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Template XeH Clinical Document 2021‑09‑07 16:23:15

Id2.16.840.1.113883.2.51.10.4Effective Date2021‑09‑07 16:23:15
Statusactive ActiveVersion Label1.0
NameXeHCommonHeaderDisplay NameXeH Clinical Document
DescriptionHeader Template common to all the XeHealth specified documents (e.g., Laboratory report, Hospital Discharge report, etc ...)
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 15 templates
Uses as NameVersion
2.16.840.1.113883.2.51.10.5Includeactive XeH CDA author (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.6Includeactive XeH CDA custodian (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.7Includeactive XeH CDA dataEnterer (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.8Includeactive XeH CDA legalAuthenticator (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.9Includeactive XeH CDA recordTarget (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.10Includeactive XeH ComponentOf (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.14Includeactive XeH Information Recipient (1.0)DYNAMIC
2.16.840.1.113883.10.12.107Includeactive CDA authenticatorDYNAMIC
2.16.840.1.113883.10.12.108Includeactive CDA participantDYNAMIC
2.16.840.1.113883.10.12.109Includeactive CDA inFulfillmentOfDYNAMIC
2.16.840.1.113883.10.12.110Includeactive CDA documentationOfDYNAMIC
2.16.840.1.113883.10.12.112Includeactive CDA componentDYNAMIC
2.16.840.1.113883.10.12.114Includeactive CDA AuthorizationDYNAMIC
2.16.840.1.113883.10.12.154Includeactive CDA InformantDYNAMIC
2.16.840.1.113883.10.22.2.7Includepending IPS CDA relatedDocument (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
Example
Example
<cda:ClinicalDocument classCode="DOCCLIN" moodCode="EVN">
  <cda:realmCode/>  <cda:typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <cda:templateId root="2.16.840.1.113883.3.1937.99.61.67.10.18"/>  <cda:id root="1.2.3.999" extension="--example only--"/>  <cda:code code="--code--" codeSystem="2.16.840.1.113883.6.1"/>  <cda:title>title</cda:title>  <statusCode code="normal"/>  <cda:effectiveTime value="20220218092823"/>  <cda:confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/>  <cda:languageCode/>  <cda:setId root="1.2.3.999" extension="--example only--"/>  <cda:versionNumber value="1"/>  <!-- include template 2.16.840.1.113883.2.51.10.9 'XeH CDA recordTarget' (dynamic) 1..* R -->
  <!-- include template 2.16.840.1.113883.2.51.10.5 'XeH CDA author' (dynamic) 1..* R -->
  <!-- include template 2.16.840.1.113883.2.51.10.7 'XeH CDA dataEnterer' (dynamic) 0..1 O -->
  <!-- include template 2.16.840.1.113883.10.12.154 'CDA Informant' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.2.51.10.6 'XeH CDA custodian' (dynamic) 1..1 R -->
  <!-- include template 2.16.840.1.113883.2.51.10.14 'XeH Information Recipient' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.2.51.10.8 'XeH CDA legalAuthenticator' (dynamic) 0..1 R -->
  <!-- include template 2.16.840.1.113883.10.12.107 'CDA authenticator' (dynamic) 0..* R -->
  <!-- include template 2.16.840.1.113883.10.12.108 'CDA participant' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.10.12.109 'CDA inFulfillmentOf' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.10.12.110 'CDA documentationOf' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.10.22.2.7 'IPS CDA relatedDocument' (dynamic) 0..2 R -->
  <!-- include template 2.16.840.1.113883.10.12.114 'CDA Authorization' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.2.51.10.10 'XeH ComponentOf' (dynamic) 0..1 O -->
  <!-- include template 2.16.840.1.113883.10.12.112 'CDA component' (dynamic) 1..1 R -->
</cda:ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
XeHCdotsader
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:realmCode
CS0 … 1R

This attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question.

This element should not be used for identifying the originating country.

XeHCdotsader
hl7:typeId
II1 … 1RXeHCdotsader
@root
uid1 … 1F2.16.840.1.113883.1.3
@extension
st1 … 1FPOCD_HD000040
hl7:templateId
II1 … 1RXeHCdotsader
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.67.10.18
hl7:id
II1 … 1RXeHCdotsader
hl7:code
CE1 … 1RThe code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note).
The value set is drawn from LOINC.
XeHCdotsader
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MNarrative title of the document, usually shown to the user.
XeHCdotsader
xeh:documentStatus
CO0 … 1XeHCdotsader
hl7:effectiveTime
TS1 … 1R

The date/time of document creation.

Where the CDA document is transformed into another format, the ClinicalDocument.effectiveTime of the original document is preserved.

XeHCdotsader
hl7:confidentialityCode
CE1 … 1RXeHCdotsader
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS (preferred)1 … 1RXeHCdotsader
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:setId
II1 … 1R
Common identifier to all revisions of the document
XeHCdotsader
hl7:versionNumber
INT1 … 1RXeHCdotsader
Included1 … *R from 2.16.840.1.113883.2.51.10.9 XeH CDA recordTarget (DYNAMIC)
The recordTarget represents the medical record that this document belongs to.

A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated.
hl7:recordTarget
1 … *RXeHCdotsrget
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
 Example<recordTarget typeCode="RCT" contextControlCode="OP">
  <patientRole classCode="PAT">
    <id root="1.2.3.999" extension="__example only__"/>    <addr>
      <streetAddressLine>HSE M CASSAR STR</streetAddressLine>      <city>ISLA</city>      <country>MT</country>    </addr>    <telecom use="HP" value="tel:+356124567891"/>    <telecom use="WP" value="mailto:elif@foo.too.mt"/>    <patient>
      <name>
        <family>BORG</family>        <given>TANIA</given>      </name>      <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/>      <birthTime value="19430130"/>      <!-- Optional guardian information ; see example below-->
      <!-- Optional languageCommunication information see example below -->
    </patient>  </patientRole></recordTarget>
hl7:patientRole
1 … 1MXeHCdotsrget
@classCode
cs0 … 1FPAT
hl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)XeHCdotsrget
hl7:addr
AD.IPS1 … *RThe patient address.XeHCdotsrget
 ConstraintWhen used for cross-border exchange the country address part has to be provided.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. XeHCdotsrget
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
 Example<telecom use="HP" value="tel:+356124567891"/>
 Example<telecom use="WP" value="mailto:elif@foo.too.mt"/>
 Example<telecom nullFlavor="NI"/>
hl7:patient
1 … 1MXeHCdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
 Example
Japanese example (Person Name)
<patient>
  <name use="IDE">
    <family>木村</family>    <given>通男</given>  </name>  <name use="SYL">
    <family>きむら</family>    <given>みちお</given>  </name>  <name use="ABC">
    <family>KIMURA</family>    <given>MICHIO</given>  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient>
hl7:name
PN1 … *MPatient NameXeHCdotsrget
 ConstraintThe Alphabetic representation of the name SHALL be always provided
hl7:family
1 … *RPatient's Family Name/SurnameXeHCdotsrget
hl7:given
1 … *RPatient's Given NameXeHCdotsrget
hl7:administrativeGenderCode
CE.IPS1 … 1RPatient's GenderXeHCdotsrget
@nullFlavor
cs0 … 1FUNK
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
 Example<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
  <translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>
hl7:birthTime
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.XeHCdotsrget
hl7:guardian
0 … *R

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

XeHCdotsrget
@classCode
cs1 … 1FGUARD
 Example<guardian classCode="GUARD">
  <code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/>  <addr nullFlavor="NI"/>  <telecom use="MC" value="tel:+33-12345678"/>  <guardianPerson>
    <name>
      <family>Curie</family>      <given>Marie</given>    </name>  </guardianPerson></guardian>
hl7:code
CD.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. XeHCdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr
AD.IPS1 … *RXeHCdotsrget
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. XeHCdotsrget
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
hl7:guardianPerson
1 … 1RXeHCdotsrget
hl7:name
PN1 … *RPatient Guardian's NameXeHCdotsrget
hl7:family
ENXP1 … *RPatient Guardian's Family Name/SurnameXeHCdotsrget
hl7:given
ENXP1 … *RPatient Guardian's Given NameXeHCdotsrget
hl7:languageCommunication
0 … *RXeHCdotsrget
hl7:languageCode
CS1 … 1RPatient’s languageXeHCdotsrget
 ConstraintThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)
 Example
British English
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertrolered error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code) 
Included1 … *R from 2.16.840.1.113883.2.51.10.5 XeH CDA author (DYNAMIC)
Represents the humans and/or machines that authored the document.
The role of the author can also be recorded in the Author.functionCode or AssignedAuthor.code attribute.
If either of these attributes is included, they should be equivalent to or further specialize the role inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply "Physician Progress Note" and the value of Author.functionCode is "rounding physician"), and shall not conflict with the role inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.
hl7:author
1 … *RXeHCdotsthor
@typeCode
cs0 … 1FAUT
@contextControlCode
cs0 … 1FOP
 Example<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr use="WP">
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>    </assignedPerson>  </assignedAuthor>  <representedOrganization>
    <!-- template 'IPS CDA Organization' (dynamic) -->
  </representedOrganization></author>
hl7:functionCode
CE.IPS0 … 1RFunction of the author (e.g. "Physician on duty", ...). Binding of this element is left open and needs to be set according to project policies.XeHCdotsthor
hl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. XeHCdotsthor
 Example<time value="201212290600+0100"/>
hl7:assignedAuthor
1 … 1RXeHCdotsthor
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *RAuthor Identifier(s)

in case the author is a device, the UDI Device Identifier MAY be specified as a second id element.		XeHCdotsthor
@nullFlavor
cs0 … 1 
hl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.XeHCdotsthor
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
 Example<code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>
hl7:addr
AD.IPS1 … *RXeHCdotsthor
 Example<addr use="WP">
  <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr>
hl7:telecom
TEL.IPS1 … *RXeHCdotsthor
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@value
st0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
hl7:assignedPerson
0 … 1CXeHCdotsthor
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this documentXeHCdotsthor
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … *RXeHCdotsthor
hl7:given
1 … *RXeHCdotsthor
hl7:assignedAuthoringDevice
0 … 1CContains 2.16.840.1.113883.2.51.10.90 XeH CDA Device (DYNAMIC)XeHCdotsthor
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
hl7:representedOrganization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHCdotsthor
Included0 … 1 from 2.16.840.1.113883.2.51.10.7 XeH CDA dataEnterer (DYNAMIC)
hl7:dataEnterer
0 … 1RXeHCdotserer
hl7:time
TS.IPS.TZ1 … 1RTime of entering the data into the originating system XeHCdotserer
hl7:assignedEntity
0 … 1RRepresents the participant who has transformed a dictated note into text. A person entering the data into the originating system.XeHCdotserer
hl7:id
0 … *RUnique identification of the data entererXeHCdotserer
hl7:addr
AD.IPS1 … *RXeHCdotserer
hl7:telecom
TEL.IPS1 … *RXeHCdotserer
hl7:assignedPerson
1 … 1RXeHCdotserer
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … *MName of the data entererXeHCdotserer
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … *RFamily Name/SurnameXeHCdotserer
hl7:given
1 … *RGiven NameXeHCdotserer
hl7:representedOrganization
0 … 1ROrganization the data enterer is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)		XeHCdotserer
Included0 … * from 2.16.840.1.113883.10.12.154 CDA Informant (DYNAMIC)
hl7:informant
0 … *CDAidotsmant
@typeCode
cs0 … 1FINF
@contextControlCode
cs0 … 1FOP
Choice1 … 1Elements to choose from:
hl7:assignedEntity
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAidotsmant
hl7:relatedEntity
Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)CDAidotsmant
Included1 … 1R from 2.16.840.1.113883.2.51.10.6 XeH CDA custodian (DYNAMIC)
Represents the organization that is in charge of maintaining the document.

The custodian is the steward that is entrusted with the care of the document.
hl7:custodian
1 … 1RXeHCdotsdian
@typeCode
cs0 … 1FCST
 Example<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>  </assignedCustodian></custodian>
hl7:assignedCustodian
1 … 1RXeHCdotsdian
@classCode
cs0 … 1FASSIGNED
hl7:representedCustodianOrganization
1 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHCdotsdian
Included0 … * from 2.16.840.1.113883.2.51.10.14 XeH Information Recipient (DYNAMIC)
Represents a recipient who should receive a copy of the document.


hl7:informationRecipient
0 … *XeHIdotsient
hl7:templateId
II1 … 1MXeHIdotsient
@root
uid1 … 1F2.16.840.1.113883.2.51.10.14
hl7:templateId
II1 … 1MXeHIdotsient
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.67.10.15
hl7:templateId
II0 … *RXeHIdotsient
hl7:intendedRecipient
1 … 1RXeHIdotsient
hl7:id
II0 … *RXeHIdotsient
hl7:addr
AD1 … *RXeHIdotsient
hl7:telecom
TEL1 … *RXeHIdotsient
hl7:informationRecipient
0 … 1Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)XeHIdotsient
hl7:receivedOrganization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHIdotsient
Included0 … 1R from 2.16.840.1.113883.2.51.10.8 XeH CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1RXeHCdotsator
 Example<legalAuthenticator>
  <time value="20111013150937-0800"/>  <signatureCode code="S"/>  <assignedEntity>
    <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/>    <assignedPerson>
      <name>
        <given>John</given>        <family>Español Smith</family>      </name>    </assignedPerson>    <representedOrganization>
      <name>Healthcare Facility's name</name>      <addr>
        <country>NL</country>        <streetName>Duinweg</streetName>        <houseNumber>23</houseNumber>        <postalCode>7364 RX</postalCode>        <city>Amsterdam</city>      </addr>    </representedOrganization>  </assignedEntity></legalAuthenticator>
hl7:time
TS.IPS.TZ1 … 1MTime of signing the documentXeHCdotsator
hl7:signatureCode
CS1 … 1RSignature codeXeHCdotsator
@code
CONF0 … 1FS
hl7:assignedEntity
0 … 1RThe entity that is responsible for the legal authentication of the CDA documentXeHCdotsator
hl7:id
1 … *RUnique identification of legal authenticatorXeHCdotsator
hl7:code
CE.IPS (preferred)A code, which identifies the profession/competence/specialty of the author when it is a person.
XeHCdotsator
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
hl7:addr
AD.IPS1 … *RXeHCdotsator
hl7:telecom
TEL.IPS1 … *RXeHCdotsator
hl7:assignedPerson
1 … 1RContains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)XeHCdotsator
hl7:representedOrganization
1 … 1MOrganization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)		XeHCdotsator
Included0 … *R from 2.16.840.1.113883.10.12.107 CDA authenticator (DYNAMIC)
hl7:authenticator
0 … *RCDAadotsator
@typeCode
cs0 … 1FAUTHEN
hl7:time
TS1 … 1RCDAadotsator
hl7:signatureCode
CS1 … 1RCDAadotsator
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAadotsator
Included0 … * from 2.16.840.1.113883.10.12.108 CDA participant (DYNAMIC)
hl7:participant
0 … *CDApdotspant
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)
@contextControlCode
cs0 … 1FOP
hl7:functionCode
CE0 … 1CDApdotspant
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
IVL_TS0 … 1CDApdotspant
hl7:associatedEntity
1 … 1CDApdotspant
@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)
hl7:id
II0 … *CDApdotspant
hl7:code
CE0 … 1CDApdotspant
 CONF
shall be drawn from concept domain "RoleCode"
hl7:addr
AD0 … *CDApdotspant
hl7:telecom
TEL0 … *CDApdotspant
hl7:associatedPerson
0 … 1Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)CDApdotspant
hl7:scopingOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDApdotspant
Included0 … * from 2.16.840.1.113883.10.12.109 CDA inFulfillmentOf (DYNAMIC)
hl7:inFulfillmentOf
0 … *CDAidotsntOf
@typeCode
cs0 … 1FFLFS
hl7:order
1 … 1CDAidotsntOf
@classCode
cs0 … 1FACT
@moodCode
cs1 … 1FRQO
hl7:id
II1 … *RCDAidotsntOf
hl7:code
CE0 … 1CDAidotsntOf
 CONF
shall be drawn from concept domain "ActCode"
hl7:priorityCode
CE0 … 1CDAidotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
Included0 … * from 2.16.840.1.113883.10.12.110 CDA documentationOf (DYNAMIC)
hl7:documentationOf
0 … *CDAddotsonOf
@typeCode
cs1 … 1FDOC
hl7:serviceEvent
1 … 1CDAddotsonOf
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *CDAddotsonOf
hl7:code
CE0 … 1CDAddotsonOf
 CONF
shall be drawn from concept domain "ActCode"
hl7:effectiveTime
IVL_TS0 … 1CDAddotsonOf
hl7:performer
0 … *CDAddotsonOf
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)
hl7:functionCode
CE0 … 1CDAddotsonOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
IVL_TS0 … 1CDAddotsonOf
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAddotsonOf
Included0 … 2R from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)
A reference to a ParentDocument representing the source of a document revision, addenda, or transformation. 
 Constraint
hl7:relatedDocument
0 … 2RIPSCdotsment
@typeCode
cs1 … 1R
 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 … 1RIPSCdotsment
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RIPSCdotsment
hl7:code
CD.IPS0 … 1RIPSCdotsment
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1RIPSCdotsment
hl7:setId
II0 … 1RIPSCdotsment
hl7:versionNumber
INT0 … 1RIPSCdotsment
Included0 … * from 2.16.840.1.113883.10.12.114 CDA Authorization (DYNAMIC)
hl7:authorization
0 … *CDAadotstion
@typeCode
cs0 … 1FAUTH
hl7:consent
1 … 1CDAadotstion
@classCode
cs0 … 1FCONS
@moodCode
cs0 … 1FEVN
hl7:id
II0 … *CDAadotstion
hl7:code
CE0 … 1CDAadotstion
 CONF
shall be drawn from concept domain "ActCode"
hl7:statusCode
CS1 … 1RCDAadotstion
@code
CONF0 … 1Fcompleted
Included0 … 1 from 2.16.840.1.113883.2.51.10.10 XeH ComponentOf (DYNAMIC)
A reference to the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note.
hl7:componentOf
0 … 1XeHCdotsntOf
@typeCode
cs0 … 1FCOMP
hl7:templateId
II1 … 1MXeHCdotsntOf
@root
uid1 … 1F2.16.840.1.113883.2.51.10.10
hl7:encompassingEncounter
1 … 1RXeHCdotsntOf
@classCode
cs0 … 1FENC
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RIdentifier of the encounter (e.g. identifier of the hospital stay)XeHCdotsntOf
hl7:code
CE (extensible)0 … 1Code describing the kind of clinical encounter during which the documented act(s) or ServiceEvent occurred.
XeHCdotsntOf
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
hl7:effectiveTime
IVL_TS1 … 1RXeHCdotsntOf
hl7:low
IVXB_TS1 … 1RStart date time of the encounter (e.g. date of admission)XeHCdotsntOf
hl7:high
IVXB_TS1 … 1REnd date time of the encounter (e.g. date of discharge)
XeHCdotsntOf
hl7:dischargeDispositionCode
CE (extensible)0 … 1RDepict the disposition of the patient at the time of hospital discharge (e.g., discharged to home, expired, against medical advice, etc.).
XeHCdotsntOf
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.4.642.3.259 Discharge disposition (DYNAMIC)
hl7:responsibleParty
0 … 1
The provider (person or organization) who has primary responsibility for the encounter. The responsible provider is not necessarily present in an encounter, but is accountable for the action through the power to delegate, and the duty to review actions with the performing participant.

When the responsible party is an organization, the responsible party is reflected by the presence of a scoping Organization, without a playing entity.

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)		XeHCdotsntOf
@typeCode
cs0 … 1FRESP
hl7:encounterParticipant
0 … 1RAdmitter
XeHCdotsntOf
@typeCode
cs1 … 1FADM
hl7:time
IVL_TS0 … 1The time when the participation occurred
XeHCdotsntOf
hl7:assignedEntity
1 … 1RThe clinician assigned to the role (e.g. Admitter) by the scoping organization (e.g the hospital)

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)		XeHCdotsntOf
hl7:encounterParticipant
0 … 1RDischarger
XeHCdotsntOf
@typeCode
cs1 … 1FDIS
hl7:time
IVL_TS0 … 1The time when the participation occurred
XeHCdotsntOf
hl7:assignedEntity
1 … 1RThe clinician assigned to the role (e.g. Admitter) by the scoping organization (e.g the hospital)

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)		XeHCdotsntOf
hl7:encounterParticipant
0 … *ROther clinicians directly associated with the encounter.
XeHCdotsntOf
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
hl7:time
IVL_TS0 … 1The time when the participation occurred
XeHCdotsntOf
hl7:assignedEntity
1 … 1RThe clinician assigned to the role (e.g. Admitter) by the scoping organization (e.g the hospital)

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)		XeHCdotsntOf
hl7:location
0 … 1
The location where the service is done. May be a static building (or room therein) or a moving location (e.g., ambulance, helicopter, aircraft, train, truck, ship, etc.)

The setting of an encounter (e.g. cardiology clinic, primary care clinic, rehabilitation hospital, skilled nursing facility) can be expressed in HealthCareFacility.code. Note that setting and physical location are not the same. 
XeHCdotsntOf
@typeCode
cs0 … 1FLOC
hl7:healthCareFacility
1 … 1RXeHCdotsntOf
@classCode
cs0 … 1FSDLOC
hl7:id
II0 … *XeHCdotsntOf
hl7:code
CE0 … 1XeHCdotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
hl7:location
0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)XeHCdotsntOf
hl7:serviceProviderOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)XeHCdotsntOf
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