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Template Heart Failure ClinicalDocument 2015‑05‑09 10:51:13

Id2.16.840.1.113883.3.1937.99.61.17.10.1Effective Date2015‑05‑09 10:51:13
Statusdraft DraftVersion Label
NameshnhfdocDisplay NameHeart Failure ClinicalDocument
DescriptionSHN Heart Failure Example Document
ContextPathname hl7:ClinicalDocument
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 12 templates
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.17.10.3Includedraft SHN componentDYNAMIC
2.16.840.1.113883.10.12.101Includeactive CDA recordTargetDYNAMIC
2.16.840.1.113883.10.12.102Includeactive CDA authorDYNAMIC
2.16.840.1.113883.10.12.103Includeactive CDA dataEntererDYNAMIC
2.16.840.1.113883.10.12.104Includeactive CDA custodianDYNAMIC
2.16.840.1.113883.10.12.105Includeactive CDA informationRecipientDYNAMIC
2.16.840.1.113883.10.12.106Includeactive CDA legalAuthenticatorDYNAMIC
2.16.840.1.113883.10.12.107Includeactive CDA authenticatorDYNAMIC
2.16.840.1.113883.10.12.108Includeactive CDA participantDYNAMIC
2.16.840.1.113883.10.12.110Includeactive CDA documentationOfDYNAMIC
2.16.840.1.113883.10.12.111Includeactive CDA relatedDocumentDYNAMIC
2.16.840.1.113883.10.12.154Includeactive CDA InformantDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
Example
Example
<ClinicalDocument>
  <realmCode code="US"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <!-- SHN Heart Failure Template id -->
  <templateId root="2.16.840.1.113883.3.1937.99.61.17.10.1"/>  <!-- CCD template ID-->
  <templateId root="2.16.840.1.113883.10.20.22.1.2"/>  <!-- Globally unique identifier for the document -->
  <id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/>  <code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <!-- Title of this document - EDITED MS - Called Heart Failure Report for now, need to find a better name -->
  <title>Heart Failure Report</title>  <effectiveTime value="201308151030-0800"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/>  <hl7:languageCode code="en-US"/>  <setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>  <!-- Version of this document -->
  <hl7:versionNumber value="1"/>  <recordTarget>
    <!-- Patient -->
  </recordTarget>  <author>
    <!-- The author represents the person who provides the content in the document -->
  </author>  <dataEnterer>
    <!-- The dataEnterer transferred the content created by the author into the document -->
  </dataEnterer>  <informant>
    <!-- The informant represents any sources of information for document content -->
  </informant>  <custodian>
    <!-- The custodian represents the organization charged with maintaining the original source document -->
  </custodian>  <informationRecipient>
    <!-- The informationRecipient represents the intended recipient of the document -->
  </informationRecipient>  <hl7:legalAuthenticator>
    <!-- The legalAuthenticator represents the individual who is responsible for the document -->
  </hl7:legalAuthenticator>  <authenticator>
    <!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
  </authenticator>  <participant typeCode="IND">
    <!-- The participant represents supporting entities -->
  </participant>  <documentationOf>
    <!-- The service event -->
  </documentationOf>  <component>
    <!-- CDA Body -->
  </component></ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
shnhfdoc
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:realmCode
CS0 … 1Rshnhfdoc
hl7:typeId
II1 … 1Rshnhfdoc
@root
uid1 … 1F2.16.840.1.113883.1.3
@extension
st1 … 1FPOCD_HD000040
hl7:templateId
II1 … 1Mshnhfdoc
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.17.10.1
hl7:templateId
II1 … 1Rshnhfdoc
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.2
hl7:id
II1 … 1Rshnhfdoc
hl7:code
CE1 … 1Rshnhfdoc
@code
CONF0 … 1F34133-9
@displayName
0 … 1FSummarization of Episode Note
@codeSystem
0 … 1F2.16.840.1.113883.6.1
hl7:title
ST0 … 1shnhfdoc
hl7:effectiveTime
TS1 … 1Rshnhfdoc
hl7:confidentialityCode
CE1 … 1Rshnhfdoc
 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 … 1shnhfdoc
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:setId
II0 … 1shnhfdoc
hl7:versionNumber
INT0 … 1shnhfdoc
Included1 … *R from 2.16.840.1.113883.10.12.101 CDA recordTarget (DYNAMIC)
hl7:recordTarget
1 … *RCDArdotsrget
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
hl7:patientRole
1 … 1CDArdotsrget
@classCode
cs0 … 1FPAT
hl7:id
II1 … *CDArdotsrget
hl7:addr
AD0 … *CDArdotsrget
hl7:telecom
TEL0 … *CDArdotsrget
hl7:patient
0 … 1CDArdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … 1CDArdotsrget
hl7:name
PN0 … *CDArdotsrget
hl7:administrativeGenderCode
CE0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
hl7:birthTime
TS0 … 1CDArdotsrget
hl7:maritalStatusCode
CE0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12212 Marital Status (DYNAMIC)
hl7:religiousAffiliationCode
CE0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19185 Religious Affiliation (DYNAMIC)
hl7:raceCode
CE0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14914 Race (DYNAMIC)
hl7:ethnicGroupCode
CE0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15836 Ethnicity (DYNAMIC)
hl7:guardian
0 … *CDArdotsrget
@classCode
cs0 … 1FGUARD
hl7:id
II0 … *CDArdotsrget
hl7:code
CE0 … 1CDArdotsrget
 CONF
shall be drawn from concept domain "RoleCode"
hl7:addr
AD0 … *CDArdotsrget
hl7:telecom
TEL0 … *CDArdotsrget
Choice1 … 1Elements to choose from:
hl7:guardianPerson
Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)CDArdotsrget
hl7:guardianOrganization
Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDArdotsrget
hl7:birthplace
0 … 1CDArdotsrget
@classCode
cs0 … 1FBIRTHPL
hl7:place
1 … 1CDArdotsrget
@classCode
cs0 … 1FPLC
@determinerCode
cs0 … 1FINSTANCE
hl7:name
EN0 … 1CDArdotsrget
hl7:addr
AD0 … 1CDArdotsrget
hl7:languageCommunication
0 … *CDArdotsrget
hl7:languageCode
CS0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:modeCode
CE0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
hl7:proficiencyLevelCode
CE0 … 1CDArdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
hl7:preferenceInd
BL0 … 1CDArdotsrget
hl7:providerOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDArdotsrget
Included1 … *R from 2.16.840.1.113883.10.12.102 CDA author (DYNAMIC)
hl7:author
1 … *RCDAauthor
@typeCode
cs0 … 1FAUT
@contextControlCode
cs0 … 1FOP
hl7:functionCode
CE0 … 1CDAauthor
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
TS1 … 1RCDAauthor
hl7:assignedAuthor
1 … 1CDAauthor
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *RCDAauthor
hl7:code
CE0 … 1CDAauthor
 CONF
shall be drawn from concept domain "RoleCode"
hl7:addr
AD0 … *CDAauthor
hl7:telecom
TEL0 … *CDAauthor
Choice0 … 1Elements to choose from:
hl7:assignedPerson
Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)CDAauthor
hl7:assignedAuthoringDevice
Contains 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC)CDAauthor
hl7:representedOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDAauthor
Included0 … 1 from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC)
hl7:dataEnterer
0 … 1CDAddotserer
@typeCode
cs0 … 1FENT
@contextControlCode
cs0 … 1FOP
hl7:time
TS0 … 1CDAddotserer
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAddotserer
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 2.16.840.1.113883.10.12.104 CDA custodian (DYNAMIC)
hl7:custodian
1 … 1RCDAcdotsdian
@typeCode
cs0 … 1FCST
hl7:assignedCustodian
1 … 1CDAcdotsdian
@classCode
cs0 … 1FASSIGNED
hl7:representedCustodianOrganization
1 … 1CDAcdotsdian
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II1 … *MCDAcdotsdian
hl7:name
ON0 … 1CDAcdotsdian
hl7:telecom
TEL0 … 1CDAcdotsdian
hl7:addr
AD0 … 1CDAcdotsdian
Included0 … * from 2.16.840.1.113883.10.12.105 CDA informationRecipient (DYNAMIC)
hl7:informationRecipient
0 … *CDAidotsient
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
hl7:intendedRecipient
1 … 1CDAidotsient
@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.16772 x_InformationRecipientRole (DYNAMIC)
hl7:id
II0 … *RCDAidotsient
hl7:addr
AD0 … *CDAidotsient
hl7:telecom
TEL0 … *CDAidotsient
hl7:informationRecipient
0 … 1Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)CDAidotsient
hl7:receivedOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDAidotsient
Included0 … 1 from 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1CDAldotsator
@typeCode
cs0 … 1FLA
@contextControlCode
cs0 … 1FOP
hl7:time
TS1 … 1RCDAldotsator
hl7:signatureCode
CS1 … 1RCDAldotsator
 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)CDAldotsator
Included0 … * from 2.16.840.1.113883.10.12.107 CDA authenticator (DYNAMIC)
hl7:authenticator
0 … *CDAadotsator
@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 2.16.840.1.113883.10.12.110 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 … * from 2.16.840.1.113883.10.12.111 CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … *CDArdotsment
@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 … 1CDArdotsment
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RCDArdotsment
hl7:code
CD0 … 1CDArdotsment
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1CDArdotsment
hl7:setId
II0 … 1CDArdotsment
hl7:versionNumber
INT0 … 1CDArdotsment
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.17.10.3 SHN component (DYNAMIC)
hl7:component
1 … 1RSHNcdotsnent
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R
Choice1 … 1Elements to choose from:
Included from 2.16.840.1.113883.3.1937.99.61.17.10.2 SHN StructuredBody (2015‑05‑09 11:18:02)
hl7:structuredBody
SHNSdotsBody
@classCode
cs0 … 1FDOCBODY
@moodCode
cs0 … 1FEVN
hl7:confidentialityCode
CE0 … 1SHNSdotsBody
 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 … 1SHNSdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:component
1 … *RContains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (DYNAMIC)SHNSdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R
hl7:component
1 … *RContains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (DYNAMIC)SHNSdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R
hl7:component
1 … *RContains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (DYNAMIC)SHNSdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R
hl7:component
1 … *RContains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (DYNAMIC)SHNSdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R
hl7:component
1 … *RContains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (DYNAMIC)SHNSdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R
hl7:component
1 … *RContains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (DYNAMIC)SHNSdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R
hl7:component
1 … *RContains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (DYNAMIC)SHNSdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl1 … 1R