Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | C | When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALL include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32946).
| TranryV2 |
cda:templateId
| II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF2936 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.13 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-28239) such that it | CONF8239 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.13 | CONF8240 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.13" (CONF:1198-28240). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF2907 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32907). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet TransferDocumentType urn:oid:2.16.840.1.113883.1.11.20.2.4 DYNAMIC (CONF:1198-28243).The Transfer Summary recommends use of the document type code 18761-7 "Provider Unspecified Transfer Summary", 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. For example, an Obstetrics and Gynecology Transfer Summary note would not be authored by a Pediatric Cardiologist. Pre-coordinated codes are those that indicate the specialty or service provided in the LOINC Long Common Name (Print Name in the TransferDocumentType valueSet table). When using a generic type of code such as 18761-7 (Provider - Unspecified Transfer Summary), the types of services involved in the care are handled in documentationOf/serviceEvent with the use of serviceEvent/code (e.g., use a SNOMED CT procedure code such as 69031006 (Excision of breast tissue) while performers/providers involved in the care can be identified using the functionCode (bound to Healthcare Provider Taxonomy role codes). | CONF8243 |
| CONF | |
cda:title
| | 1 … 1 | | SHALL contain exactly one [1..1] title (CONF:1198-29838). | CONF9838 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31599) such that it | CONF1599 |
where [@typeCode='IND'] | |
@typeCode
| cs | 1 … 1 | F | IND | CONF1872 |
| SHALL contain exactly one [1..1] @typeCode="IND" indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31872). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31600). | CONF1600 |
@classCode
| cs | 1 … 1 | R | This associatedEntity SHALL contain exactly one [1..1] @classCode, which SHALL be selected from ValueSet INDRoleclassCodes urn:oid:2.16.840.1.113883.11.20.9.33 DYNAMIC (CONF:1198-31873). | CONF1873 |
| CONF | |
cda:associatedPerson
| | 1 … 1 | M | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31601). | CONF1601 |
cda:name
| | 1 … * | R | This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31602). | CONF1602 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31626) such that it | CONF1626 |
where [@typeCode='CALLBCK'] | |
@typeCode
| cs | 1 … 1 | F | CALLBCK | CONF1627 |
| SHALL contain exactly one [1..1] @typeCode="CALLBCK" Call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31627). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31628). | CONF1628 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF1641 |
| This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110) (CONF:1198-31641). |
cda:id
| II | 1 … * | | This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31629). | CONF1629 |
cda:addr
| AD | 0 … * | R | This associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1198-31630). | CONF1630 |
cda:telecom
| TEL | 1 … * | | This associatedEntity SHALL contain at least one [1..*] telecom (CONF:1198-31631). | CONF1631 |
cda:associatedPerson
| | 1 … 1 | M | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31632). | CONF1632 |
cda:name
| | 1 … * | R | This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31633). | CONF1633 |
cda:scopingOrganization
| | 0 … 1 | | This associatedEntity MAY contain zero or one [0..1] scopingOrganization (CONF:1198-31634). | CONF1634 |
cda:documentationOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] documentationOf (CONF:1198-31570). | CONF1570 |
cda:serviceEvent
| | 1 … 1 | M | This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:1198-31571).The serviceEvent in a Transfer Note contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | CONF1571 |
@classCode
| cs | 1 … 1 | F | PCPR | CONF1572 |
| This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-31572). |
cda:code
| | 0 … 1 | | This serviceEvent MAY contain zero or one [0..1] code (CONF:1198-32650).Use serviceEvent/code when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the service. | CONF2650 |
cda:performer
| | 1 … * | M | This serviceEvent SHALL contain at least one [1..*] performer (CONF:1198-31574) such that it | CONF1574 |
@typeCode
| cs | 1 … 1 | F | PRF | CONF1575 |
| SHALL contain exactly one [1..1] @typeCode="PRF" Participation of Physical Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC) (CONF:1198-31575). |
cda:functionCode
| CE | 0 … 1 | | MAY contain zero or one [0..1] functionCode, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32651).Use performer/functionCode when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the provider. | CONF2651 |
| CONF | |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-28251). | CONF8251 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-28252). | CONF8252 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.21.1 Advance Directives Section (entries required) (V3) (2015‑08‑01) | CONF8253 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies and Intolerances Section (entries required) (V3) (2015‑08‑01) | CONF8255 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01) | CONF8257 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.22.1 Encounters Section (entries required) (V3) (2015‑08‑01) | CONF8261 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF8263 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF8265 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.24 Discharge Diagnosis Section (V3) (2015‑08‑01) | CONF8271 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01) | CONF8273 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09) | CONF8275 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09) | CONF8277 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (V3) (2015‑08‑01) | CONF8279 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF8281 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (2015‑08‑01) | CONF8283 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (V2) (2014‑06‑09) | CONF8285 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01) | CONF8287 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF8289 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01) | CONF8291 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01) | CONF8327 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13) | CONF8838 |
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) | CONF0239 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF0776 |
cda:component
| | 1 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 Reason for Referral Section (V2) (2014‑06‑09) | CONF1342 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01) | CONF1561 |
cda:component
| | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13) | CONF1563 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09) | CONF1565 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13) | CONF1567 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.44 Admission Medications Section (entries optional) (V3) (2015‑08‑01) | CONF2445 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.43 Admission Diagnosis Section (V3) (2015‑08‑01) | CONF2447 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.64 Course of Care Section (2015‑08‑13) | CONF2648 |
| Schematron assert | role | error | |
| test | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'] or ( //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] and //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'] ) | |
| Message | This structuredBody *SHALL* contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09). | |
| Schematron assert | role | error | |
| test | not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or ( not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) ) | |
| 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. | |