| Item | DT | Card | Conf | Description | Label |
|---|
cda:ClinicalDocument
| | | | | Выпи криз |
cda:templateId
| | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:8463) such that it | conf‑8463 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.8 | conf0044 |
cda:code
| | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:17178). | conf7178 |
cda:participant
| | 0 … * | | MAY contain zero or more [0..*] participant (CONF:8467).If present, the participant/associatedEntity element SHALL have an associatedPerson or scopingOrganization element. b. 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‑8467 |
| | Schematron assert | role |  error | |
| | test | cda:associatedEntity[cda:associatedPerson | cda:scopingOrganization] | |
| | Message | If present, the participant/associatedEntity element SHALL have an associatedPerson or scopingOrganization element. | |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:8471). | conf‑8471 |
cda:encompassingEncounter
| | 1 … 1 | M | This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8472). | conf‑8472 |
cda:effectiveTime
| | 1 … | | | conf‑8472 |
cda:low
| | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/low (CONF:8473). | conf‑8473 |
cda:high
| | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/high (CONF:8475). | conf‑8475 |
hl7:dischargeDispositionCode
| CE | 0 … 1 | | The dischargeDispositionCode SHALL be present where the value of code SHOULD be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status DYNAMIC (www.nubc.org)The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, SHALL be displayed when the document is rendered | conf‑8472 |
| | CONF | |
hl7:responsibleParty
| | 0 … 1 | | The responsibleParty element MAY be present. If present, the responsibleParty/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | conf‑8472 |
@typeCode
| cs | 0 … 1 | F | RESP |
hl7:encounterParticipant
| | 0 … * | | The encounterParticipant elements MAY be present. If present, the encounterParticipant/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present. | conf‑8472 |
@typeCode
| cs | 1 … 1 | R | |
| | CONF | |
hl7:time
| IVL_TS | 0 … 1 | | | conf‑8472 |
hl7:assignedEntity
| | 1 … 1 | | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | conf‑8472 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:9539).A Discharge Summary can have either a structuredBody or a nonXMLBody.A Discharge Summary 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 2.16.840.1.113883.10.20.22.1.8), coded entries are optional.If structuredBody, the component/structuredBody SHALL conform to the section constraints below SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section | conf‑9539 |
| | Schematron assert | role | error | |
| | test | count(//cda:structuredBody | //cda:nonXMLBody)=1 | |
| | Message | A Discharge Summary can have either a structuredBody or a nonXMLBody. | |
| Choice | 1 … 1 | | Elements to choose from:- cda:nonXMLBody
- cda:structuredBody
|
cda:nonXMLBody
| | | | | conf‑9539 |
cda:structuredBody
| | | | | conf‑9539 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.6 Allergies and Intolerances Section (entries optional) (V3) (DYNAMIC) | conf‑9542 |
cda:component
| | 1 … 1 | M | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (DYNAMIC) | conf‑9544 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.24 Discharge Diagnosis Section (V3) (DYNAMIC) | conf‑9546 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.11 Discharge Medications Section (entries optional) (V3) (DYNAMIC) | conf‑9548 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (DYNAMIC) | conf‑9550 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (DYNAMIC) | conf‑9554 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (DYNAMIC) | conf‑9556 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.33 Discharge Diet Section (DEPRECATED) (DYNAMIC) | conf‑9558 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (DYNAMIC) | conf‑9560 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (DYNAMIC) | conf‑9562 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (DYNAMIC) | conf‑9564 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC) | conf‑9566 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (DYNAMIC) | conf‑9568 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (DYNAMIC) | conf‑9570 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (DYNAMIC) | conf‑9572 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (V3) (DYNAMIC) | conf‑9574 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (DYNAMIC) | conf‑9576 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (DYNAMIC) | conf‑9578 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (DYNAMIC) | conf‑9580 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (DYNAMIC) | conf‑9582 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (DYNAMIC) | conf‑9584 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (DYNAMIC) | conf‑9924 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (DYNAMIC) | conf‑9926 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.43 Admission Diagnosis Section (V3) (DYNAMIC) | conf‑9928 |
| | Schematron assert | role | error | |
| | test | count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=0) | |
| | Message | SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section | |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.44 Admission Medications Section (entries optional) (V3) (DYNAMIC) | conf0111 |
Draft
Discharge Diet Section (DEPRECATED) (2.1)
CDA AssignedEntity