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Template BC CDA MedicalImaging 2020‑06‑13 00:18:42

Id2.16.840.1.113883.3.1937.99.61.21.10.51Effective Date2020‑06‑13 00:18:42
Statusdraft DraftVersion Label
NameNH_CDAClinicalDocument_MI_TrialDisplay NameBC CDA MedicalImaging
DescriptionTemplate CDA ClinicalDocument (prototype, directly derived from POCD_RM000040 MIF)
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 28 templates
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.21.10.10Includedraft BC CDA recordTargetDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.11Includedraft BC CDA authorDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.12Includedraft BC CDA custodianDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.13Includedraft BC CDA informationRecipientDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.16Includedraft BC CDA dataEntererDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.18Includedraft BC CDA authenticatorDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.53Includedraft BC CDA MI documentationOfDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.55Includedraft BC CDA inFulfillmentOfDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.56Includedraft BC CDA relatedDocumentDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.57Includedraft BC CDA componentOfDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.58Includedraft BC Physician of Record Participant (1.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.60Includedraft BC CDA Ordering ProviderDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.61Includedraft BC CDA primarycarephysicianDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.62Containmentdraft DICOM Object Catalog Section - DCM 121181 (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.63Containmentdraft BC Findings (1.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.64Containmentdraft Complications (V3) (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.65Containmentdraft Medical (General) History (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.67Containmentdraft Clinical Presentation (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.68Containmentdraft Key Images (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.69Containmentdraft Radiology Reason for Study (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.70Containmentdraft Fetus Subject Context (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.71Containmentdraft Observer Context (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.72Containmentdraft Procedure Context (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.73Containmentdraft BC RecommendationsDYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.74Containmentdraft BC Impressions (2.1)DYNAMIC
2.16.840.1.113883.3.1937.99.61.21.10.75Containmentdraft Radiology Comparison Study - ObservationDYNAMIC
2.16.840.1.113883.10.12.112Includeactive CDA componentDYNAMIC
2.16.840.1.113883.10.20.22.2.27Containmentdraft Current Imaging Procedure Descriptions (2.1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MCONF‑0001
@classCode
cs1 … 1FDOCCLINCONF‑0502
@moodCode
cs1 … 1FEVNCONF‑0502
 ConstraintThe root of a document conforming to this specification SHALL be a ClinicalDocument element from the urn:hl7-org:v3 namespace.
hl7:realmCode
CS (extensible)1 … 1MCONF‑0005
@code
CONF1 … 1Fen-CA
hl7:typeId
II1 … 1MCONF‑0002
@root
uid1 … 1F2.16.840.1.113883.1.3CONF‑0003
@extension
st1 … 1FPOCD_HD000040CONF‑0004
hl7:templateId
II1 … 1MCONF‑0176
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.21.10.51
hl7:id
II1 … 1MCONF‑0001
@extension
uid1 … 1RCONF‑0015
@root
oid1 … 1RCONF‑0014
 Constraint
id SHALL contain exactly one [1..1] id with an id.root containing the ID’s namespace OID.
id.extension attribute SHALL be a GUID.
hl7:code
CE1 … 1MCONF‑0177
@code
CONF1 … 1F18748-4
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1FDiagnostic Imaging Report
hl7:title
ST1 … 1MCONF‑0023
 Constraint
The value for ClinicalDocument/title SHALL contain exactly one [1..1]title element valued with a string that specifies the local name used for the document.

The value for ClinicalDocument/title SHOULD match the official text for the ClinicalDocument/code  and SHALL NOT conflict with it.
 Example
Example of a ClinicalDocument/title element
<title>Lab Report</title>
hl7:effectiveTime
TS.IPS.TZ1 … 1MCONF‑0001
 ConstraintThe effectiveTime.value SHALL be precise to the day, and SHOULD be precise to the minute and, if more precise than day, SHALL include a time zone offset.
 Example
Example of a ClinicalDocument/effectiveTime element
<effectiveTime value="202006181150-0800"/>
hl7:confidentialityCode
CE1 … 1MCONF‑BC0027, CONF‑BC0028, CONF‑BC0503
 ConstraintCONF-BC0028:  confidentialityCode.code SHOULD be fixed to N (normal) from Value Set 2.16.840.1.113883.2.20.3.139 x_BasicConfidentialityKind STATIC.  Where appropriate to the use case, the following values from x_BasicConfidentialityKind may also be used: Restricted, Very Restricted, and Taboo.
@code
CONF1 … 1FN
@codeSystem
1 … 1F2.16.840.1.113883.5.25
@displayName
1 … 1FNormal
 Example<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/>
hl7:languageCode
CS1 … 1MCONF‑BC0029, CONF‑BC0030
 CONF
@code shall be "en"
or
@code shall be "en-CA"
 Example<languageCode code="en-CA"/>
hl7:setId
II0 … 1CCONF‑BC0554, CONF‑BC0555
 Constraint
setId.extension SHALL be a GUID

Where setId is leveraged, CDA document SHALL contain exactly 1 [1..1] versionNumber element

Where setId is leveraged, subsequent related documents must have the same ClinicalDocument/setID value as the first document in the series. 

ClinicalDocument/setId and ClinicalDocument/versionNumber  are used to denote document revision numbers. The ClinicalDocument/effectiveTime is set to the time of the new revision.  The ClinicalDocument/relatedDocument.typeCodewould be set to RPLC (replace), unless for specific instances for Diagnosting Imaging, where it may be set to XFRM (transform).
hl7:versionNumber
INT0 … 1CCONF‑BC0019, CONF‑BC0020
 Constraint
versionNumber.value attribute SHALL be an integer representing the version of the document, with the initial version of 1, incrementing with each version of the document.

Where setId is leveraged, the versionNumber SHALL be set at the value of “1” for the original version of the document, and in the instance of a replacement document the versionNumber SHALL be an increment of 1 from the document version it replaces.

Where setId is leveraged, setId and versionNumber SHALL both be present.
hl7:participant
0 … *CONF‑0001
Included from 2.16.840.1.113883.3.1937.99.61.21.10.58 BC Physician of Record Participant (DYNAMIC)
@typeCode
cs1 … 1FATNDconf‑8881
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId/@root="2.16.840.1.113883.10.20.6.2.2" (CONF:8440).conf‑8440
where [@root='2.16.840.1.113883.10.20.6.2.2']
@root
uid0 … 1F2.16.840.1.113883.10.20.6.2.2confdots6073
cda:templateId
II0 … *MAY contain zero or more [0..*] templateId (CONF:16072).confdots6072
where [not(@root='2.16.840.1.113883.10.20.6.2.2')]
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:8886).conf‑8886
cda:id
II1 … *MThis assignedEntity SHALL contain at least one [1..*] id (CONF:8887).

The id SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier

conf‑8887
@root
uid1 … 1F2.16.840.1.113883.4.6
cda:code
CE1 … 1RThis assignedEntity SHALL contain exactly one [1..1] code (CONF:8888).conf‑8888
cda:representedOrganization
0 … 1This assignedEntity MAY contain zero or one [0..1] representedOrganization (CONF:16074).confdots6074
cda:name
0 … 1RThe representedOrganization, if present, SHOULD contain zero or one [0..1] name (CONF:16075).confdots6075
cda:name
0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] name (CONF:8890).conf‑8890
Included from 2.16.840.1.113883.3.1937.99.61.21.10.11 BC CDA author (DYNAMIC)
hl7:author
1 … *MCONF‑0058
@typeCode
cs1 … 1FAUTCONF‑0510
@contextControlCode
cs1 … 1FOPCONF‑0510
hl7:time
TS1 … 1MCONF‑BC0059, CONF‑BC0060
 ConstraintThe author/time.valueSHALL be precise to the day and SHOULD be precise to the minute. If more precise than the day, SHALL include a time zone offset.  This represents the date/time that the clinical document was dictated by the assignedPerson.  In instances where the clinical document is authored by an assignedAuthoringDevice , this date/time represents the time that the document was created by the device. (e.g. ECG auto-interpretation)
hl7:assignedAuthor
1 … 1MCONF‑0061
@classCode
cs1 … 1FASSIGNEDCONF‑0511
hl7:id
II1 … *MCONF‑BC0062, CONF‑BC0063, CONF‑BC0064
 Constraint
If the author is a Provider, the id elements SHALL conform to section 4.2.1.3.

If the author is a not a Provider, assignedAuthor/id  MAY be a locally assigned identifier
hl7:code
CE0 … 1CONF‑0061
 CONF
shall be drawn from concept domain "2.16.840.1.113883.5.111"
hl7:addr
AD.CA0 … *CONF‑0061
hl7:telecom
TEL.CA.PHONE0 … *CONF‑0061
Choice0 … 1Elements to choose from:
  • hl7:assignedPerson
  • hl7:assignedAuthoringDevice
hl7:assignedPerson
0 … 1RCONF‑0061
Included from 2.16.840.1.113883.3.1937.99.61.21.10.14 BC CDA Person (DYNAMIC)
@classCode
cs1 … 1FPSNCONF‑0519
@determinerCode
cs1 … 1FINSTANCECONF‑0519
hl7:name
PN.CA1 … 1MCONF‑0100
 Constraint assignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names
hl7:assignedAuthoringDevice
0 … 1RCONF‑0061
Included from 2.16.840.1.113883.3.1937.99.61.21.10.52 CDA Device (DYNAMIC)
@classCode
cs1 … 1FDEV
@determinerCode
cs1 … 1FINSTANCE
hl7:code
CE0 … 1BCCDdotsvice
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
hl7:manufacturerModelName
SC0 … 1BCCDdotsvice
hl7:softwareName
SC0 … 1BCCDdotsvice
Included1 … 1M from 2.16.840.1.113883.3.1937.99.61.21.10.10 BC CDA recordTarget (DYNAMIC)
hl7:recordTarget
1 … 1MCONF‑0047
@typeCode
cs1 … 1FRCTCONF‑0507
@contextControlCode
cs1 … 1FOP
hl7:patientRole
1 … 1MCONF‑0047
@classCode
cs1 … 1FPATCONF‑0508
hl7:id
II1 … *RCONF‑0048
hl7:addr
AD.CA0 … *CONF‑0051
hl7:telecom
TEL.CA.PHONE0 … *CONF‑0052
hl7:patient
1 … 1MCONF‑0053
@classCode
cs1 … 1FPSNCONF‑0509
@determinerCode
cs1 … 1FINSTANCE
hl7:name
PN.CA1 … *MCONF‑0054
hl7:administrativeGenderCode
CE (required)1 … 1MCONF‑0055
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
hl7:birthTime
TS1 … 1MCONF‑0056
hl7:languageCommunication
0 … *CONF‑0057
hl7:languageCode
CS0 … 1CONF‑0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:modeCode
CE0 … 1CONF‑0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
hl7:proficiencyLevelCode
CE0 … 1CONF‑0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
hl7:preferenceInd
BL0 … 1CONF‑0057
Included1 … *M from 2.16.840.1.113883.3.1937.99.61.21.10.11 BC CDA author (DYNAMIC)
hl7:author
1 … *MCONF‑0058
@typeCode
cs1 … 1FAUTCONF‑0510
@contextControlCode
cs1 … 1FOPCONF‑0510
hl7:time
TS1 … 1MCONF‑BC0059, CONF‑BC0060
 ConstraintThe author/time.valueSHALL be precise to the day and SHOULD be precise to the minute. If more precise than the day, SHALL include a time zone offset.  This represents the date/time that the clinical document was dictated by the assignedPerson.  In instances where the clinical document is authored by an assignedAuthoringDevice , this date/time represents the time that the document was created by the device. (e.g. ECG auto-interpretation)
hl7:assignedAuthor
1 … 1MCONF‑0061
@classCode
cs1 … 1FASSIGNEDCONF‑0511
hl7:id
II1 … *MCONF‑BC0062, CONF‑BC0063, CONF‑BC0064
 Constraint
If the author is a Provider, the id elements SHALL conform to section 4.2.1.3.

If the author is a not a Provider, assignedAuthor/id  MAY be a locally assigned identifier
hl7:code
CE0 … 1CONF‑0061
 CONF
shall be drawn from concept domain "2.16.840.1.113883.5.111"
hl7:addr
AD.CA0 … *CONF‑0061
hl7:telecom
TEL.CA.PHONE0 … *CONF‑0061
Choice0 … 1Elements to choose from:
  • hl7:assignedPerson
  • hl7:assignedAuthoringDevice
hl7:assignedPerson
0 … 1RCONF‑0061
Included from 2.16.840.1.113883.3.1937.99.61.21.10.14 BC CDA Person (DYNAMIC)
@classCode
cs1 … 1FPSNCONF‑0519
@determinerCode
cs1 … 1FINSTANCECONF‑0519
hl7:name
PN.CA1 … 1MCONF‑0100
 Constraint assignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names
hl7:assignedAuthoringDevice
0 … 1RCONF‑0061
Included from 2.16.840.1.113883.3.1937.99.61.21.10.52 CDA Device (DYNAMIC)
@classCode
cs1 … 1FDEV
@determinerCode
cs1 … 1FINSTANCE
hl7:code
CE0 … 1BCCDdotsvice
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
hl7:manufacturerModelName
SC0 … 1BCCDdotsvice
hl7:softwareName
SC0 … 1BCCDdotsvice
Included1 … 1M from 2.16.840.1.113883.3.1937.99.61.21.10.12 BC CDA custodian (DYNAMIC)
hl7:custodian
1 … 1MCONF‑0082
@typeCode
cs1 … 1FCSTCONF‑0083
hl7:assignedCustodian
1 … 1MCONF‑0084
@classCode
cs1 … 1FASSIGNEDCONF‑0514
hl7:representedCustodianOrganization
1 … 1MCONF‑0085
@classCode
cs1 … 1FORGCONF‑0515
@determinerCode
cs1 … 1FINSTANCECONF‑0515
hl7:id
II1 … 1MCONF‑0085
 Constraint

a.If the clinical document is generated from a Health Authority, this id SHALL contain the root OID of the Health Authority, and the facility id shall be used as the extension. 

b.If the clinical document is generated from an EMR, this id SHALL NOT contain the root OID of a Health Authority or of the BC Ministry of Health.

hl7:name
ON0 … 1CONF‑0087
Included0 … 1 from 2.16.840.1.113883.3.1937.99.61.21.10.16 BC CDA dataEnterer (DYNAMIC)
hl7:dataEnterer
0 … 1CONF‑BC0088, CONF‑BC0089
@typeCode
cs1 … 1FENTCONFdots0516
@contextControlCode
cs1 … 1FOP
 Constraintif dataEnterer is not the same as the author, dataEnterer SHOULD be present
hl7:time
TS1 … 1MCONF‑BC0088, CONF‑BC0089
 ConstraintThe dataEnterer/time.valueSHALL be precise to the day and SHOULD be precise to the minute. If more precise than the day, SHALL include a time zone offset.  This represents the date/time that the clinical document was transcribed by the dataEnterer. 
hl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.17 BC CDA AssignedEntity (DYNAMIC)CONFdots0090
Included0 … * from 2.16.840.1.113883.3.1937.99.61.21.10.13 BC CDA informationRecipient (DYNAMIC)
hl7:informationRecipient
0 … *CONF‑BC0070, CONF‑BC0071
@typeCode
cs1 … 1R
 Constraint
informationRecipientSHALL have the attribute typeCode whichSHALL be either “PRCP” (primary recipient) or “TRC” (secondary recipient),  from HL7 Value Set x_InformationRecipient.   

There SHALL be at least one [1..*] primary recipient (“PRCP”).
hl7:intendedRecipient
1 … 1MCONF‑0072
@classCode
cs1 … 1FASSIGNEDCONF‑0074
hl7:id
II1 … 2RCONF‑BC0073, CONF‑BC0075, CONF‑BC0076
 Constraint
If the informationRecipient is a Provider, the id elements SHALL conform to section 4.2.1.3.

If the informationRecipient is a not a Provider, intendedRecipient/id.extension MAY be a locally assigned identifier
hl7:addr
AD.CA0 … *CONF‑0077
 Constraint
If present, intendedRecipient/addr SHALL conform to the restrictions for the described in common elements for addresses.
hl7:telecom
TEL.CA.PHONE0 … *CONF‑0078
 Constraint
If present, telecom SHALL conform to the restrictions for the pan-Canadian data type flavor TEL.PHONE or TEL.EMAIL
hl7:informationRecipient
1 … 1RCONF‑0072
Included from 2.16.840.1.113883.3.1937.99.61.21.10.14 BC CDA Person (DYNAMIC)
@classCode
cs1 … 1FPSNCONF‑0519
@determinerCode
cs1 … 1FINSTANCECONF‑0519
hl7:name
PN.CA1 … 1MCONF‑0100
 Constraint assignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names
hl7:receivedOrganization
0 … 1CONF‑0080
Included from 2.16.840.1.113883.3.1937.99.61.21.10.15 BC CDA Organization (DYNAMIC)
@classCode
cs1 … 1FORGCONF‑0533
@determinerCode
cs1 … 1FINSTANCE
hl7:id
II1 … *MCDAOdots‑gwu
hl7:name
ON1 … 1MCONF‑0534
Included0 … * from 2.16.840.1.113883.3.1937.99.61.21.10.18 BC CDA authenticator (DYNAMIC)
hl7:authenticator
0 … *CDAadots‑gwu
@typeCode
cs1 … 1FAUTHEN
hl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.17 BC CDA AssignedEntity (DYNAMIC)CDAadots‑gwu
Included0 … * from 2.16.840.1.113883.3.1937.99.61.21.10.55 BC CDA inFulfillmentOf (DYNAMIC)
hl7:inFulfillmentOf
0 … *CDAidotsntOf
@typeCode
cs1 … 1FFLFSCONFdots0524
 Constraint
The inFulfillmentOf/order element MAY be present and represents the Placer Order (HL7 V2: ORC-2) or the Placer Group (HL7 V2: ORC-4) that was fulfilled, the identifier of which is carried in inFulfillmentOf/order/id.  When present, these elements conform to the constraints described in the general header section of this guide.

If  the inFulfillmentOf/order element is present, it SHALL contain exactly one [1..1] statusCode(HL7 V2: ORC-5),which represents the status code of the order.  Therefore, if present, code.codeSystem SHALL contain “statusCode” and  code.code SHALL contain “completed,” “active,” or “aborted.”
hl7:order
1 … 1MCONFdots0123
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FRQO
hl7:id
II1 … *MCONFdots0123
hl7:code
CE0 … 1CONFdots0123
 ConstraintinFulfillmentOf/order element MAY contain one [0..1] code element.  If present, code SHALL contain the status code of the order. Therefore, if present, code.codeSystem SHALL contain “statusCode” and  code.code SHALL contain “completed,” “active,” or “aborted.”
Included0 … * from 2.16.840.1.113883.3.1937.99.61.21.10.53 BC CDA MI documentationOf (DYNAMIC)
hl7:documentationOf
0 … *RCONFdots0520
@typeCode
cs1 … 1FDOC
 Constraint
documentationOf/serviceEventMAY be present. Where present, serviceEvent  SHALL conform to the requirements specified in the general BC header definition.
hl7:serviceEvent
1 … 1MCONFdots0103
@classCode
cs1 … 1FACTCONFdots0521
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *CONFdots0103
hl7:code
CE0 … 1CONFdots0103
@codeSystem
0 … 1F2.16.840.1.113883.5.4
 Constraint
The value of ServiceEvent/code SHOULD be from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC, or the value of ServiceEvent/code MAY be from ICD10-CA (codeSystem 2.16.840.1.113881.6.94) or CCI (codeSystem 2.16.840.1.113883.6.94).
bc:statusCode
CS (required)0 … 1CONFdots0103
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
hl7:effectiveTime
IVL_TS1 … 1MCONFdots0103
hl7:performer
0 … *CONFdots0104
 Constraint
If present, performer SHALL contain the typeCode attribute whose value SHALL be either “PPRF” (primary performer) or “SPRF” (secondary performer).
Included from 2.16.840.1.113883.3.1937.99.61.21.10.54 BC Physician Reading Study Performer (DYNAMIC)
@typeCode
cs1 … 1FPRFconf‑8424
cda:time
0 … 1MAY contain zero or one [0..1] time (CONF:8425).

The content of time SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)

conf‑8425
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:8426).

Every assignedEntity element SHALL have at least one assignedPerson or representedOrganization.

conf‑8426
cda:id
II1 … *MThis assignedEntity SHALL contain at least one [1..*] id (CONF:10033).

The id SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier

confdots0033
@root
uid1 … 1F2.16.840.1.113883.4.6
cda:code
CE1 … 1RThis assignedEntity SHALL contain exactly one [1..1] code (CONF:8427).conf‑8427
Choice1 … 
Every assignedEntity element SHALL have at least one assignedPerson or representedOrganization.
Elements to choose from:
  • cda:assignedPerson
  • cda:representedOrganization
cda:assignedPerson
conf‑8426
cda:representedOrganization
conf‑8426
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId/@root="2.16.840.1.113883.10.20.6.2.1" (CONF:8423).conf‑8423
@root
uid1 … 1F2.16.840.1.113883.10.20.6.2.1
Included0 … 2 from 2.16.840.1.113883.3.1937.99.61.21.10.56 BC CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … 2CONFdots0125
@typeCode
cs1 … 1RCONFdots0126
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument
1 … 1MCONFdots0127
@classCode
cs1 … 1FDOCCLIN
@moodCode
cs1 … 1FEVN
hl7:id
II1 … *RCONF‑BC0556, CONF‑BC0557, CONF‑BC0558, CONF‑BC0527
 Constraint
ClinicalDocument/relatedDocument/ParentDocument/id/@root SHALL be the ClinicalDocument/Id/@root for the document it relates to.

ClinicalDocument/relatedDocument/ParentDocument/id/@extension SHALL be the ClinicalDocument/Id/@extension for the document it relates to

ClinicalDocument/relatedDocument/ParentDocument/id/@assigningAuthorityName SHALL be the ClinicalDocument/Id/@assigningAuthorityName for the document it relates to.
hl7:code
CD0 … 1CONFdots0127
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1CONFdots0128
 Constraint
parentDocumentMAY contain the text element with the text.mediaType attribute set to indicate the MIME type of the related document.

The related document SHALL NOT be embedded inparentDocument/text element.

When sending a relatedDocument, the ClinicalDocument/relatedDocument.typeCode  SHALL be present, set at the value of “RPLC” for the original version of the document, and in the instance of a replacement document the versionNumberif present, SHALL be an increment of 1 from the document version it replaces. 

Replacement documents are meant to completely replace the previous version of a document, and as such SHALL NOT be handled as addendums in receiving systems.

Replacement documents SHALL represent a transitive relationship, where document A.1 can be replaced by A.2, A.2 can be replaced by A.3, and so on.  Multiple documents SHALL NOT replace the same document; i.e. A.1 being replaced by A.2 and also by A.3.

Receiving systems MAY retain parent documents that are considered superseded for historical and auditing purposes.  If parent documents are maintained, the receiving system SHALL very clearly identify the parent document as superseded by a more current version of the document.
hl7:setId
II0 … 1CONFdots0127
hl7:versionNumber
INT0 … 1CONFdots0127
Included1 … 1M from 2.16.840.1.113883.3.1937.99.61.21.10.57 BC CDA componentOf (DYNAMIC)
hl7:componentOf
1 … 1MCDAcdotsntOf
@typeCode
cs1 … 1FCOMPCONFdots0528
hl7:encompassingEncounter
1 … 1RCONFdots0114
@classCode
cs1 … 1FENCCONFdots0529
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *CONFdots0114
hl7:effectiveTime
IVL_TS1 … 1RCONFdots0114
hl7:responsibleParty
0 … 1Contains 2.16.840.1.113883.3.1937.99.61.21.10.17 BC CDA AssignedEntity (DYNAMIC)CONFdots0116
@typeCode
cs1 … 1FRESPCONFdots0530
hl7:encounterParticipant
0 … *CONFdots0115
@typeCode
cs1 … 1RCONFdots0117
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
 Constraint
MAY contain zero or more [0..*]encounterParticipantelements. If present, the encounterParticipant/assignedEntity element SHALL have at least one of assignedPerson or representedOrganization element present.
hl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.17 BC CDA AssignedEntity (DYNAMIC)CONFdots0115
Included0 … * from 2.16.840.1.113883.3.1937.99.61.21.10.60 BC CDA Ordering Provider (DYNAMIC)
hl7:participant
0 … *CONF‑8504
@typeCode
cs1 … 1FREFCONFdotsR‑48
@contextControlCode
cs1 … 1FOPCONF‑8505
hl7:associatedEntity
1 … 1MCONF‑8507
@classCode
cs1 … 1FPROV
hl7:id
II1 … 2RCONF‑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
CE0 … 1CONF‑8507
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
hl7:addr
AD.CA0 … *CONFdots0101
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0102
hl7:associatedPerson
1 … 1MContains 2.16.840.1.113883.3.1937.99.61.21.10.14 BC CDA Person (DYNAMIC)CONF‑8508
Included0 … * from 2.16.840.1.113883.3.1937.99.61.21.10.61 BC CDA primarycarephysician (DYNAMIC)
hl7:participant
0 … *CONF‑8504
@typeCode
cs1 … 1FINDCONF‑8505
@contextControlCode
cs1 … 1FOPCONF‑8505
hl7:functionCode
CE1 … 1MCONF‑8506
@code
CONF1 … 1FPCP
@codeSystem
1 … 1F2.16.840.1.113883.5.88
@codeSystemName
1 … 1FHL7ParticipationFunction
@displayName
1 … 1FPrimary Care Physician
hl7:associatedEntity
1 … 1RCONF‑8507
@classCode
cs1 … 1FPROVCONF‑8504
hl7:id
II1 … 2RCONF‑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
CE0 … 1CONF‑8507
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
hl7:addr
AD.CA0 … *CONFdots0101
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0102
hl7:associatedPerson
1 … 1MContains 2.16.840.1.113883.3.1937.99.61.21.10.14 BC CDA Person (DYNAMIC)CONF‑8507
hl7:component
1 … 1MCONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:structuredBody
1 … 1MCONF‑0001
@classCode
cs1 … 1FDOCBODY
@moodCode
cs1 … 1FEVN
hl7:confidentialityCode
CE (required)0 … 1CONF‑0001
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.99.61.21.11.4 x_NormalRestrictedTabooConfidentialityKind (DYNAMIC)
hl7:languageCode
cs0 … 1CONF‑0001
hl7:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.62 DICOM Object Catalog Section - DCM 121181 (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.63 BC Findings (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.64 Complications (V3) (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.65 Medical (General) History (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.67 Clinical Presentation (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.68 Key Images (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.69 Radiology Reason for Study (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … *RContains 2.16.840.1.113883.3.1937.99.61.21.10.70 Fetus Subject Context (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … *RContains 2.16.840.1.113883.3.1937.99.61.21.10.71 Observer Context (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … *RContains 2.16.840.1.113883.3.1937.99.61.21.10.72 Procedure Context (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.73 BC Recommendations (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.10.20.22.2.27 Current Imaging Procedure Descriptions (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.74 BC Impressions (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:component
0 … 1RContains 2.16.840.1.113883.3.1937.99.61.21.10.75 Radiology Comparison Study - Observation (DYNAMIC)CONF‑0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
Included1 … 1R from 2.16.840.1.113883.10.12.112 CDA component (DYNAMIC)
hl7:component
1 … 1RCDAcdotsnent
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
Choice1 … 1Elements to choose from:
Included from 2.16.840.1.113883.10.12.203 CDA NonXMLBody (DYNAMIC)
hl7:nonXMLBody
CDANdotsBody
@classCode
cs0 … 1FDOCBODY
@moodCode
cs0 … 1FEVN
hl7:text
ED1 … 1CDANdotsBody
hl7:confidentialityCode
CE0 … 1CDANdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS0 … 1CDANdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Included from 2.16.840.1.113883.10.12.202 CDA StructuredBody (DYNAMIC)
hl7:structuredBody
CDASdotsBody
@classCode
cs0 … 1FDOCBODY
@moodCode
cs0 … 1FEVN
hl7:confidentialityCode
CE0 … 1CDASdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS0 … 1CDASdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:component
1 … *Contains 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC)CDASdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue