| Item | DT | Card | Conf | Description | Label |
|---|
cda:ClinicalDocument
| | | | | BCCD ryV3 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8463) such that it | CONF8463 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.3.51.60.2.4 | CONF0044 |
| | SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.8" (CONF:1198-10044). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF2517 |
| | SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32517). |
cda:code
| | 1 … 1 | R | SHALL contain exactly one [1..1] code (CONF:1198-17178). The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | CONF7178 |
cda:participant
| | 0 … * | | MAY contain zero or more [0..*] participant (CONF:1198-8467). The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. | CONF8467 |
| | Constraint | 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 |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:1198-8471). The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | CONF8471 |
cda:encompassingEncounter
| | 1 … 1 | M | This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-8472). | CONF8472 |
cda:effectiveTime
| IVL_TS | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:1198-32611). | CONF2611 |
cda:low
| TS | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-8473). The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | CONF8473 |
cda:high
| TS | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] high (CONF:1198-8475). The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | CONF8475 |
cda:dischargeDispositionCode
| CE | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] dischargeDispositionCode, which SHOULD be selected from ValueSet 2.16.840.1.113883.2.20.3.43 EncounterDischargeDisposition
| CONF8476 |
cda:responsibleParty
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8479). The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | CONF8479 |
cda:assignedEntity
| | 1 … 1 | M | The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32613). | CONF2613 |
| | Schematron assert | role |  error | |
| | test | cda:assignedPerson | cda:representedOrganization | |
| | Message | This assignedEntity *SHALL* contain an assignedPerson or a representedOrganization or both. | |
| Included | | | from 2.16.840.1.113883.3.51.60.1.9.2 BC CDA Ordering Provider (DYNAMIC) |
hl7:participant
| | 0 … * | | | CONF‑8504 |
@typeCode
| cs | 1 … 1 | F | REF | CONFR‑48 |
@contextControlCode
| cs | 1 … 1 | F | OP | CONF‑8505 |
hl7:associatedEntity
| | 1 … 1 | M | | CONF‑8507 |
@classCode
| cs | 1 … 1 | F | PROV | CONF‑8507 |
hl7:id
| II | 1 … 2 | R | | CONF‑BC0097, CONF‑BC0098 |
| | Constraint | If the participant is a provider, the id elements SHALL conform to section 4.2.1.3.
If the participant is a not a Provider, associatedEntity/id.extension MAY be a locally assigned identifier
|
hl7:code
| CE | 0 … 1 | | | CONF‑8507 |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 |
hl7:addr
| AD.CA | 0 … * | | | CONF0101 |
hl7:telecom
| TEL.CA.PHONE | 0 … * | | | CONF0102 |
hl7:associatedPerson
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC) | CONF‑8508 |
cda:encounterParticipant
| | 0 … * | | This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8478). The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | CONF8478 |
cda:assignedEntity
| | 1 … 1 | M | The encounterParticipant, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32615). | CONF2615 |
| | Schematron assert | role | error | |
| | test | cda:assignedPerson | cda:representedOrganization | |
| | Message | This assignedEntity *SHALL* contain an assignedPerson or a representedOrganization or both. | |
hl7:location
| | 0 … 1 | | The discharge location SHOULD be included with information on the place and mode of discharge, defined as a standard BC extension | CONF8472 |
@typeCode
| cs | 0 … 1 | F | LOC |
bc:dischargeMode
| CE (extensible) | 0 … 1 | | mode of Discharge (wheelchair, ambulance, etc)
get value set from CIHI | CONF8472 |
bc:dischargeLocation
| | 1 … 1 | M | Role representing the discharge location. Location name will be in the place name element | CONF8472 |
@classCode
| cs | 0 … 1 | F | LOCE |
hl7:code
| CE (example) | 0 … 1 | | code indicating the location discharged to. Value Set definition required. | CONF8472 |
hl7:location
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) | CONF8472 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-9539). | CONF9539 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30518). In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. | CONF0518 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.3.8 BC CDA Allergies and Intolerances Section (entries optional) (V3) (2019‑03‑15 13:13:08) | CONF0519 |
cda:component
| | 1 … 1 | M | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (2019‑03‑09 13:38:58) | CONF0521 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.3.19 BC CDA Discharge Diagnosis Section (V3) (2019‑03‑15 13:34:11) | CONF0519 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.3.17 BC CDA Discharge Medications Section (entries optional) (V3) (2019‑03‑15 14:34:42) | CONF0523 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.3.36 BC CDA Plan of Treatment Section (V2) (2019‑04‑29 08:44:11) | CONF0527 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.45 Chief Complaint Section (2019‑03‑16 08:58:47) | CONF0529 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.46 Reason for Visit Section (2019‑03‑16 20:08:36) | CONF0533 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.33 Discharge Diet Section (2019‑03‑29 06:55:23) | CONF0533 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2019‑03‑16 20:24:33) | CONF0535 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2019‑03‑16 20:25:20) | CONF0537 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2019‑03‑29 07:01:27) | CONF0537 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.3.51.60.3.23 BC CDA Admission Diagnosis Section (V3) (2019‑04‑25 09:07:06) | CONF0543 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.3.51.60.3.21 BC CDA Admission Medications Section (entries optional) (V3) (2019‑03‑16 21:05:50) | CONF0545 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (2019‑03‑16 21:06:48) | CONF0547 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (2019‑03‑16 21:08:03) | CONF0549 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (2019‑03‑16 21:08:57) | CONF0551 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (2019‑03‑16 21:10:19) | CONF0553 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.3.51.60.3.25 BC CDA Immunizations Section (entries optional) (V3) (2019‑04‑25 09:50:31) | CONF0555 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.3.51.60.3.12 BC CDA Problem Section (entries optional) (V3) (2019‑03‑16 21:22:30) | CONF0557 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2019‑03‑16 21:12:43) | CONF0559 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2019‑03‑16 21:13:31) | CONF0563 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2019‑03‑16 21:14:36) | CONF0565 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (2019‑03‑16 21:15:51) | CONF0567 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.48 Advance Directives Section (entries optional) (V3) (2019‑03‑16 21:16:48) | CONF1586 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.3.51.60.3.41 BC CDA Results Section (entries optional) (V3) (2019‑03‑16 19:55:12) | CONF1586 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.3.51.60.3.15 BC CDA Complications DS Section (V3) (2019‑03‑26 10:19:55) | CONF1586 |
| | Schematron assert | role | error | |
| | test | count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=0) | |
| | Message | This structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present | |
Under pre-publication review
CDA Place