| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ClinicalDocument
|
CDAR2.ClinicalDocument |
XML Namespace:
urn:hl7-org:v3 This logical model cannot be the target of a reference |
||
realmCode
|
1..1 | realmCode | ||
code
|
1.. | Required Pattern: US | ||
|
typeId
|
1..1 | typeId | ||
|
root
|
1..1 |
root Required Pattern: 2.16.840.1.113883.1.3 |
||
extension
|
1..1 |
extension Required Pattern: POCD_HD000040 |
||
Slices for templateId
|
1 .. | Slice: Unordered, Open by value:root, value:extension | ||
templateId:primary
|
1..1 | templateId | ||
root
|
1..1 |
root Required Pattern: 2.16.840.1.113883.10.20.22.1.1 |
||
extension
|
1..1 |
extension Required Pattern: 2023-05-01 |
||
|
id
|
C | 1..1 |
id 4537-9991: This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). |
|
|
code
|
C | 1..1 |
code 4537-9992: This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). 4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). |
|
|
title
|
1..1 | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | ||
effectiveTime
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/TS | effectiveTime | |
|
confidentialityCode
|
1..1 |
confidentialityCode Binding: HL7 BasicConfidentialityKind ( preferred ) |
||
|
languageCode
|
1..1 |
languageCode Binding: todo ( required ) |
||
|
setId
|
C | 0..1 |
setId 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). |
|
|
versionNumber
|
C | 0..1 |
versionNumber 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). |
|
|
recordTarget
|
1..* |
recordTarget |
||
|
patientRole
|
1..1 | patientRole | ||
|
id
|
1..* |
id |
||
|
addr
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
telecom
|
1..* |
telecom |
||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
patient
|
1..1 | patient | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
administrativeGenderCode
|
1..1 |
administrativeGenderCode Binding: Administrative Gender (HL7 V3) ( required ) |
||
|
birthTime
|
C | 1..1 |
birthTime 4537-5299: **SHALL** be precise to year (CONF:4537-5299). 4537-5300: **SHOULD** be precise to day (CONF:4537-5300). 4537-32418: **MAY** be precise to the minute (CONF:4537-32418). |
|
|
sdtcDeceasedInd
|
C | 0..1 |
sdtc:deceasedInd 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). |
|
|
sdtcDeceasedTime
|
0..1 | sdtc:deceasedTime | ||
|
value
|
C | 0..1 |
value 4537-32991: **SHALL** be precise to to the year (CONF:4537-32991). 4537-32992: **SHOULD** be precise to the day (CONF:4537-32992). |
|
|
maritalStatusCode
|
0..1 |
maritalStatusCode Binding: Marital Status ( required ) |
||
|
religiousAffiliationCode
|
0..1 |
religiousAffiliationCode Binding: Religious Affiliation ( required ) |
||
|
raceCode
|
1..1 |
raceCode Binding: Race Category Excluding Nulls ( required ) |
||
|
sdtcRaceCode
|
C | 0..* |
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. Binding: Race Value Set ( required ) 4537-31347: If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). |
|
|
ethnicGroupCode
|
1..1 |
ethnicGroupCode Binding: Ethnicity ( required ) |
||
|
sdtcEthnicGroupCode
|
0..* |
ethnicGroupCode Binding: Detailed Ethnicity ( required ) |
||
|
guardian
|
0..* |
guardian |
||
|
code
|
0..1 |
code Binding: Personal And Legal Relationship Role Type ( required ) |
||
|
addr
|
0..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
telecom
|
0..* |
telecom |
||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
guardianPerson
|
1..1 | guardianPerson | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
birthplace
|
0..1 | birthplace | ||
|
place
|
1..1 | place | ||
|
addr
|
C | 1..1 |
addr 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *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). |
|
|
country
|
0..1 |
country Binding: todo ( required ) |
||
|
languageCommunication
|
0..* |
languageCommunication |
||
|
languageCode
|
1..1 |
languageCode Binding: todo ( required ) |
||
|
modeCode
|
0..1 |
modeCode Binding: LanguageAbilityMode ( required ) |
||
|
proficiencyLevelCode
|
0..1 |
proficiencyLevelCode Binding: LanguageAbilityProficiency ( required ) |
||
|
preferenceInd
|
0..1 | preferenceInd | ||
|
providerOrganization
|
0..1 | providerOrganization | ||
|
id
|
1..* |
id |
||
|
root
|
0..1 |
root Required Pattern: 2.16.840.1.113883.4.6 |
||
|
name
|
1..* |
name |
||
|
telecom
|
1..* |
telecom |
||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
addr
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
author
|
1..* |
author |
||
|
time
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/TS | time | |
|
assignedAuthor
|
C | 1..1 |
assignedAuthor 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). |
|
|
Slices for id
|
1 .. | Slice: Unordered, Open by value:root | ||
|
id:id1
|
0..1 | id | ||
|
nullFlavor
|
0..1 |
nullFlavor Fixed Value: UNK |
||
|
root
|
1..1 |
root Required Pattern: 2.16.840.1.113883.4.6 |
||
|
extension
|
0..1 | extension | ||
|
code
|
0..1 | code | ||
|
code
|
1..1 |
code Binding: Healthcare Provider Taxonomy ( preferred ) |
||
|
addr
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
telecom
|
1..* |
telecom |
||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
assignedPerson
|
0..1 | assignedPerson | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
assignedAuthoringDevice
|
0..1 | assignedAuthoringDevice | ||
|
manufacturerModelName
|
1..1 | manufacturerModelName | ||
|
softwareName
|
1..1 | softwareName | ||
|
dataEnterer
|
0..1 | dataEnterer | ||
|
assignedEntity
|
1..1 | assignedEntity | ||
|
id
|
1..* |
id |
||
|
root
|
0..1 |
root Required Pattern: 2.16.840.1.113883.4.6 |
||
|
code
|
0..1 |
code Binding: Healthcare Provider Taxonomy ( preferred ) |
||
|
addr
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
telecom
|
1..* |
telecom |
||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
assignedPerson
|
1..1 | assignedPerson | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
Slices for informant
|
Slice: Unordered, Open by value:relatedEntity | |||
informant:informant1
|
0..* |
informant |
||
assignedEntity
|
1..1 | assignedEntity | ||
|
id
|
C | 1..* |
id 4537-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). |
|
|
code
|
0..1 |
code Binding: Healthcare Provider Taxonomy ( preferred ) |
||
|
addr
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
assignedPerson
|
1..1 | assignedPerson | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
informant:informant2
|
0..* |
informant |
||
|
relatedEntity
|
1..1 | relatedEntity | ||
|
custodian
|
1..1 | custodian | ||
|
assignedCustodian
|
1..1 | assignedCustodian | ||
|
representedCustodianOrganization
|
1..1 | representedCustodianOrganization | ||
|
id
|
1..* |
id |
||
|
root
|
0..1 |
root Required Pattern: 2.16.840.1.113883.4.6 |
||
|
name
|
1..1 | name | ||
|
telecom
|
1..1 | telecom | ||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
addr
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/AD | addr | |
|
informationRecipient
|
0..* |
informationRecipient |
||
|
intendedRecipient
|
1..1 | intendedRecipient | ||
|
id
|
0..* |
id |
||
|
informationRecipient
|
0..1 | informationRecipient | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
receivedOrganization
|
0..1 | receivedOrganization | ||
|
name
|
1..1 | name | ||
|
legalAuthenticator
|
0..1 | legalAuthenticator | ||
|
time
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/TS | time | |
|
signatureCode
|
1..1 | signatureCode | ||
|
code
|
1..1 |
code Required Pattern: S |
||
|
sdtcSignatureText
|
0..1 | 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. | ||
|
assignedEntity
|
1..1 | assignedEntity | ||
|
id
|
1..* |
id |
||
|
root
|
0..1 |
root Required Pattern: 2.16.840.1.113883.4.6 |
||
|
code
|
0..1 |
code Binding: Healthcare Provider Taxonomy ( preferred ) |
||
|
addr
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
telecom
|
1..* |
telecom |
||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
assignedPerson
|
1..1 | assignedPerson | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
Slices for authenticator
|
Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |||
|
authenticator:authenticator1
|
0..* |
authenticator |
||
|
time
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/TS | time | |
|
signatureCode
|
1..1 | signatureCode | ||
code
|
1..1 |
code Required Pattern: S |
||
|
sdtcSignatureText
|
0..1 | 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. | ||
|
assignedEntity
|
1..1 | assignedEntity | ||
|
id
|
1..* |
id |
||
|
root
|
0..1 |
root Required Pattern: 2.16.840.1.113883.4.6 |
||
|
code
|
0..1 | code | ||
|
code
|
0..1 |
code Binding: Healthcare Provider Taxonomy ( preferred ) |
||
|
addr
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/AD |
addr |
|
|
telecom
|
1..* |
telecom |
||
|
use
|
0..1 |
use Binding: Telecom Use (US Realm Header) ( required ) |
||
|
assignedPerson
|
1..1 | assignedPerson | ||
|
name
|
1..* | http://hl7.org/cda/stds/core/StructureDefinition/PN |
name |
|
|
participant
|
C | 0..* |
4537-10006:
**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). 4537-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). |
|
|
time
|
0..1 | time | ||
|
inFulfillmentOf
|
0..* |
inFulfillmentOf |
||
|
order
|
1..1 | order | ||
|
id
|
1..* |
id |
||
|
documentationOf
|
0..* |
documentationOf |
||
|
serviceEvent
|
1..1 | serviceEvent | ||
|
effectiveTime
|
1..1 | effectiveTime | ||
|
low
|
1..1 | low | ||
|
performer
|
0..* |
performer |
||
|
typeCode
|
1..1 |
typeCode Binding: x_ServiceEventPerformer ( required ) |
||
|
functionCode
|
0..1 | functionCode | ||
|
code
|
0..1 |
code Binding: Care Team Member Function ( preferred ) |
||
|
assignedEntity
|
1..1 | assignedEntity | ||
|
id
|
1..* |
id |
||
|
root
|
0..1 |
root Required Pattern: 2.16.840.1.113883.4.6 |
||
|
code
|
0..1 |
code Binding: Healthcare Provider Taxonomy ( preferred ) |
||
|
authorization
|
0..* |
authorization |
||
|
consent
|
1..1 | consent | ||
|
id
|
0..* |
id |
||
|
code
|
0..1 | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. | ||
|
statusCode
|
1..1 | statusCode | ||
|
code
|
1..1 |
code Fixed Value: completed |
||
|
componentOf
|
0..1 | componentOf | ||
|
encompassingEncounter
|
1..1 | encompassingEncounter | ||
|
id
|
1..* |
id |
||
|
effectiveTime
|
1..1 | effectiveTime | ||
|
Documentation for this format
|
||||