Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | R | When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALLinclude both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32934).
| ContCDV3 |
cda:templateId
| II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF2936 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.2 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8450) such that it | CONF8450 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.2 | CONF0038 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.2" (CONF:1198-10038). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF2516 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32516). |
cda:code
| | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-17180). | CONF7180 |
@code
| CONF | 1 … 1 | F | 34133-9 |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.6.1 |
cda:author
| | 1 … * | M | SHALL contain at least one [1..*] author (CONF:1198-9442). | CONF9442 |
cda:assignedAuthor
| | 1 … 1 | M | Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:1198-9443). | CONF9443 |
| Schematron assert | role | error | |
| test | cda:assignedPerson | (cda:assignedAuthoringDevice and cda:representedOrganization) | |
| Message | SHALL contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) | |
| Schematron assert | role | error | |
| test | not(cda:representedOrganization) or cda:assignedPerson or cda:assignedAuthoringDevice or cda:id/@nullFlavor='NA' | |
| Message | If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” *SHALL* be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC. | |
cda:documentationOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] documentationOf (CONF:1198-8452).The documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | CONF8452 |
cda:serviceEvent
| | 1 … 1 | M | This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:1198-8480).The main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present. | CONF8480 |
@classCode
| cs | 1 … 1 | F | PCPR | CONF8453 |
| This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-8453). |
cda:effectiveTime
| | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:1198-8481). | CONF8481 |
cda:low
| | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-8454). | CONF8454 |
cda:high
| | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] high (CONF:1198-8455). | CONF8455 |
cda:performer
| | 0 … * | R | This serviceEvent SHOULD contain zero or more [0..*] performer (CONF:1198-8482).The serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | CONF8482 |
@typeCode
| cs | 1 … 1 | F | PRF | CONF8458 |
| The performer, if present, SHALL contain exactly one [1..1] @typeCode="PRF" Participation physical performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8458). |
cda:assignedEntity
| | 0 … 1 | | The performer, if present, MAY contain zero or one [0..1] assignedEntity (CONF:1198-8459). | CONF8459 |
cda:id
| II | 1 … * | | The assignedEntity, if present, SHALL contain at least one [1..*] id (CONF:1198-30882) such that it | CONF0882 |
| Schematron assert | role | warning | |
| test | not(cda:assignedPerson) or cda:id/@root='2.16.840.1.113883.4.6' | |
| Message | If this assignedEntity is an assignedPerson, the assignedEntity/id SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466). | |
cda:assignedPerson
| | 0 … 1 | | The assignedEntity, if present, MAY contain zero or one [0..1] assignedPerson (CONF:1198-32467). | CONF2467 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-30659). | CONF0659 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30660). | CONF0660 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies and Intolerances Section (entries required) (V3) (2015‑08‑01) | CONF0661 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09) | CONF0663 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (2015‑08‑01) | CONF0665 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (V2) (2014‑06‑09) | CONF0667 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01) | CONF0669 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (V3) (2015‑08‑01) | CONF0671 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.22 Encounters Section (entries optional) (V3) (2015‑08‑01) | CONF0673 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF0675 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF0677 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2.1 Immunizations Section (entries required) (V3) (2015‑08‑01) | CONF0679 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09) | CONF0681 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (V3) (2015‑08‑01) | CONF0683 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF0685 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF0687 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01) | CONF0689 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01) | CONF2143 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF2624 |