| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ClinicalDocument
|
||||
realmCode
|
1..1 | Required Pattern: US | ||
|
typeId
|
1..1 | |||
root
|
1..1 | Required Pattern: 2.16.840.1.113883.1.3 | ||
extension
|
1..1 | Required Pattern: POCD_HD000040 | ||
Slices for templateId
|
Slice: Unordered, Open by value:root, value:extension | |||
templateId:primary
|
1..1 | |||
root
|
1..1 | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | ||
extension
|
1..1 | Required Pattern: 2015-08-01 | ||
|
id
|
C | 1..1 | 1198-9991: This id **SHALL** be a globally unique identifier for the document (CONF:1198-9991). | |
|
code
|
C | 1..1 |
1198-9992:
This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992). 1198-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948). |
|
|
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/fhir/cda/StructureDefinition/TS | ||
|
confidentialityCode
|
1..1 | Binding: HL7 BasicConfidentialityKind ( preferred ) | ||
|
languageCode
|
1..1 | Binding: todo ( required ) | ||
|
setId
|
C | 0..1 | 1198-6380: If setId is present versionNumber **SHALL** be present (CONF:1198-6380). | |
|
versionNumber
|
C | 0..1 | 1198-6387: If versionNumber is present setId **SHALL** be present (CONF:1198-6387). | |
|
recordTarget
|
1..* |
The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element |
||
|
patientRole
|
1..1 | |||
|
id
|
1..* | |||
|
addr
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
telecom
|
1..* | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
patient
|
1..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
administrativeGenderCode
|
1..1 | Binding: Administrative Gender (HL7 V3) ( required ) | ||
|
birthTime
|
C | 1..1 |
1198-5299:
**SHALL** be precise to year (CONF:1198-5299). 1198-5300: **SHOULD** be precise to day (CONF:1198-5300). 1198-32418: **MAY** be precise to the minute (CONF:1198-32418). For cases where information about newborn's time of birth needs to be captured. |
|
|
maritalStatusCode
|
0..1 | Binding: Marital Status ( required ) | ||
|
religiousAffiliationCode
|
0..1 | Binding: Religious Affiliation ( required ) | ||
|
raceCode
|
1..1 | Binding: Race Category Excluding Nulls ( required ) | ||
|
sdtcRaceCode
|
0..* |
XML Namespace:
urn:hl7-org:sdtc Binding: Race Value Set |
||
|
ethnicGroupCode
|
1..1 | Binding: Ethnicity ( required ) | ||
|
sdtcEthnicGroupCode
|
0..* |
XML Namespace:
urn:hl7-org:sdtc Binding: Detailed Ethnicity |
||
|
guardian
|
0..* | |||
|
code
|
0..1 | Binding: Personal And Legal Relationship Role Type ( required ) | ||
|
addr
|
0..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
telecom
|
0..* | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
guardianPerson
|
1..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
birthplace
|
0..1 | |||
|
place
|
1..1 | |||
|
addr
|
C | 1..1 |
1198-5402:
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:1198-5402). 1198-5403: 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:1198-5403). |
|
|
country
|
0..1 | Binding: todo ( required ) | ||
|
languageCommunication
|
0..* | |||
|
languageCode
|
1..1 | Binding: todo ( required ) | ||
|
modeCode
|
0..1 | Binding: LanguageAbilityMode ( required ) | ||
|
proficiencyLevelCode
|
0..1 | Binding: LanguageAbilityProficiency ( required ) | ||
|
preferenceInd
|
0..1 | |||
|
providerOrganization
|
0..1 | |||
|
id
|
1..* | |||
|
root
|
0..1 | Required Pattern: 2.16.840.1.113883.4.6 | ||
|
name
|
1..* | |||
|
telecom
|
1..* | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
addr
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
author
|
1..* |
The author element represents the creator of the clinical document. The author may be a device or a person. |
||
|
time
|
1..1 | http://hl7.org/fhir/cda/StructureDefinition/TS | ||
|
assignedAuthor
|
C | 1..1 | 1198-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790). | |
|
Slices for id
|
C |
Slice:
Unordered, Open by value:root
1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). |
||
|
id:id1
|
0..1 | |||
|
nullFlavor
|
0..1 |
If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Required Pattern: UNK |
||
|
root
|
1..1 | Required Pattern: 2.16.840.1.113883.4.6 | ||
|
extension
|
0..1 | |||
|
code
|
0..1 | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. | ||
|
code
|
1..1 | Binding: Healthcare Provider Taxonomy ( preferred ) | ||
|
addr
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
telecom
|
1..* | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
assignedPerson
|
0..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
assignedAuthoringDevice
|
0..1 | |||
|
manufacturerModelName
|
1..1 | |||
|
softwareName
|
1..1 | |||
|
dataEnterer
|
0..1 | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | ||
|
assignedEntity
|
1..1 | |||
|
id
|
1..* | |||
|
root
|
0..1 | Required Pattern: 2.16.840.1.113883.4.6 | ||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( preferred ) | ||
|
addr
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
telecom
|
1..* | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
assignedPerson
|
1..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
Slices for 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.
Slice: Unordered, Open by value:relatedEntity |
|||
informant:informant1
|
0..* |
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 | |||
|
id
|
C | 1..* |
1198-9946:
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:1198-9946). |
|
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( preferred ) | ||
|
addr
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
assignedPerson
|
1..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
informant:informant2
|
0..* | |||
|
relatedEntity
|
1..1 | |||
|
custodian
|
1..1 | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | ||
|
assignedCustodian
|
1..1 | |||
|
representedCustodianOrganization
|
1..1 | |||
|
id
|
1..* | |||
|
root
|
0..1 | Required Pattern: 2.16.840.1.113883.4.6 | ||
|
name
|
1..1 | |||
|
telecom
|
1..1 | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
addr
|
1..1 | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
informationRecipient
|
0..* |
The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. |
||
|
intendedRecipient
|
1..1 | |||
|
id
|
0..* | |||
|
informationRecipient
|
0..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
receivedOrganization
|
0..1 | |||
|
name
|
1..1 | |||
|
legalAuthenticator
|
0..1 | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | ||
|
signatureText
|
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.
undefined XML Namespace: urn:hl7-org:sdtc |
||
|
time
|
1..1 | http://hl7.org/fhir/cda/StructureDefinition/TS | ||
|
signatureCode
|
1..1 | |||
|
code
|
1..1 | Required Pattern: S | ||
|
assignedEntity
|
1..1 | |||
|
id
|
1..* | |||
|
root
|
0..1 | Required Pattern: 2.16.840.1.113883.4.6 | ||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( preferred ) | ||
|
addr
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
telecom
|
1..* | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
assignedPerson
|
1..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
Slices for authenticator
|
The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Slice: Unordered, Open by value:signatureCode, value:assignedEntity |
|||
|
authenticator:authenticator1
|
0..* | |||
|
signatureText
|
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.
undefined XML Namespace: urn:hl7-org:sdtc |
||
|
time
|
1..1 | http://hl7.org/fhir/cda/StructureDefinition/TS | ||
|
signatureCode
|
1..1 | |||
code
|
1..1 | Required Pattern: S | ||
|
assignedEntity
|
1..1 | |||
|
id
|
1..* | |||
|
root
|
0..1 | Required Pattern: 2.16.840.1.113883.4.6 | ||
|
code
|
0..1 | |||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( preferred ) | ||
|
addr
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/AD | ||
|
telecom
|
1..* | |||
|
use
|
0..1 | Binding: Telecom Use (US Realm Header) ( required ) | ||
|
assignedPerson
|
1..1 | |||
|
name
|
1..* | http://hl7.org/fhir/cda/StructureDefinition/PN | ||
|
Slices for participant
|
The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by |
|||
|
participant:participant1
|
C | 0..* |
1198-10006:
**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). 1198-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007). |
|
|
time
|
0..1 | |||
|
inFulfillmentOf
|
0..* |
The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. |
||
|
order
|
1..1 | |||
|
id
|
1..* | |||
|
documentationOf
|
0..* | |||
|
serviceEvent
|
1..1 | 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. | ||
|
effectiveTime
|
1..1 | |||
|
low
|
1..1 | |||
|
performer
|
0..* |
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 | Binding: x_ServiceEventPerformer ( required ) | ||
|
functionCode
|
0..1 | |||
|
code
|
0..1 | Binding: Care Team Member Function ( preferred ) | ||
|
assignedEntity
|
1..1 | |||
|
id
|
1..* | |||
|
root
|
0..1 | Required Pattern: 2.16.840.1.113883.4.6 | ||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( preferred ) | ||
|
Slices for 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.
Slice: Unordered, Open by value:consent |
|||
|
authorization:authorization1
|
0..* | |||
|
consent
|
1..1 | |||
|
id
|
0..* | |||
|
code
|
0..1 | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. | ||
|
statusCode
|
1..1 | |||
|
code
|
1..1 | |||
|
componentOf
|
0..1 | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | ||
|
encompassingEncounter
|
1..1 | |||
|
id
|
1..* | |||
|
effectiveTime
|
1..1 | |||
|
Documentation for this format
|
||||