Item | DT | Card | Conf | Description | Label |
---|
hl7:ClinicalDocument
| | 1 … 1 | M | | CONF 0001 |
@classCode
| cs | 1 … 1 | F | DOCCLIN | CONF 0502 |
@moodCode
| cs | 1 … 1 | F | EVN |
hl7:realmCode
| CS (required) | 1 … 1 | M | | CONF 0005 |
@code
| CONF | 1 … 1 | F | CA-BC |
hl7:typeId
| II | 1 … 1 | M | | CONF 0002 |
@root
| oid | 1 … 1 | F | 2.16.840.1.113883.1.3 | CONF 0003 |
@extension
| st | 1 … 1 | F | POCD_HD000040 | CONF 0004 |
hl7:templateId
| II | 1 … 1 | M | | CONF 0130 |
@root
| oid | 1 … 1 | F | 2.16.840.1.113883.3.51.60.2.1 |
hl7:id
| II | 1 … 1 | M | | CONF‑BC0014, CONF‑BC0015 |
@extension
| uid | 1 … 1 | R | | CONF 0015 |
@root
| oid | 1 … 1 | R | | CONF 0014 |
| Constraint | SHALL contain exactly one [1..1] id with an id.root containing the ID’s namespace OID
id.extension attribute SHALL be a GUID
|
hl7:code
| CE | 1 … 1 | M | | CONF‑BC0131, CONF‑BC0132, CONF‑BC0021, CONF‑BC0022 |
| Constraint | If the document is a (potentially) multi-disciplinary laboratory report, the value for ClinicalDocument/code SHALL be 11502-2 LABORATORY REPORT.TOTAL 2.16.840.1.113883.6.1 LOINC STATIC
If the document is a single discipline laboratory report, the value for ClinicalDocument/code SHOULD be selected from Value Set Laboratory Specialties DYNAMIC
SHALL contain exactly one [1..1] code
The value for code.code SHOULD be selected from the value set 2.16.840.1.113883.2.20.5.1 pCLOCD DocumentTypeCodes DYNAMIC and MAY be selected from 2.16.840.1.113883.6.1 LOINC DocumentTypeCodes DYNAMIC. The OID of the code system used SHALL be placed in the code.codeSystem attribute, and the code system name SHOULD be placed in the code.codeSystemName attribute. The code.displayName attribute SHOULD contain the text equivalent of the code. This text value will probably be the same as the value of ClinicalDocument/title, or very similar. |
@codeSystem
| CONF | 1 … 1 | F | 2.16.840.1.113883.6.1 |
hl7:title
| ST | 1 … 1 | M | | CONF 0023 |
hl7:effectiveTime
| TS | 1 … 1 | M | | CONF‑BC0025, CONF‑BC0026 |
hl7:confidentialityCode
| CE (required) | 1 … 1 | M | | CONF‑BC0027, CONF‑BC0028, CONF‑BC0503 |
| CONF | @code shall be "N" | @codeSystem shall be "2.16.840.1.113883.5.25" | @displayName shall be "Normal" | or | The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.99.61.26.11.66 x_NormalRestrictedTabooConfidentialityKind (DYNAMIC) |
|
hl7:languageCode
| CS | 1 … 1 | M | | CONF‑BC0029, CONF‑BC0030 |
| CONF | @code shall be "en" | or | @code shall be "en-CA" |
|
hl7:setId
| II | 0 … 1 | C | | CONF‑BC0016, CONF‑BC0552, CONF‑BC0553, CONF‑BC0017 |
| Constraint | setId.extension SHALL be aGUID
setId SHALL contain exactly 1 [1..1] versionNumber
Where setId is leveraged, subsequent related documents must have the same ClinicalDocument/setID value as the first document in the series.
ClinicalDocument/setId and ClinicalDocument/versionNumber are used to denote document revision numbers. The ClinicalDocument/effectiveTime is set to the time of the new revision. The ClinicalDocument/relatedDocument.typeCodewould be set to RPLC (replace), unless for specific instances for Diagnosting Imaging, where it may be set to XFRM (transform). |
hl7:versionNumber
| INT | 0 … 1 | C | | CONF‑BC0018, CONF‑BC0019, CONF‑BC0020, CONF‑BC0554, CONF‑BC0555 |
| Constraint | versionNumber.value attribute SHALL be an integer representing the version of the document, with the initial version of 1, incrementing with each version of the document.
Where setId is leveraged, the versionNumberSHALL be set at the value of “1” for the original version of the document, and in the instance of a replacement document the versionNumberSHALL be an increment of 1 from the document version it replaces. |
Included | 1 … 1 | M | from 2.16.840.1.113883.3.51.60.1.3 BC CDA recordTarget (DYNAMIC) |
| Constraint | Exactly one recordTarget element SHALL be present and SHALL contain exactly one patientRole element.
|
hl7:recordTarget
| | 1 … 1 | M | | CONF 0047 |
@typeCode
| cs | 1 … 1 | F | RCT | CONF 0507 |
@contextControlCode
| cs | 1 … 1 | F | OP |
hl7:patientRole
| | 1 … 1 | M | | CONF 0047 |
@classCode
| cs | 1 … 1 | F | PAT | CONF 0508 |
hl7:id
| II | 1 … * | R | | CONF 0048 |
hl7:addr
| AD.CA | 0 … * | | | CONF 0051 |
hl7:telecom
| TEL.CA.PHONE | 0 … * | | | CONF 0052 |
hl7:patient
| | 1 … 1 | M | | CONF 0053 |
@classCode
| cs | 1 … 1 | F | PSN | CONF 0509 |
@determinerCode
| cs | 1 … 1 | F | INSTANCE |
hl7:name
| PN.CA | 1 … * | M | | CONF 0054 |
hl7:administrativeGenderCode
| CE (required) | 1 … 1 | M | | CONF 0055 |
| CONF | |
hl7:birthTime
| TS | 1 … 1 | M | | CONF 0056 |
hl7:languageCommunication
| | 0 … * | | | CONF 0057 |
hl7:languageCode
| CS | 0 … 1 | | | CONF 0057 |
| CONF | |
hl7:modeCode
| CE | 0 … 1 | | | CONF 0057 |
| CONF | |
hl7:proficiencyLevelCode
| CE | 0 … 1 | | | CONF 0057 |
| CONF | |
hl7:preferenceInd
| BL | 0 … 1 | | | CONF 0057 |
Included | 1 … * | M | from 2.16.840.1.113883.3.51.60.1.4 BC CDA author (DYNAMIC) |
hl7:author
| | 1 … * | M | | CONF 0058 |
@typeCode
| cs | 1 … 1 | F | AUT | CONF 0510 |
@contextControlCode
| cs | 1 … 1 | F | OP | CONF 0510 |
hl7:time
| TS | 1 … 1 | M | | CONF‑BC0059, CONF‑BC0060 |
| Constraint | The author/time.valueSHALL be precise to the day and SHOULD be precise to the minute. If more precise than the day, SHALL include a time zone offset. This represents the date/time that the clinical document was dictated by the assignedPerson. In instances where the clinical document is authored by an assignedAuthoringDevice , this date/time represents the time that the document was created by the device. (e.g. ECG auto-interpretation) |
hl7:assignedAuthor
| | 1 … 1 | M | | CONF 0061 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF 0511 |
hl7:id
| II | 1 … * | M | | CONF‑BC0062, CONF‑BC0063, CONF‑BC0064 |
| Constraint | If the author is a Provider, the id elements SHALL conform to section 4.2.1.3.
If the author is a not a Provider, assignedAuthor/id MAY be a locally assigned identifier |
hl7:code
| CE | 0 … 1 | | | CONF 0061 |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 |
hl7:addr
| AD.CA | 0 … * | | | CONF 0061 |
hl7:telecom
| TEL.CA.PHONE | 0 … * | | | CONF 0061 |
Choice | 0 … 1 | | Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice
|
hl7:assignedPerson
| | 0 … 1 | R | | CONF 0065 |
Included | | | from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC) |
@classCode
| cs | 1 … 1 | F | PSN | CONF 0519 |
@determinerCode
| cs | 1 … 1 | F | INSTANCE | CONF 0519 |
hl7:name
| PN.CA | 1 … * | M | | CONF 0100 |
| Constraint | assignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names |
hl7:assignedAuthoringDevice
| | 0 … 1 | R | | CONF 0065 |
Included | | | from 2.16.840.1.113883.3.51.60.1.21 BC CDA Device (DYNAMIC) |
@classCode
| cs | 1 … 1 | F | DEV |
@determinerCode
| cs | 1 … 1 | F | INSTANCE |
hl7:code
| CE | 0 … 1 | | | BCCD vice |
| CONF | |
hl7:manufacturerModelName
| SC | 0 … 1 | | | BCCD vice |
hl7:softwareName
| SC | 0 … 1 | | | BCCD vice |
Included | 1 … 1 | R | from 2.16.840.1.113883.3.51.60.1.6 BC CDA custodian (DYNAMIC) |
hl7:custodian
| | 1 … 1 | M | | CONF 0082 |
@typeCode
| cs | 1 … 1 | F | CST | CONF 0083 |
hl7:assignedCustodian
| | 1 … 1 | M | | CONF 0084 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF 0514 |
hl7:representedCustodianOrganization
| | 1 … 1 | M | | CONF 0085 |
@classCode
| cs | 1 … 1 | F | ORG | CONF 0515 |
@determinerCode
| cs | 1 … 1 | F | INSTANCE | CONF 0515 |
hl7:id
| II | 1 … 1 | M | | CONF 0086 |
| Constraint | a.If the clinical document is generated from a Health Authority, this id SHALL contain the root OID of the Health Authority, and the facility id shall be used as the extension. b.If the clinical document is generated from an EMR, this id SHALL NOT contain the root OID of a Health Authority or of the BC Ministry of Health. |
hl7:name
| ON | 0 … 1 | | | CONF 0087 |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.5 BC CDA informationRecipient (DYNAMIC) |
hl7:informationRecipient
| | 0 … * | | | CONF‑BC0070, CONF‑BC0071 |
@typeCode
| cs | 1 … 1 | R | |
| Constraint | informationRecipientSHALL have the attribute typeCode whichSHALL be either “PRCP” (primary recipient) or “TRC” (secondary recipient), from HL7 Value Set x_InformationRecipient.
There SHALL be at least one [1..*] primary recipient (“PRCP”). |
hl7:intendedRecipient
| | 1 … 1 | M | | CONF 0072 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF 0074 |
hl7:id
| II | 1 … 2 | R | | CONF‑BC0073, CONF‑BC0075, CONF‑BC0076 |
| Constraint | If the informationRecipient is a Provider, the id elements SHALL conform to section 4.2.1.3.
If the informationRecipient is a not a Provider, intendedRecipient/id.extension MAY be a locally assigned identifier
|
hl7:addr
| AD.CA | 0 … * | | | CONF 0077 |
| Constraint | If present, intendedRecipient/addr SHALL conform to the restrictions for the described in common elements for addresses. |
hl7:telecom
| TEL.CA.PHONE | 0 … * | | | CONF 0078 |
| Constraint | If present, telecomSHALL conform to the restrictions for the pan-Canadian data type flavor TEL.PHONE or TEL.EMAIL |
hl7:informationRecipient
| | 1 … 1 | R | | CONF 0072 |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC) |
@classCode
| cs | 1 … 1 | F | PSN | CONF 0519 |
@determinerCode
| cs | 1 … 1 | F | INSTANCE | CONF 0519 |
hl7:name
| PN.CA | 0 … * | M | ![notice](https://art-decor.org/ADAR/rv/assets/notice.png) | Warning: If isMandatory=true, minimumMultiplicity shall be greater than 0. |
| CONF 0100 |
| Constraint | assignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names |
hl7:receivedOrganization
| | 0 … 1 | | | CONF 0080 |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.5.1 BC CDA Organization (DYNAMIC) |
@classCode
| cs | 1 … 1 | F | ORG | CONF 0533 |
@determinerCode
| cs | 1 … 1 | F | INSTANCE |
hl7:id
| II | 0 … * | M | ![notice](https://art-decor.org/ADAR/rv/assets/notice.png) | Warning: If isMandatory=true, minimumMultiplicity shall be greater than 0. |
| CDAO tion |
hl7:name
| ON | 0 … * | M | ![notice](https://art-decor.org/ADAR/rv/assets/notice.png) | Warning: If isMandatory=true, minimumMultiplicity shall be greater than 0. |
| CONF 0534 |
Included | 0 … 1 | | from 2.16.840.1.113883.3.51.60.1.7 BC CDA dataEnterer (DYNAMIC) |
hl7:dataEnterer
| | 0 … 1 | | | CONF‑BC0088, CONF‑BC0089 |
@typeCode
| cs | 1 … 1 | F | ENT | CONF 0516 |
@contextControlCode
| cs | 1 … 1 | F | OP |
| Constraint | if dataEnterer is not the same as the author, dataEnterer SHOULD be present |
hl7:time
| TS | 1 … 1 | M | | CONF‑BC0088, CONF‑BC0089 |
| Constraint | The dataEnterer/time.valueSHALL be precise to the day and SHOULD be precise to the minute. If more precise than the day, SHALL include a time zone offset. This represents the date/time that the clinical document was transcribed by the dataEnterer. |
hl7:assignedEntity
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.1.7.1 BC CDA assignedEntity (DYNAMIC) | CONF 0090 |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.8 BC CDA authenticator (DYNAMIC) |
| Constraint | ClinicalDocument/authenticator MAY be present
|
hl7:authenticator
| | 0 … * | | | BCCD ator |
@typeCode
| cs | 1 … 1 | F | AUTHEN |
hl7:assignedEntity
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.51.60.1.7.1 BC CDA assignedEntity (DYNAMIC) | BCCD ator |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.10 BC CDA documentationOf (DYNAMIC) |
hl7:documentationOf
| | 0 … * | R | | CONF 0520 |
@typeCode
| cs | 1 … 1 | F | DOC |
| Constraint | documentationOf/serviceEventMAY be present. Where present, serviceEvent SHALL conform to the requirements specified in the general BC header definition. |
hl7:serviceEvent
| | 1 … 1 | M | | CONF 0103 |
@classCode
| cs | 1 … 1 | F | ACT | CONF 0521 |
@moodCode
| cs | 1 … 1 | F | EVN |
hl7:id
| II | 0 … * | | | CONF 0103 |
hl7:code
| CE | 0 … 1 | | | CONF 0103 |
| Constraint | The value of ServiceEvent/code SHOULD be from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC, or the value of ServiceEvent/code MAY be from ICD10-CA (codeSystem 2.16.840.1.113881.6.94) or CCI (codeSystem 2.16.840.1.113883.6.94).
|
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.4 |
bc:statusCode
| CS (required) | 0 … 1 | | | CONF 0103 |
| CONF | |
hl7:effectiveTime
| IVL_TS | 1 … 1 | M | | CONF 0103 |
hl7:performer
| | 0 … * | | | CONF 0104 |
@typeCode
| cs | 1 … 1 | R | | CONF 0105 |
| Constraint | If present, performer SHALL contain the typeCode attribute whose value SHALL be either “PPRF” (primary performer) or “SPRF” (secondary performer). |
hl7:assignedEntity
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | CONF 0106 |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.12 BC CDA inFulfillmentOf (DYNAMIC) |
hl7:inFulfillmentOf
| | 0 … * | | | CDAi ntOf |
@typeCode
| cs | 1 … 1 | F | FLFS | CONF 0524 |
| Constraint | The inFulfillmentOf/order element MAY be present and represents the Placer Order (HL7 V2: ORC-2) or the Placer Group (HL7 V2: ORC-4) that was fulfilled, the identifier of which is carried in inFulfillmentOf/order/id. When present, these elements conform to the constraints described in the general header section of this guide.
If the inFulfillmentOf/order element is present, it SHALL contain exactly one [1..1] statusCode(HL7 V2: ORC-5),which represents the status code of the order. Therefore, if present, code.codeSystem SHALL contain “statusCode” and code.code SHALL contain “completed,” “active,” or “aborted.”
|
hl7:order
| | 1 … 1 | M | | CONF 0123 |
@classCode
| cs | 1 … 1 | F | ACT | CONF 0525 |
@moodCode
| cs | 1 … 1 | F | RQO |
hl7:id
| II | 1 … * | M | | CONF 0124 |
hl7:code
| CE | 0 … 1 | | | CONF 0526 |
| Constraint | inFulfillmentOf/order element MAY contain one [0..1] code element. If present, code SHALL contain the status code of the order. Therefore, if present, code.codeSystem SHALL contain “statusCode” and code.code SHALL contain “completed,” “active,” or “aborted.” |
Included | 0 … 2 | | from 2.16.840.1.113883.3.51.60.1.13 BC CDA relatedDocument (DYNAMIC) |
hl7:relatedDocument
| | 0 … 2 | | | CONF 0125 |
@typeCode
| cs | 1 … 1 | R | | CONF 0126 |
| CONF | |
hl7:parentDocument
| | 1 … 1 | M | | CONF 0127 |
@classCode
| cs | 1 … 1 | F | DOCCLIN |
@moodCode
| cs | 1 … 1 | F | EVN |
hl7:id
| II | 1 … 1 | M | | CONF‑BC0556, CONF‑BC0557, CONF‑BC0558, CONF‑BC0527 |
| Constraint | ClinicalDocument/relatedDocument/ParentDocument/id/@root SHALL be the ClinicalDocument/Id/@root for the document it relates to.
ClinicalDocument/relatedDocument/ParentDocument/id/@extension SHALL be the ClinicalDocument/Id/@extension for the document it relates to
ClinicalDocument/relatedDocument/ParentDocument/id/@assigningAuthorityName SHALL be the ClinicalDocument/Id/@assigningAuthorityName for the document it relates to.
|
hl7:code
| CD | 0 … 1 | | | CONF 0127 |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.6.1 |
hl7:text
| ED | 0 … 1 | | | CONF 0128 |
| Constraint | parentDocumentMAY contain the text element with the text.mediaType attribute set to indicate the MIME type of the related document.
The related document SHALL NOT be embedded inparentDocument/text element.
When sending a relatedDocument, the ClinicalDocument/relatedDocument.typeCode SHALL be present, set at the value of “RPLC” for the original version of the document, and in the instance of a replacement document the versionNumberif present, SHALL be an increment of 1 from the document version it replaces.
Replacement documents are meant to completely replace the previous version of a document, and as such SHALL NOT be handled as addendums in receiving systems.
Replacement documents SHALL represent a transitive relationship, where document A.1 can be replaced by A.2, A.2 can be replaced by A.3, and so on. Multiple documents SHALL NOT replace the same document; i.e. A.1 being replaced by A.2 and also by A.3.
Receiving systems MAY retain parent documents that are considered superseded for historical and auditing purposes. If parent documents are maintained, the receiving system SHALL very clearly identify the parent document as superseded by a more current version of the document.
|
hl7:setId
| II | 0 … 1 | | | CONF 0127 |
hl7:versionNumber
| INT | 0 … 1 | | | CONF 0127 |
Included | 0 … 1 | | from 2.16.840.1.113883.3.51.60.1.11 BC CDA componentOf (DYNAMIC) |
hl7:componentOf
| | 0 … 1 | | | CDAc ntOf |
@typeCode
| cs | 1 … 1 | F | COMP | CONF 0528 |
hl7:encompassingEncounter
| | 1 … 1 | R | | CONF 0114 |
@classCode
| cs | 1 … 1 | F | ENC | CONF 0529 |
@moodCode
| cs | 1 … 1 | F | EVN |
hl7:id
| II | 0 … * | | | CONF 0114 |
hl7:effectiveTime
| IVL_TS | 1 … 1 | R | | CONF 0114 |
hl7:responsibleParty
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | CONF 0116 |
@typeCode
| cs | 1 … 1 | F | RESP | CONF 0530 |
hl7:encounterParticipant
| | 0 … * | | | CONF 0115 |
@typeCode
| cs | 1 … 1 | R | | CONF 0117 |
| CONF | |
| Constraint | MAY contain zero or more [0..*]encounterParticipantelements. If present, the encounterParticipant/assignedEntity element SHALL have at least one of assignedPerson or representedOrganization element present. |
hl7:assignedEntity
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | CONF 0115 |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.9.2 BC CDA Ordering Provider (DYNAMIC) |
hl7:participant
| | 0 … * | | | CONF‑8504 |
@typeCode
| cs | 1 … 1 | F | REF | CONF R‑48 |
@contextControlCode
| cs | 1 … 1 | F | OP | CONF‑8505 |
hl7:associatedEntity
| | 1 … 1 | M | | CONF‑8507 |
@classCode
| cs | 1 … 1 | F | PROV | CONF‑8507 |
hl7:id
| II | 1 … 2 | R | | CONF‑BC0097, CONF‑BC0098 |
| Constraint | If the participant is a provider, the id elements SHALL conform to section 4.2.1.3.
If the participant is a not a Provider, associatedEntity/id.extension MAY be a locally assigned identifier
|
hl7:code
| CE | 0 … 1 | | | CONF‑8507 |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 |
hl7:addr
| AD.CA | 0 … * | | | CONF 0101 |
hl7:telecom
| TEL.CA.PHONE | 0 … * | | | CONF 0102 |
hl7:associatedPerson
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC) | CONF‑8508 |
Included | 0 … * | | from 2.16.840.1.113883.3.51.60.1.8.1 BC CDA legalAuthenticator (DYNAMIC) |
| Constraint | If the Legal Authenticator of a Lab Results document is included, and that person is also one of the validators of the laboratory results in the report, they SHALL also be included as a validator as described in this section.
|
hl7:legalAuthenticator
| | 0 … * | | | CDAl ator |
@typeCode
| cs | 1 … 1 | F | LA |
@contextControlCode
| cs | 1 … 1 | F | OP |
hl7:time
| TS | 1 … 1 | R | | CDAl ator |
| Constraint | timeSHALL be precise to the day and SHOULD be precise to the minute and, if more precise than the day, SHALL include a time zone offset. |
hl7:signatureCode
| CS | 1 … 1 | R | | CDAl ator |
hl7:assignedEntity
| | 1 … 1 | M | Contains 2.16.840.1.113883.3.51.60.1.7.1 BC CDA assignedEntity (DYNAMIC) | CDAl ator |
hl7:component
| | 1 … 1 | M | | CONF 0001 |
@typeCode
| cs | 1 … 1 | F | COMP |
@contextConductionInd
| bl | 1 … 1 | F | true |
hl7:structuredBody
| | 1 … 1 | M | | CONF 0001 |
hl7:component
| | 1 … * | R | | CONF 0001 |
@contextConductionInd
| bl | 1 … 1 | F | true |