Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | | | ProgNote |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:7588) such that it | conf‑7588 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.9 | conf0052 |
cda:code
| | 1 … 1 | R | SHALL contain exactly one [1..1] code (CONF:17189). SHALL contain exactly one [1..1] code/@code, which SHALL be selected from ValueSet ProgressNoteDocumentTypeCode 2.16.840.1.113883.11.20.8.1 DYNAMIC (CONF:7589). | conf‑17189 / conf‑7589 |
| CONF | |
cda:documentationOf
| | 0 … 1 | R | SHOULD contain zero or one [0..1] documentationOf (CONF:7603). | conf‑7603 |
cda:serviceEvent
| | 1 … 1 | M | The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:7604). | conf‑7604 |
@classCode
| cs | 1 … 1 | F | PCPR | conf6420 |
cda:templateId
| II | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] templateId (CONF:9480) such that it | conf‑9480 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.21.3.1 | conf0068 |
cda:effectiveTime
| IVL_TS | 0 … 1 | R | This serviceEvent SHOULD contain zero or one [0..1] effectiveTime (CONF:9481). The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element If a width element is not present, the serviceEvent SHALL include effectiveTime/highThe content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | conf‑9481 |
| Schematron assert | role | error | |
| test | not(.//@value[not(parent::cda:width)][string-length()<8]) | |
| Message | The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | |
cda:low
| | 1 … 1 | R | The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element. | conf‑9481 |
Choice | 1 … 1 | | If a width element is not present, the serviceEvent SHALL include effectiveTime/high Elements to choose from: |
cda:width
| PQ | | | | conf‑9481 |
cda:high
| | | | | conf‑9481 |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:7595). | conf‑7595 |
cda:encompassingEncounter
| | 1 … 1 | M | This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:7596). | conf‑7596 |
cda:id
| II | 1 … * | R | This encompassingEncounter SHALL contain at least one [1..*] id (CONF:7597). | conf‑7597 |
cda:effectiveTime
| | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:7598).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | conf‑7598 |
| Schematron assert | role | error | |
| test | not(.//@value[not(parent::cda:width)][string-length()<8]) | |
| Message | The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | |
cda:low
| | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] low (CONF:7599). | conf‑7599 |
cda:location
| | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] location/healthCareFacility/id (CONF:7611). | conf‑7611 |
cda:healthCareFacility
| | 1 … 1 | R | | conf‑7611 |
cda:id
| II | 1 … * | R | | conf‑7611 |
cda:component
| | 1 … 1 | R | SHALL contain exactly one [1..1] component (CONF:9591).A Progress Note can have either a structuredBody or a nonXMLBodyA Progress Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.9), coded entries are optional If structuredBody, the component/structuredBody SHALL conform to the section constraints belowSHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section. SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present | conf‑9591 |
Choice | 1 … 1 | | Elements to choose from:- cda:nonXMLBody
- cda:structuredBody
|
cda:nonXMLBody
| | | | | conf‑9591 |
cda:structuredBody
| | | | | conf‑9591 |
| 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 | SHALL include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan Section (2.16.840.1.113883.10.20.22.2.10). | |
| 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 | SHALL NOT include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9) when an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (2.16.840.1.113883.10.20.22.2.10) are present | |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.21.2.1 Objective Section (2013‑01‑31) | conf‑8770 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (2013‑01‑31) | conf‑8771 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31) | conf‑8772 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31) | conf‑8773 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (2013‑01‑31) | conf‑8774 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31) | conf‑8775 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2013‑01‑31) | conf‑8776 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.21.2.3 Interventions Section (2013‑01‑31) | conf‑8778 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (2013‑01‑31) | conf‑8780 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (2013‑01‑31) | conf‑8782 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31) | conf‑8784 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (2013‑01‑31) | conf‑8786 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31) | conf‑8788 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.21.2.2 Subjective Section (2013‑01‑31) | conf‑8790 |