityCode.code | preferred | HL7BasicConfidentialityKind http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.16926 | |
ClinicalDocument.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.recordTarget.patientRole.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAThttp://terminology.hl7.org/ValueSet/v3-RoleClassRelationshipFormal | |
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.patient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | AdministrativeGenderHL7V3 http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.1 | |
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12212 | |
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | ReligiousAffiliation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19185 | |
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | RaceCategoryExcludingNulls http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.2074.1.1.3 | |
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | RaceValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914 | |
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837 | |
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | DetailedEthnicity http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAgent | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPLhttp://terminology.hl7.org/ValueSet/v3-RoleClassPassive | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLChttp://terminology.hl7.org/ValueSet/v3-EntityClassPlace | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.use | required | CDAPostalAddressUsehttp://hl7.org/cda/stds/core/ValueSet/CDAPostalAddressUse | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.delimiter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.country.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.state.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.county.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.city.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postalCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumber.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.houseNumberNumeric.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.direction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetName.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameBase.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.streetNameType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.additionalLocator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitID.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.unitType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.careOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.censusTract.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryAddressLine.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationType.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationArea.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryInstallationQualifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryMode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.deliveryModeIdentifier.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.buildingNumberSuffix.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.postBox.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item.precinct.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12249 | |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12199 | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
ClinicalDocument.author.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.typeCode | required | Fixed Value: AUThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.author.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.author.assignedAuthor.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.author.assignedAuthor.id:npi.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
ClinicalDocument.author.assignedAuthor.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.author.assignedAuthor.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEVhttp://terminology.hl7.org/ValueSet/v3-EntityClassDevice | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | example | CDAEntityCodehttp://hl7.org/cda/stds/core/ValueSet/CDAEntityCode | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExamplehttp://terminology.hl7.org/ValueSet/v3-ManufacturerModelNameExample | |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExamplehttp://terminology.hl7.org/ValueSet/v3-SoftwareNameExample | |
ClinicalDocument.dataEnterer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.dataEnterer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.informant:provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.informant:provider.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.informant:provider.assignedEntity.code | preferred | HealthcareProviderTaxonomy (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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:provider.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.informant:non-provider.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.informant:non-provider.relatedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.relatedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.relatedEntity.classCode | required | CDARoleClassMutualRelationshiphttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassMutualRelationship | |
ClinicalDocument.informant:non-provider.relatedEntity.code | example | PersonalRelationshipRoleTypehttp://terminology.hl7.org/ValueSet/v3-PersonalRelationshipRoleType | |
ClinicalDocument.informant:non-provider.relatedEntity.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informant:non-provider.relatedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.custodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.typeCode | required | Fixed Value: CSThttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.custodian.assignedCustodian.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.typeCode | required | XInformationRecipienthttp://terminology.hl7.org/ValueSet/v3-xInformationRecipient|2.0.0 | |
ClinicalDocument.informationRecipient.intendedRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.classCode | required | CDAInformationRecipientRolehttp://hl7.org/cda/stds/core/ValueSet/CDAInformationRecipientRole | |
ClinicalDocument.informationRecipient.intendedRecipient.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORGhttp://terminology.hl7.org/ValueSet/v3-EntityClassOrganization | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | example | OrganizationIndustryClassNAICShttp://terminology.hl7.org/ValueSet/v3-OrganizationIndustryClassNAICS | |
ClinicalDocument.legalAuthenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LAhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.legalAuthenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy (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.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.code.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.typeCode | required | Fixed Value: AUTHENhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.authenticator.signatureCode | required | CDASignatureCodehttp://hl7.org/cda/stds/core/ValueSet/CDASignatureCode | |
ClinicalDocument.authenticator.signatureCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.authenticator.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authenticator.assignedEntity.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy (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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.telecom.use | required | TelecomUseUSRealmHeader http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.20 | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSNhttp://terminology.hl7.org/ValueSet/v3-EntityClassLivingSubject | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authenticator.assignedEntity.assignedPerson.sdtcAsPatientRelationship.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.typeCode | required | CDAParticipationTypehttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.participant.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
ClinicalDocument.participant.associatedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.associatedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.participant.associatedEntity.classCode | required | CDARoleClassAssociativehttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative | |
ClinicalDocument.participant.associatedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.inFulfillmentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFShttp://terminology.hl7.org/ValueSet/v3-ActRelationshipFulfills|2.0.0 | |
ClinicalDocument.inFulfillmentOf.order.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.order.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.inFulfillmentOf.order.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQOhttp://hl7.org/cda/stds/core/ValueSet/CDAActMoodIntent | |
ClinicalDocument.inFulfillmentOf.order.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
ClinicalDocument.inFulfillmentOf.order.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
ClinicalDocument.documentationOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOChttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
ClinicalDocument.documentationOf.serviceEvent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.classCode | required | CDAActClasshttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | X_ServiceEventPerformer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.19601 | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | required | ParticipationFunction http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.10267 | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | PersonalAndLegalRelationshipRoleType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.12.1 | |
ClinicalDocument.authorization.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTHhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipAuthorizedBy | |
ClinicalDocument.authorization.consent.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.consent.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONShttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.authorization.consent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
ClinicalDocument.authorization.consent.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
ClinicalDocument.authorization.consent.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipHasComponent | |
ClinicalDocument.componentOf.encompassingEncounter.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENChttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
ClinicalDocument.componentOf.encompassingEncounter.code | preferred | ActEncounterCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.5 | |
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | example | USEncounterDischargeDispositionhttp://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition | |
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESPhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.location.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOChttp://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation |
Id | Grade | Path(s) | Details | Requirements |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : assignedPerson.exists() or representedOrganization.exists() | |
4537-5402 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | 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). : 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')) | |
4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | 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). : 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})?')) | |
4537-6380 | error | ClinicalDocument | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : setId.exists() implies versionNumber.exists() | |
4537-6387 | error | ClinicalDocument | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : versionNumber.exists() implies setId.exists() | |
4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : associatedEntity.associatedPerson.exists() or associatedEntity.scopingOrganization.exists() | |
4537-10007 | warning | ClinicalDocument.participant | 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 = 'IND' implies associatedEntity.classCode.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.33') | |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : (assignedPerson | assignedAuthoringDevice).count() = 1 | |
4537-21000 | error | ClinicalDocument.recordTarget.patientRole.patient | If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true : sdtcDeceasedTime.value.exists() implies sdtcDeceasedInd.exists(value='true') | |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient | If 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() | |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : item.xmlText.empty() | |
81-7296 | error | ClinicalDocument.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() | |
81-9371 | error | 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.name | The 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() | |
81-9372 | error | 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.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : item.xmlText.exists() implies (item.delimiter | item.family | item.given | item.prefix | item.suffix).empty() | |
81-10024 | error | ClinicalDocument.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 | 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). : 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')) | |
81-10025 | error | ClinicalDocument.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 | 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). : 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-1 | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.item | Can only have only one of the possible item elements in each choice : (delimiter | country | state | county | city | postalCode | streetAddressLine | houseNumber | houseNumberNumeric | direction | streetName | streetNameBase | streetNameType | additionalLocator | unitID | unitType | careOf | censusTract | deliveryAddressLine | deliveryInstallationType | deliveryInstallationArea | deliveryInstallationQualifier | deliveryMode | deliveryModeIdentifier | buildingNumberSuffix | postBox | precinct | xmlText).count() = 1 | |
ivl-ts-center | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
ivl-value-shall | error | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it shall be precise to at least the day. : value.exists() implies value.toString().length() >= 10 | |
ivl-value-should | warning | ClinicalDocument.participant.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime, ClinicalDocument.documentationOf.serviceEvent.performer.time, ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If a time interval contains @value, then it SHOULD contain a time component. : value.exists() implies value.toString().length() > 10 | |
pn-no-ls | error | ClinicalDocument.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.name | No 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-city | error | ClinicalDocument.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 contain exactly one [1..1] city (CONF:81-7292). : nullFlavor.exists() or item.city.count() = 1 | |
shall-family | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain exactly one [1..1] family (CONF:81-7159). : nullFlavor.exists() or item.family.count() = 1 | |
shall-given | error | ClinicalDocument.recordTarget.patientRole.patient.name | SHALL contain at least one [1..*] given (CONF:81-7157). : nullFlavor.exists() or item.given.exists() | |
shall-max-ad-parts | error | ClinicalDocument.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 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-suffix | error | ClinicalDocument.recordTarget.patientRole.patient.name | There may be at most one suffix : (item.suffix.empty() or item.suffix.count() = 1) | |
shall-streetAddressLine | error | ClinicalDocument.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 contain at least one and not more than 4 streetAddressLine (CONF:81-7291). : nullFlavor.exists() or (item.streetAddressLine.count() >= 1 and item.streetAddressLine.count() <= 4) | |
should-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.authenticator.assignedEntity, ClinicalDocument.participant.associatedEntity, ClinicalDocument.documentationOf.serviceEvent | SHOULD contain code : code.exists() | |
should-code-attr | warning | ClinicalDocument.documentationOf.serviceEvent.performer.functionCode | SHOULD contain @code : code.exists() | |
should-country | warning | ClinicalDocument.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.addr | SHOULD contain country : nullFlavor.exists() or item.country.exists() | |
should-extension | warning | ClinicalDocument.author.assignedAuthor.id:npi | SHOULD contain extension : extension.exists() | |
should-id | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.informationRecipient.intendedRecipient | SHOULD contain id : id.exists() | |
should-id-npi | warning | ClinicalDocument.author.assignedAuthor | SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) : id.where(root = '2.16.840.1.113883.4.6') | |
should-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-legalAuthenticator | warning | ClinicalDocument | SHOULD contain legalAuthenticator : legalAuthenticator.exists() | |
should-maritalStatusCode | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain maritalStatusCode : maritalStatusCode.exists() | |
should-npi | warning | ClinicalDocument.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 | SHOULD be NPI : $this = '2.16.840.1.113883.4.6' | |
should-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-preferenceInd | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain preferenceInd : preferenceInd.exists() | |
should-proficiencyLevelCode | warning | ClinicalDocument.recordTarget.patientRole.patient.languageCommunication | SHOULD contain proficiencyLevelCode : proficiencyLevelCode.exists() | |
should-relatedParticipant | warning | ClinicalDocument | Documents SHOULD contain a RelatedPerson participant : participant.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/RelatedPersonRelationshipAndNameParticipant').exists() | |
should-responsibleParty | warning | ClinicalDocument.componentOf.encompassingEncounter | SHOULD contain responsibleParty : responsibleParty.exists() | |
should-root | warning | ClinicalDocument.informationRecipient.intendedRecipient.id | SHOULD contain @root : root.exists() | |
should-us-addr | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain addr : addr.exists() | |
should-us-code | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian, ClinicalDocument.author.assignedAuthor, ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity | SHOULD contain code : code.exists() | |
should-us-code-attr | warning | ClinicalDocument.informant:non-provider.relatedEntity.code | SHOULD contain @code : code.exists() | |
should-us-languageCommunication | warning | ClinicalDocument.recordTarget.patientRole.patient | SHOULD contain languageCommunication : languageCommunication.exists() | |
should-us-performer | warning | ClinicalDocument.documentationOf.serviceEvent | SHOULD contain performer : performer.exists() | |
should-us-telecom | warning | ClinicalDocument.recordTarget.patientRole.patient.guardian | SHOULD contain telecom : telecom.exists() | |
should-use | warning | ClinicalDocument.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.telecom | SHOULD contain @use : nullFlavor.exists() or use.exists() | |
should-value-att | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime | SHOULD contain @value : value.exists() | |
signature | warning | ClinicalDocument.legalAuthenticator.signatureCode, ClinicalDocument.authenticator.signatureCode | CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X' | |
text-null | error | ClinicalDocument.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.precinct | xmlText and nullFlavor are mutually exclusive (one must be present) : (xmlText | nullFlavor).count() = 1 | |
ts-shall-day | error | ClinicalDocument.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-year | error | ClinicalDocument.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-day | warning | ClinicalDocument.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-minute | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.dataEnterer.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator.time, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low, ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high | **SHOULD** be precise to at least the minute : nullFlavor.exists() or value.toString().length() > 10 |
This structure is derived from USRealmHeader