Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | | | Histical |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:8283) such that it | conf‑8283 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.3 | conf0046 |
cda:code
| | 1 … 1 | R | SHALL contain exactly one [1..1] code (CONF:17185). | conf7185 |
cda:participant
| | 0 … * | | MAY contain zero or more [0..*] participant (CONF:8286).A participant element, if present, SHALL contain an associatedEntity element which SHALL contain either an associatedPerson or scopingOrganization element.A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded.c. 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 | conf‑8286 |
cda:associatedEntity
| | 1 … 1 | M | | conf‑8286 |
Choice | 1 … 1 | | A participant element, if present, SHALL contain an associatedEntity element which SHALL contain either an associatedPerson or scopingOrganization element. Elements to choose from:- cda:associatedPerson
- cda:scopingOrganization
|
cda:associatedPerson
| | | | | conf‑8286 |
cda:scopingOrganization
| | | | | conf‑8286 |
cda:inFulfillmentOf
| | 0 … * | | MAY contain zero or more [0..*] inFulfillmentOf (CONF:8336).An inFulfillmentOf element records the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and this H&P Note may be in partial fulfillment of that referral. | conf‑8336 |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:8338). | conf‑8338 |
cda:encompassingEncounter
| | 1 … 1 | M | This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8339). | conf‑8339 |
cda:id
| II | 1 … * | R | This encompassingEncounter SHALL contain exactly one [1..1] id (CONF:8340). | conf‑8340 |
cda:effectiveTime
| | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8341).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | conf‑8341 |
| Schematron assert | role | error | |
| test | not(.//@value[not(parent::cda:width)][string-length()<8]) | |
| Message | The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | |
cda:responsibleParty
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8345).The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care.The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both. | conf‑8345 |
cda:assignedEntity
| | 1 … 1 | M | | conf‑8345 |
Choice | 1 … 2 | | The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both. Elements to choose from:- cda:associatedPerson
- cda:representedOrganization
|
cda:associatedPerson
| | | | | conf‑8345 |
cda:representedOrganization
| | | | | conf‑8345 |
cda:encounterParticipant
| | 0 … * | | This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:8342).An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both.The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care. | conf‑8342 |
cda:assignedEntity
| | 1 … 1 | M | | conf‑8342 |
Choice | 1 … 2 | | The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both. Elements to choose from:- cda:associatedPerson
- cda:representedOrganization
|
cda:associatedPerson
| | | | | conf‑8342 |
cda:representedOrganization
| | | | | conf‑8342 |
cda:location
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] location (CONF:8344). | conf‑8344 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:8349).A History and Physical document can have either a structuredBody or a nonXMLBody.A History and Physical document can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.3), coded entries are optional.If structuredBody, the component/structuredBody SHALL conform to the section constraints below SHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit SectionSHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section. SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are presentSHALL NOT contain a Chief Complaint and Reason for Visit Section when either a Chief Complaint Section or a Reason for Visit Section is present | conf‑8349 |
Choice | 1 … 1 | | A History and Physical document can have either a structuredBody or a nonXMLBody. Elements to choose from:- cda:nonXMLBody
- cda:structuredBody
|
cda:nonXMLBody
| | | | | conf‑8349 |
cda:structuredBody
| | | | | conf‑8349 |
| Schematron assert | role | error | |
| test | .//cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1' or .//cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12' or .//cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.13' | |
| Message | SHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit Section | |
| Schematron assert | role | error | |
| test | not(.//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'] and (.//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] or .//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])) | |
| Message | SHALL NOT contain a Chief Complaint and Reason for Visit Section when either a Chief Complaint Section or a Reason for Visit Section is present | |
| Schematron assert | role | error | |
| test | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'] or (//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] and //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) | |
| Message | SHALL include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan Section (2.16.840.1.113883.10.20.22.2.10). | |
| Schematron assert | role | error | |
| test | not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or ( not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) ) | |
| Message | SHALL NOT include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9) when an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (2.16.840.1.113883.10.20.22.2.10) are present | |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31) | conf‑9602 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2013‑01‑31) | conf‑9605 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31) | conf‑9607 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31) | conf‑9611 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2013‑01‑31) | conf‑9613 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (2013‑01‑31) | conf‑9615 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2013‑01‑31) | conf‑9617 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (2013‑01‑31) | conf‑9619 |
cda:component
| | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2013‑01‑31) | conf‑9621 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (2013‑01‑31) | conf‑9623 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (2013‑01‑31) | conf‑9625 |
cda:component
| | 0 … 1 | | MAY contain zero or one [0..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2013‑01‑31) | conf‑9627 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (2013‑01‑31) | conf‑9629 |
cda:component
| | 1 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31) | conf‑9631 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (2013‑01‑31) | conf‑9633 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31) | conf‑9635 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (2013‑01‑31) | conf‑9987 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (2013‑01‑31) | conf‑9988 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (2013‑01‑31) | conf‑9989 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (2013‑01‑31) | conf‑9990 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (2013‑01‑31) | conf6807 |