Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | | | phcropts |
cda:realmCode
| | 1 … 1 | M | SHALL contain exactly one [1..1] realmCode="US" (CONF:1198-16791). | CONF6791 |
cda:typeId
| | 1 … 1 | M | SHALL contain exactly one [1..1] typeId (CONF:1198-5361). | CONF5361 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.1.3 | CONF5250 |
| This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" (CONF:1198-5250). |
@extension
| st | 1 … 1 | F | POCD_HD000040 | CONF5251 |
| This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:1198-5251). |
cda:templateId
| | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (PHCR-2) such that it | phcroc‑2 |
@root
| uid | 1 … 1 | F | phcr-OID | phcroc‑2 |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONFoc‑3 |
| SHALL contain exactly one [1..1] @extension="2015-11-3" (CONF:1198-32503). |
| Constraint | When asserting this templateId, all document, section, and entry templates *SHALL* include a templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail. |
cda:id
| | 1 … 1 | M | SHALL contain exactly one [1..1] id (CONF:1198-5363). | CONF5363 |
| Constraint | This id *SHALL* be a globally unique identifier for the document. |
cda:code
| CS | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-5253). | CONF5253 |
@code
| CONF | 1 … 1 | F | 55751-2 |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.6.1 |
@displayName
| 1 … 1 | F | Public Health Case report |
cda:title
| ST | 1 … 1 | M | SHALL contain exactly one [1..1] title (CONF:1198-5254). | CONF5254 |
| CONF | element content shall be "Initial Public Health Case Report" |
|
cda:effectiveTime
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.4 US Realm Date and Time (DTM.US.FIELDED) (2015‑08‑13) | CONF5256 |
| Constraint | SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1198-5256). |
cda:confidentialityCode
| | 1 … 1 | M | SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926 STATIC (CONF:1198-5259). | CONF5259 |
| CONF | |
cda:languageCode
| | 1 … 1 | M | SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:1198-5372). | CONF5372 |
| CONF | |
cda:recordTarget
| | 1 … * | M | SHALL contain at least one [1..*] recordTarget (CONF:1198-5266).The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | CONF5266 |
cda:patientRole
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13) | CONF5267 |
cda:id
| | 1 … * | M | This patientRole SHALL contain at least one [1..*] id (CONF:1198-5268). | CONF5268 |
cda:telecom
| | 1 … * | M | This patientRole SHALL contain at least one [1..*] telecom (CONF:1198-5280). | CONF5280 |
cda:patient
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13) | CONF5283 |
cda:administrativeGenderCode
| | 1 … 1 | M | This patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1 DYNAMIC (CONF:1198-6394). | CONF6394 |
| CONF | |
cda:birthTime
| | 1 … 1 | M | This patient SHALL contain exactly one [1..1] birthTime (CONF:1198-5298).*MAY* be precise to the minute. | CONF5298 |
| Schematron assert | role | error | |
| test | string-length(@value) >= 4 | |
| Message | *SHALL* be precise to year. | |
| Schematron assert | role | warning | |
| test | string-length(@value) >= 8 | |
| Message | *SHOULD* be precise to day. | |
sdtc:deceasedTime
| | 0 … 1 | R | The subject SHOULD contain zero to one [O..1] sdtc:deceasedTime. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedTime element (phcr-doc-nn).SHALL be precise to yearSHOULD be precise to day | phcrc‑nn |
| Schematron assert | role | error | |
| test | string-length(@value) >= 4 | |
| Message | SHALL be precise to year | |
| Schematron assert | role | error | |
| test | string-length(@value) >= 8 | |
| Message | SHOULD be precise to day | |
cda:maritalStatusCode
| | 0 … 1 | R | This patient SHOULD contain zero or one [0..1] maritalStatusCode, which SHALL be selected from ValueSet Marital Status urn:oid:2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:1198-5303). | CONF5303 |
| CONF | |
cda:raceCode
| | 1 … 1 | M | This patient SHALL contain exactly one [1..1] raceCode, which SHALL be selected from ValueSet Race Category Excluding Nulls urn:oid:2.16.840.1.113883.3.2074.1.1.3 DYNAMIC (CONF:1198-5322). | CONF5322 |
| CONF | |
cda:ethnicGroupCode
| | 1 … 1 | M | This patient SHALL contain exactly one [1..1] ethnicGroupCode, which SHALL be selected from ValueSet Ethnicity urn:oid:2.16.840.1.114222.4.11.837 DYNAMIC (CONF:1198-5323). | CONF5323 |
| CONF | |
cda:guardian
| | 1 … * | R | This patient SHALL contain guardian if available (PHCP-NN).
Contains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13) | phcrc‑nn |
cda:code
| | 0 … 1 | R | The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-5326). | CONF5326 |
| CONF | |
cda:telecom
| | 1 … * | R | The guardian, if present, SHOULD contain zero or more [0..*] telecom (CONF:1198-5382). | CONF5382 |
cda:guardianPerson
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13) | CONF5385 |
cda:languageCommunication
| | 0 … * | R | This patient SHOULD contain zero or more [0..*] languageCommunication (CONF:1198-5406). | CONF5406 |
cda:languageCode
| | 1 … 1 | M | The languageCommunication, if present, SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:1198-5407). | CONF5407 |
| CONF | |
cda:proficiencyLevelCode
| | 0 … 1 | R | The languageCommunication, if present, SHOULD contain zero or one [0..1] proficiencyLevelCode, which SHALL be selected from ValueSet LanguageAbilityProficiency urn:oid:2.16.840.1.113883.1.11.12199 DYNAMIC (CONF:1198-9965). | CONF9965 |
| CONF | |
cda:preferenceInd
| | 0 … 1 | R | The languageCommunication, if present, SHOULD contain zero or one [0..1] preferenceInd (CONF:1198-5414). | CONF5414 |
cda:author
| | 1 … * | M | The author element represents the creator of the clinical document. The author may be a device or a person.
NOTE: In a public health case report, the author may be software or may be a person in the role of infection control professional (ICP). In a population summary report, the author will be the software forming the message. The effect of the CDA Release 2.1 requirements is: An author element shall be present. The author element shall contain a time element that represents the time of authoring of the information, and an assignedAuthor element that represents the author of the information. The assignedAuthor element shall contain an id element. (from CDA R2) When the report author is vendor software, it can record the software installation id, an email address, and the vendor name Contains 2.16.840.1.113883.10.20.22.5.4 US Realm Date and Time (DTM.US.FIELDED) (2015‑08‑13) | CONF5444 |
cda:assignedAuthor
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13) | CONF5448 |
cda:id
| | 1 … * | M | This assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). | CONF5449 |
cda:id
| | 0 … 1 | R | If this assignedAuthor is an assignedPerson | CONF2882 |
where [parent::cda:assignedPerson] | |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.4.6 | CONF2884 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32884). |
cda:code
| | 0 … 1 | R | This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:1198-16787).Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. | CONF6787 |
cda:telecom
| | 1 … * | M | This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:1198-5428). | CONF5428 |
cda:assignedPerson
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13) | CONF5430 |
| Constraint | This assignedAuthor SHOULD contain zero or one [0..1] assignedPerson (CONF:1198-5430). |
cda:assignedAuthoringDevice
| | 0 … 1 | R | | CONF6783 |
| Constraint | This assignedAuthor SHOULD contain zero or one [0..1] assignedAuthoringDevice (CONF:1198-16783). |
cda:manufacturerModelName
| | 1 … 1 | M | The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] manufacturerModelName (CONF:1198-16784). | CONF6784 |
cda:softwareName
| | 1 … 1 | M | The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] softwareName (CONF:1198-16785). | CONF6785 |
| Schematron assert | role | error | |
| test | cda:assignedPerson |cda:assignedAuthoringDevice | |
| Message | There *SHALL* be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice. | |
cda:custodian
| | 1 … 1 | M | SHALL contain exactly one [1..1] custodian (CONF:1198-5519).The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | CONF5519 |
cda:assignedCustodian
| | 1 … 1 | M | This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:1198-5520). | CONF5520 |
cda:representedCustodianOrganization
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13) | CONF5521 |
cda:id
| | 1 … * | M | This representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:1198-5522). | CONF5522 |
cda:name
| | 1 … 1 | M | This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:1198-5524). | CONF5524 |
cda:telecom
| | 1 … 1 | M | This representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:1198-5525). | CONF5525 |
cda:legalAuthenticator
| | 0 … 1 | R | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. Contains 2.16.840.1.113883.10.20.22.5.4 US Realm Date and Time (DTM.US.FIELDED) (2015‑08‑13) | CONF5579 |
cda:signatureCode
| | 1 … 1 | M | The legalAuthenticator, if present, SHALL contain exactly one [1..1] signatureCode (CONF:1198-5583). | CONF5583 |
@code
| | 1 … 1 | F | S | CONF5584 |
| This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: Participationsignature urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:1198-5584). |
@code
| CONF | 1 … 1 | F | S |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.5.89 |
cda:assignedEntity
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13) | CONF5585 |
cda:id
| | 1 … * | M | This assignedEntity SHALL contain at least one [1..*] id (CONF:1198-5586). | CONF5586 |
cda:telecom
| | 1 … * | M | This assignedEntity SHALL contain at least one [1..*] telecom (CONF:1198-5595). | CONF5595 |
cda:assignedPerson
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13) | CONF5597 |
Included | 1 … 1 | R | from 2.16.840.1.113883.3.1937.99.61.20.10.16 PHCR Documentation Of Template (2015‑11‑03 21:56:01) adding PHCR DocumentationOfConstraints |
cda:documentationOf
| | 1 … 1 | R | SHALL contain 1 or more [1..*] documentationOf (CONF:PHCP-NN)NOTE: For public health case reporting this element is used for documenting the trigger event code. | PHCP‑NN |
cda:serviceEvent
| | 1 … 1 | M | The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:14836). | phcp‑nn |
@classCode
| cs | 1 … 1 | F | HCASE | conf6819 |
cda:effectiveTime
| | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:14837). | conf4837 |
cda:low
| | 1 … 1 | M | This effectiveTime SHALL contain exactly one [1..1] low (CONF:14838). | conf4838 |
cda:id
| | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] id (CONF:phcr-nn).NOTE: This element is used to identify the trigger code row and table version. | phcr‑nn |
cda:code
| CD | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] (CONF:phcr-nn).NOTE: This element is used to identify the trigger code. It SHALL contain the code and codeSystem and MAY contain the codeDescription and codeSystemName | CONFr‑nn |
@code
| | 1 … 1 | R | | phcp‑nn |
@displayName
| | 0 … 1 | | | phcp‑nn |
@codeSystem
| | 1 … 1 | R | | phcp‑nn |
@codeSystemName
| | 0 … 1 | | | phcp‑nn |
| CONF | |
Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.99.61.20.10.14 PHCR ComponentOf Template (2015‑11‑03) adding PHCR ComponentOf Constraints |
cda:componentOf
| | 1 … 1 | M | SHALL contain one [1..1] componentOf (phcr-nn).NOTE: The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred (CDA R2). For the public health case report, the provider in charge of care and the facility in which care was provided when the case was triggered are contained within this element. | phcr‑nn |
cda:encompassingEncounter
| | 1 … 1 | M | The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:9956). | conf‑9956 |
cda:id
| | 1 … * | M | This encompassingEncounter SHALL contain at least one [1..*] id (CONF:9959). EH: will this be used as a local identifier for the case? | conf‑9959 |
cda:effectiveTime
| | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:9958). The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | conf‑9958 |
| Schematron assert | role | error | |
| test | string-length(@value)>=8 | |
| Message | The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | |
cda:responsibleParty
| | 1 … 1 | M | This encompassingEncounter SHALL contain at least one responsibleParty (phcr-nn). | phcr‑nn |
cda:assignedEntity
| | 1 … 1 | M | Such responsibleParty SHALL contain exactly one [1..1] assignedEntity (phcr-nn). | phcr‑nn |
cda:id
| | 1 … * | R | This responsibleParty SHALL contain at least one [1..*] id (CONF:5268). | conf‑5268 |
cda:addr
| | 1 … * | R | This responsibleParty SHALL contain at least one [1..*] addr (CONF:5271).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) | conf‑5271 |
| Schematron assert | role | error | |
| test | cda:streetAddressLine and cda:city and (cda:country!='US' or ((not(cda:country) or cda:country='US') and cda:state and cda:postalCode)) | |
| Message | The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) | |
cda:telecom
| | 1 … * | R | This responsibleParty SHALL contain at least one [1..*] telecom (CONF:5280). | conf‑5280 |
@use
| set_cs | 0 … 1 | | | conf‑5375 |
| CONF | |
cda:assignedPerson
| | 1 … 1 | M | This responsibleParty SHALL contain exactly one [1..1] patient (CONF:5283). | conf‑5283 |
cda:name
| | 1 … * | R | This assignedPerson SHALL contain at least one [1..*] name (CONF:5284).The content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1) | conf‑5284 |
| Schematron assert | role | error | |
| test | cda:given and cda:family | |
| Message | The content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1) | |
cda:representedOrganization
| | 1 … 1 | M | This assignedCustodian SHALL contain exactly one [1..1] representedOrganization (CONF:5521). | conf‑5521 |
cda:name
| | 1 … 1 | R | This representedOrganization SHALL contain exactly one [1..1] name (CONF:5524). | conf‑5524 |
cda:addr
| | 1 … 1 | R | This representedOrganization SHALL contain exactly one [1..1] addr (CONF:5559).NOTE: The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) | conf‑5559 |
| Schematron assert | role | error | |
| test | cda:streetAddressLine and cda:city and ((not(cda:country) or cda:country!='US') or (cda:country='US' and cda:state and cda:postalCode)) | |
| Message | The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) | |
cda:location
| | 1 … 1 | M | This encompassingEncounter SHALL contain at least one location (phcr-nn). | phcr‑nn |
cda:healthCareFacility
| | 1 … 1 | M | The location SHALL contain one healthCareFacility (phcr-nn). | phcr‑nn |
cda:id
| | 1 … * | R | This healthCareFacility SHALL contain at least one [1..*] id (CONF:5268). | conf‑5268 |
@root
| uid | 0 … 1 | F | 2.16.840.1.113883.4.6 | conf6822 |
cda:code
| | 1 … 1 | R | This healthCareFacility SHALL contain at least one code (CONF:5268). | conf‑5268 |
| CONF | |
cda:serviceProviderOrganization
| | 1 … 1 | M | This assignedCustodian SHALL contain exactly one [1..1] serviceProviderOrganization (CONF:5521). | conf‑5521 |
cda:name
| | 1 … 1 | R | This representedOrganization SHALL contain exactly one [1..1] name (CONF:5524). | conf‑5524 |
cda:telecom
| | 1 … * | R | This serviceProviderOrganization SHALL contain at least one [1..*] telecom (CONF:5280). | conf‑5280 |
@use
| set_cs | 0 … 1 | | | conf‑5375 |
| CONF | |
cda:addr
| | 1 … 1 | R | This representedOrganization SHALL contain exactly one [1..1] addr (CONF:5559).NOTE: The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) | conf‑5559 |
| Schematron assert | role | error | |
| test | cda:streetAddressLine and cda:city and ((not(cda:country) or cda:country!='US') or (cda:country='US' and cda:state and cda:postalCode)) | |
| Message | The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) | |
Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.99.61.20.10.6 PHCR Document Body (2015‑10‑30 05:51:33) adding list of Section Templates Based upon the CSTE Des |
cda:component
| | 1 … 1 | M | | phcrBody |
cda:structuredBody
| | 1 … 1 | M | | phcrBody |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.1937.99.61.20.10.7 Encounters Section (entries required) (V3) (DYNAMIC) | phcrnt‑1 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.99.61.20.10.8 History of Present Illness Section (DYNAMIC) | phcrnt‑2 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.99.61.20.10.9 Medications Section (entries required) (V2) (DYNAMIC) | phcrnt‑3 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.99.61.20.10.10 Problem Section (entries required) (V3) (DYNAMIC) | phcrnt‑4 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.99.61.20.10.11 Reason for Visit Section (DYNAMIC) | phcrnt‑5 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.99.61.20.10.12 Results Section (entries required) (V3) (DYNAMIC) | phcrnt‑6 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.99.61.20.10.13 Social History Section (V3) (DYNAMIC) | phcrnt‑7 |