Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | | | CDACulta |
cda:templateId
| II | 1 … 1 | M | | CDACulta |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.4 | CONF0040 |
@extension
| st | 1 … 1 | F | 2015-08-01 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32502). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ConsultDocumentType urn:oid:2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:1198-17176).The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | CONF7176 |
| CONF | |
cda:inFulfillmentOf
| | 1 … * | M | SHALL contain at least one [1..*] inFulfillmentOf (CONF:1198-8382).The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | CONF8382 |
cda:order
| | 1 … 1 | M | Such inFulfillmentOfs SHALL contain exactly one [1..1] order (CONF:1198-29923). | CONF9923 |
cda:id
| II | 1 … * | | This order SHALL contain at least one [1..*] id (CONF:1198-29924).Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | CONF9924 |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:1198-8386). A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | CONF8386 |
cda:encompassingEncounter
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13) | CONF8387 |
cda:id
| II | 1 … * | | This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-8388). | CONF8388 |
cda:responsibleParty
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8391). | CONF8391 |
cda:assignedEntity
| | 1 … 1 | M | The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32904). | CONF2904 |
| Schematron assert | role | error | |
| test | cda:assignedPerson | cda:representedOrganization | |
| Message | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both | |
cda:encounterParticipant
| | 0 … * | | This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8392).The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | CONF8392 |
cda:assignedEntity
| | 1 … 1 | M | The encounterParticipant, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32902). | CONF2902 |
| Schematron assert | role | error | |
| test | cda:assignedPerson | cda:representedOrganization | |
| Message | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both | |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-8397). | CONF8397 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-28895). | CONF8895 |
| Constraint | This structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13) | CONF8896 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09) | CONF8898 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF8900 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13) | CONF8904 |
cda:component
| | 1 … 1 | M | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13) | CONF8906 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01) | CONF8908 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies and Intolerances Section (entries required) (V3) (2015‑08‑01) | CONF8910 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2015‑08‑13) | CONF8912 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2015‑08‑13) | CONF8915 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF8917 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13) | CONF8919 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01) | CONF8921 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01) | CONF8923 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09) | CONF8925 |
cda:component
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (2015‑08‑01) | CONF8928 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09) | CONF8930 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01) | CONF8932 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF8934 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01) | CONF8936 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (V3) (2015‑08‑01) | CONF8942 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF8944 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13) | CONF0237 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09) | CONF0904 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01) | CONF0906 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF0909 |
| Schematron assert | role | error | |
| test | count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'][@extension='2014-06-09'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'][@extension='2014-06-09'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'][@extension='2014-06-09'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'][@extension='2014-06-09'])=0) | |
| Message | This structuredBody *SHALL NOT* contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. | |
| Schematron assert | role | error | |
| test | //cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.1' or //cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12' | |
| Message | *SHALL* include a Reason for Referral or Reason for Visit section | |
| Schematron assert | role | error | |
| test | count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])=0) | |
| Message | *SHALL* include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section | |