Id2.16.840.1.113883.3.51.60.2.1Effective Date2016‑04‑02 11:52:37
Statusdraft DraftVersion Label
NameBCCDAClinicalDocument2Display Name BC CDA ClinicalDocumentLabResult
DescriptionPilot BC CDA template.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 12 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.61.26.4.2Transactiondraft Lab result document2016‑09‑08 18:19:46
Uses as NameVersion
2.16.840.1.113883.3.51.60.1.3Includedraft BC CDA recordTargetDYNAMIC
2.16.840.1.113883.3.51.60.1.4Includedraft BC CDA authorDYNAMIC
2.16.840.1.113883.3.51.60.1.5Includedraft BC CDA informationRecipientDYNAMIC
2.16.840.1.113883.3.51.60.1.6Includedraft BC CDA custodianDYNAMIC
2.16.840.1.113883.3.51.60.1.7Includedraft BC CDA dataEntererDYNAMIC
2.16.840.1.113883.3.51.60.1.8Includedraft BC CDA authenticatorDYNAMIC
2.16.840.1.113883.3.51.60.1.8.1Includedraft BC CDA legalAuthenticatorDYNAMIC
2.16.840.1.113883.3.51.60.1.9.2Includepending BC CDA Ordering Provider (2.1)DYNAMIC
2.16.840.1.113883.3.51.60.1.10Includedraft BC CDA documentationOfDYNAMIC
2.16.840.1.113883.3.51.60.1.11Includedraft BC CDA componentOfDYNAMIC
2.16.840.1.113883.3.51.60.1.12Includedraft BC CDA inFulfillmentOfDYNAMIC
2.16.840.1.113883.3.51.60.1.13Includedraft BC CDA relatedDocumentDYNAMIC
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MCONFdots0001
@classCode
cs1 … 1FDOCCLINCONFdots0502
@moodCode
cs1 … 1FEVN
hl7:realmCode
CS (required)1 … 1MCONFdots0005
@code
CONF1 … 1FCA-BC
hl7:typeId
II1 … 1MCONFdots0002
@root
oid1 … 1F2.16.840.1.113883.1.3CONFdots0003
@extension
st1 … 1FPOCD_HD000040CONFdots0004
hl7:templateId
II1 … 1MCONFdots0130
@root
oid1 … 1F2.16.840.1.113883.3.51.60.2.1
hl7:id
II1 … 1MCONF‑BC0014, CONF‑BC0015
@extension
uid1 … 1RCONFdots0015
@root
oid1 … 1RCONFdots0014
 ConstraintSHALL 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
CE1 … 1MCONF‑BC0131, CONF‑BC0132, CONF‑BC0021, CONF‑BC0022
 ConstraintIf 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
CONF1 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MCONFdots0023
hl7:effectiveTime
TS1 … 1MCONF‑BC0025, CONF‑BC0026
hl7:confidentialityCode
CE (required)1 … 1MCONF‑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
CS1 … 1MCONF‑BC0029, CONF‑BC0030
 CONF
@code shall be "en"
or
@code shall be "en-CA"
hl7:setId
II0 … 1CCONF‑BC0016, CONF‑BC0552, CONF‑BC0553, CONF‑BC0017
 ConstraintsetId.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
INT0 … 1CCONF‑BC0018, CONF‑BC0019, CONF‑BC0020, CONF‑BC0554, CONF‑BC0555
 ConstraintversionNumber.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.
Included1 … 1M from 2.16.840.1.113883.3.51.60.1.3 BC CDA recordTarget (DYNAMIC)
 ConstraintExactly one recordTarget element SHALL be present and SHALL contain exactly one patientRole element.
hl7:recordTarget
1 … 1MCONFdots0047
@typeCode
cs1 … 1FRCTCONFdots0507
@contextControlCode
cs1 … 1FOP
hl7:patientRole
1 … 1MCONFdots0047
@classCode
cs1 … 1FPATCONFdots0508
hl7:id
II1 … *RCONFdots0048
hl7:addr
AD.CA0 … *CONFdots0051
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0052
hl7:patient
1 … 1MCONFdots0053
@classCode
cs1 … 1FPSNCONFdots0509
@determinerCode
cs1 … 1FINSTANCE
hl7:name
PN.CA1 … *MCONFdots0054
hl7:administrativeGenderCode
CE (required)1 … 1MCONFdots0055
 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
TS1 … 1MCONFdots0056
hl7:languageCommunication
0 … *CONFdots0057
hl7:languageCode
CS0 … 1CONFdots0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:modeCode
CE0 … 1CONFdots0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
hl7:proficiencyLevelCode
CE0 … 1CONFdots0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
hl7:preferenceInd
BL0 … 1CONFdots0057
Included1 … *M from 2.16.840.1.113883.3.51.60.1.4 BC CDA author (DYNAMIC)
hl7:author
1 … *MCONFdots0058
@typeCode
cs1 … 1FAUTCONFdots0510
@contextControlCode
cs1 … 1FOPCONFdots0510
hl7:time
TS1 … 1MCONF‑BC0059, CONF‑BC0060
 ConstraintThe 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 … 1MCONFdots0061
@classCode
cs1 … 1FASSIGNEDCONFdots0511
hl7:id
II1 … *MCONF‑BC0062, CONF‑BC0063, CONF‑BC0064
 ConstraintIf 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
CE0 … 1CONFdots0061
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
hl7:addr
AD.CA0 … *CONFdots0061
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0061
Choice0 … 1Elements to choose from:
  • hl7:assignedPerson
  • hl7:assignedAuthoringDevice
hl7:assignedPerson
0 … 1RCONFdots0065
Included from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)
@classCode
cs1 … 1FPSNCONFdots0519
@determinerCode
cs1 … 1FINSTANCECONFdots0519
hl7:name
PN.CA1 … *MCONFdots0100
 ConstraintassignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names
hl7:assignedAuthoringDevice
0 … 1RCONFdots0065
Included from 2.16.840.1.113883.3.51.60.1.21 BC CDA Device (DYNAMIC)
@classCode
cs1 … 1FDEV
@determinerCode
cs1 … 1FINSTANCE
hl7:code
CE0 … 1BCCDdotsvice
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
hl7:manufacturerModelName
SC0 … 1BCCDdotsvice
hl7:softwareName
SC0 … 1BCCDdotsvice
Included1 … 1R from 2.16.840.1.113883.3.51.60.1.6 BC CDA custodian (DYNAMIC)
hl7:custodian
1 … 1MCONFdots0082
@typeCode
cs1 … 1FCSTCONFdots0083
hl7:assignedCustodian
1 … 1MCONFdots0084
@classCode
cs1 … 1FASSIGNEDCONFdots0514
hl7:representedCustodianOrganization
1 … 1MCONFdots0085
@classCode
cs1 … 1FORGCONFdots0515
@determinerCode
cs1 … 1FINSTANCECONFdots0515
hl7:id
II1 … 1MCONFdots0086
 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
ON0 … 1CONFdots0087
Included0 … * from 2.16.840.1.113883.3.51.60.1.5 BC CDA informationRecipient (DYNAMIC)
hl7:informationRecipient
0 … *CONF‑BC0070, CONF‑BC0071
@typeCode
cs1 … 1R
 ConstraintinformationRecipientSHALL 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 … 1MCONFdots0072
@classCode
cs1 … 1FASSIGNEDCONFdots0074
hl7:id
II1 … 2RCONF‑BC0073, CONF‑BC0075, CONF‑BC0076
 ConstraintIf 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.CA0 … *CONFdots0077
 ConstraintIf present, intendedRecipient/addr SHALL conform to the restrictions for the described in common elements for addresses.
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0078
 ConstraintIf present, telecomSHALL conform to the restrictions for the pan-Canadian data type flavor TEL.PHONE or TEL.EMAIL
hl7:informationRecipient
1 … 1RCONFdots0072
Included0 … * from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)
@classCode
cs1 … 1FPSNCONFdots0519
@determinerCode
cs1 … 1FINSTANCECONFdots0519
hl7:name
PN.CA0 … *M

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CONFdots0100
 ConstraintassignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names
hl7:receivedOrganization
0 … 1CONFdots0080
Included0 … * from 2.16.840.1.113883.3.51.60.1.5.1 BC CDA Organization (DYNAMIC)
@classCode
cs1 … 1FORGCONFdots0533
@determinerCode
cs1 … 1FINSTANCE
hl7:id
II0 … *M

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CDAOdotstion
hl7:name
ON0 … *M

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CONFdots0534
Included0 … 1 from 2.16.840.1.113883.3.51.60.1.7 BC CDA dataEnterer (DYNAMIC)
hl7:dataEnterer
0 … 1CONF‑BC0088, CONF‑BC0089
@typeCode
cs1 … 1FENTCONFdots0516
@contextControlCode
cs1 … 1FOP
 Constraintif dataEnterer is not the same as the author, dataEnterer SHOULD be present
hl7:time
TS1 … 1MCONF‑BC0088, CONF‑BC0089
 ConstraintThe 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 … 1MContains 2.16.840.1.113883.3.51.60.1.7.1 BC CDA assignedEntity (DYNAMIC)CONFdots0090
Included0 … * from 2.16.840.1.113883.3.51.60.1.8 BC CDA authenticator (DYNAMIC)
 ConstraintClinicalDocument/authenticator MAY be present
hl7:authenticator
0 … *BCCDdotsator
@typeCode
cs1 … 1FAUTHEN
hl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.3.51.60.1.7.1 BC CDA assignedEntity (DYNAMIC)BCCDdotsator
Included0 … * from 2.16.840.1.113883.3.51.60.1.10 BC CDA documentationOf (DYNAMIC)
hl7:documentationOf
0 … *RCONFdots0520
@typeCode
cs1 … 1FDOC
 ConstraintdocumentationOf/serviceEventMAY be present. Where present, serviceEvent  SHALL conform to the requirements specified in the general BC header definition.
hl7:serviceEvent
1 … 1MCONFdots0103
@classCode
cs1 … 1FACTCONFdots0521
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *CONFdots0103
hl7:code
CE0 … 1CONFdots0103
 ConstraintThe 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
CONF0 … 1F2.16.840.1.113883.5.4
bc:statusCode
CS (required)0 … 1CONFdots0103
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.99.61.26.11.15 ActStatus (DYNAMIC)
hl7:effectiveTime
IVL_TS1 … 1MCONFdots0103
hl7:performer
0 … *CONFdots0104
@typeCode
cs1 … 1RCONFdots0105
 ConstraintIf present, performer SHALL contain the typeCode attribute whose value SHALL be either “PPRF” (primary performer) or “SPRF” (secondary performer).
hl7:assignedEntity
1 … 1MContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CONFdots0106
Included0 … * from 2.16.840.1.113883.3.51.60.1.12 BC CDA inFulfillmentOf (DYNAMIC)
hl7:inFulfillmentOf
0 … *CDAidotsntOf
@typeCode
cs1 … 1FFLFSCONFdots0524
 ConstraintThe 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 … 1MCONFdots0123
@classCode
cs1 … 1FACTCONFdots0525
@moodCode
cs1 … 1FRQO
hl7:id
II1 … *MCONFdots0124
hl7:code
CE0 … 1CONFdots0526
 ConstraintinFulfillmentOf/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.”
Included0 … 2 from 2.16.840.1.113883.3.51.60.1.13 BC CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … 2CONFdots0125
@typeCode
cs1 … 1RCONFdots0126
 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 … 1MCONFdots0127
@classCode
cs1 … 1FDOCCLIN
@moodCode
cs1 … 1FEVN
hl7:id
II1 … 1MCONF‑BC0556, CONF‑BC0557, CONF‑BC0558, CONF‑BC0527
 ConstraintClinicalDocument/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
CD0 … 1CONFdots0127
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1CONFdots0128
 ConstraintparentDocumentMAY 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
II0 … 1CONFdots0127
hl7:versionNumber
INT0 … 1CONFdots0127
Included0 … 1 from 2.16.840.1.113883.3.51.60.1.11 BC CDA componentOf (DYNAMIC)
hl7:componentOf
0 … 1CDAcdotsntOf
@typeCode
cs1 … 1FCOMPCONFdots0528
hl7:encompassingEncounter
1 … 1RCONFdots0114
@classCode
cs1 … 1FENCCONFdots0529
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *CONFdots0114
hl7:effectiveTime
IVL_TS1 … 1RCONFdots0114
hl7:responsibleParty
0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CONFdots0116
@typeCode
cs1 … 1FRESPCONFdots0530
hl7:encounterParticipant
0 … *CONFdots0115
@typeCode
cs1 … 1RCONFdots0117
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
 ConstraintMAY 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 … 1RContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CONFdots0115
Included0 … * from 2.16.840.1.113883.3.51.60.1.9.2 BC CDA Ordering Provider (DYNAMIC)
hl7:participant
0 … *CONF‑8504
@typeCode
cs1 … 1FREFCONFdotsR‑48
@contextControlCode
cs1 … 1FOPCONF‑8505
hl7:associatedEntity
1 … 1MCONF‑8507
@classCode
cs1 … 1FPROVCONF‑8507
hl7:id
II1 … 2RCONF‑BC0097, CONF‑BC0098
 ConstraintIf 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
CE0 … 1CONF‑8507
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
hl7:addr
AD.CA0 … *CONFdots0101
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0102
hl7:associatedPerson
1 … 1MContains 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)CONF‑8508
Included0 … * from 2.16.840.1.113883.3.51.60.1.8.1 BC CDA legalAuthenticator (DYNAMIC)
 ConstraintIf 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 … *CDAldotsator
@typeCode
cs1 … 1FLA
@contextControlCode
cs1 … 1FOP
hl7:time
TS1 … 1RCDAldotsator
 ConstrainttimeSHALL 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
CS1 … 1RCDAldotsator
hl7:assignedEntity
1 … 1MContains 2.16.840.1.113883.3.51.60.1.7.1 BC CDA assignedEntity (DYNAMIC)CDAldotsator
hl7:component
1 … 1MCONFdots0001
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl1 … 1Ftrue
hl7:structuredBody
1 … 1MCONFdots0001
hl7:component
1 … *RCONFdots0001
@contextConductionInd
bl1 … 1Ftrue