Item | DT | Card | Conf | Description | Label |
---|
cda:act
| | | | | PCHenAct |
@classCode
| cs | 1 … 1 | F | ACT | CONF9024 |
| SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-9024). |
@moodCode
| cs | 1 … 1 | F | EVN | CONF0751 |
| SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-30751). |
hl7:templateId
| II | 1 … 1 | M | | PCHenAct |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.99.61.30.10.54 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-16772) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.3" (CONF:1198-16773). b. SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32509). | CONF6772 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.132 | CONF6773 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.3" (CONF:1198-16773). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF2861 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32509). |
cda:id
| II | 1 … * | | SHALL contain at least one [1..*] id (CONF:1198-30754). | CONF0754 |
cda:code
| CD | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-32310). | CONF2310 |
@code
| CONF | 1 … 1 | F | 75310-3 |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.6.1 |
cda:statusCode
| CS | 1 … 1 | R | SHALL contain exactly one [1..1] statusCode (CONF:1198-30758). | CONF0758 |
cda:effectiveTime
| | 0 … 1 | | MAY contain zero or one [0..1] effectiveTime (CONF:1198-30759). | CONF0759 |
cda:author
| | 0 … * | R | SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31546). A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | CONF1546 |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01) | CONF0761 |
where [@typeCode='REFR'] | |
@typeCode
| cs | 1 … 1 | F | REFR | CONF0762 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-30762). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.7 Allergy - Intolerance Observation (V2) (2014‑06‑09) | CONF1007 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1008 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31008). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF1157 |
where [@typeCode='REFR'] | |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1158 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31158). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF1160 |
where [@typeCode='COMP'] | |
@typeCode
| cs | 1 … 1 | F | COMP | CONF1161 |
| SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31161). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (2015‑08‑13) | CONF1190 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1191 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31191). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.128 Self-Care Activities (ADL and IADL) (2015‑08‑13) | CONF1232 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1264 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31264). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.74 Mental Status Observation (V3) (2015‑08‑01) | CONF1234 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1268 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31268). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.78 Smoking Status - Meaningful Use (V2) (2014‑06‑09) | CONF1235 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1269 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31269). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.80 Encounter Diagnosis (V3) (2015‑08‑01) | CONF1236 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1270 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31270). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.45 Family History Organizer (V3) (2015‑08‑01) | CONF1237 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1279 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers To (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31279). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.67 Functional Status Observation (V2) (2014‑06‑09) | CONF1238 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1282 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31282). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.34 Hospital Admission Diagnosis (V3) (2015‑08‑01) | CONF1241 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1291 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31291). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.138 Nutrition Assessment (2015‑08‑13) | CONF1244 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1300 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31300). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.51 Postprocedure Diagnosis (V3) (2015‑08‑01) | CONF1246 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1306 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31306). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.15.3.8 Pregnancy Observation (2015‑08‑13) | CONF1247 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1309 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31309). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.65 Preoperative Diagnosis (V3) (2015‑08‑01) | CONF1248 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1312 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31312). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09) | CONF1250 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1318 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31318). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01) | CONF1251 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1321 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31321). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.127 Sensory Status (2015‑08‑13) | CONF1252 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1324 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31324). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.38 Social History Observation (V3) (2015‑08‑01) | CONF1253 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1327 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31327). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.24.3.90 Substance or Device Allergy - Intolerance Observation (V2) (2014‑06‑09) | CONF1254 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1330 |
| MAY contain zero or one [0..1] typeId="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31330). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.85 Tobacco Use (V2) (2014‑06‑09) | CONF1255 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1333 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31333). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.27 Vital Sign Observation (V2) (2014‑06‑09) | CONF1256 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1336 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31336). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.114 Longitudinal Care Wound Observation (V2) (2015‑08‑01) | CONF1257 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1339 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31339). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. Contains 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01) | CONF1365 |
where [@typeCode='SPRT'] | |
@typeCode
| cs | 1 … 1 | F | SPRT | CONF1366 |
| SHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31366). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.72 Caregiver Characteristics (2015‑08‑13) | CONF1368 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1369 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31369). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.111 Cultural and Religious Observation (2015‑08‑13) | CONF1371 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1372 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31372). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.109 Characteristics of Home Environment (2015‑08‑13) | CONF1374 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1375 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31375). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.124 Nutritional Status Observation (2015‑08‑13) | CONF1377 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1378 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31378). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.1 Result Organizer (V3) (2015‑08‑01) | CONF1380 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1381 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31381). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) | CONF1442 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1443 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31443). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.3 Problem Concern Act (V3) (2015‑08‑01) | CONF1544 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1547 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31547). |
cda:entryRelationship
| | 0 … * | | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF1549 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1550 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31550). |
cda:reference
| | 0 … * | | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. Contains 2.16.840.1.113883.10.20.22.4.115 External Document Reference (2014‑06‑09) | CONF2757 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF2758 |
| The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-32758). |