Id2.16.840.1.113883.3.1937.99.61.12.10.1Effective Date2013‑02‑10
Statusdraft DraftVersion Label
NameMinimalCDAdocumentDisplay NameDocumento CDA Mínimo
Description
A minimal CDA Release 2 document, that contains only a few attributes and relationships for the ClinicalDocument class:
  • typeId: fijo
  • id: id unico del documento
  • code: clase de  document
  • effectiveTime: fecha de creación
  • confidentialityCode: código de confidencialidad
  • recordTarget: Paciente
  • author: autor del documento
  • custodian: organizacion responsable del documento
  • component: contenido del cuerpo estructurado
ContextPathname /
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 4 concepts
IdNameData Set
mais-dataelement-1draft Documento Clinico draft MAIS-Conceptos
mais-dataelement-10draft Primer Nombre del Paciente draft MAIS-Conceptos
mais-dataelement-30draft Fecha de Nacimiento draft MAIS-Conceptos
mais-dataelement-40draft Género draft MAIS-Conceptos
Used by / Uses
Used by 0 transactions and 0 templates, Uses 9 templates
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.12.10.2001Includedraft CDA recordTargetDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.2002Includedraft CDA authorDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.2003Includedraft CDA custodianDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.3001Containmentdraft EKG impressionDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.900001Includedraft CDA typeIdDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.900002Includedraft CDA idDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.900003Includedraft CDA titleDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.900004Includedraft CDA effectiveTimeDYNAMIC
2.16.840.1.113883.3.1937.99.61.12.10.900005Includedraft CDA confidentialityCodeDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example
Example
<ClinicalDocument>
  <!-- CDA Header -->
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <templateId root="2.16.840.1.113883.3.1937.99.61.12.10.1"/>  <id extension="123456789" root="2.16.840.1.113883.3.1937.99.3.2.997788.1"/>  <code code="11524-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EKG study report"/>  <effectiveTime value="20131020122709"/>  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>  <recordTarget>
    <!-- .. -->
  </recordTarget>  <author>
    <!-- .. -->
  </author>  <custodian>
    <!-- .. -->
  </custodian>  <!-- CDA Body -->
  <component>
    <structuredBody>
      <component>
        <!-- .. -->
      </component>    </structuredBody>  </component></ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
0 … *Minidotsment
Included0 … * from 2.16.840.1.113883.3.1937.99.61.12.10.900001 CDA typeId (DYNAMIC)
hl7:typeId
II0 … *M

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

CDAtypeId
@extension
st1 … 1FPOCD_HD000040
@root
uid1 … 1F2.16.840.1.113883.1.3
hl7:templateId
II1 … 1MCDA document template id for this kind of documentMinidotsment
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.12.10.1
 Example<templateId root="2.16.840.1.113883.3.1937.99.61.12.10.1"/>
Included0 … * from 2.16.840.1.113883.3.1937.99.61.12.10.900002 CDA id (DYNAMIC)
hl7:id
II0 … *M

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

CDAid
hl7:code
CE1 … 1MMinidotsment
@code
CONF1 … 1F11524-6
@codeSystem
1 … 1F2.16.840.1.113883.6.1
 Example<!-- document type -->
<code code="11524-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EKG study report"/>
Included0 … 1 from 2.16.840.1.113883.3.1937.99.61.12.10.900003 CDA title (DYNAMIC)
 Example<title>EKG Report as of 1 February 2013</title>
hl7:title
ST0 … 1CDAtitle
Included0 … * from 2.16.840.1.113883.3.1937.99.61.12.10.900004 CDA effectiveTime (DYNAMIC)
hl7:effectiveTime
TS.DATETIME.MIN0 … *M

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

CDAedotsTime
Included0 … * from 2.16.840.1.113883.3.1937.99.61.12.10.900005 CDA confidentialityCode (DYNAMIC)
hl7:confidentialityCode
CE0 … *M

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

CDAcdotsCode
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 Basic Confidentiality Kind (HL7) (DYNAMIC)
Included0 … * from 2.16.840.1.113883.3.1937.99.61.12.10.2001 CDA recordTarget (DYNAMIC)
hl7:recordTarget
0 … *CDArdotsrget
 
target
mais-dataelement-1draft Documento Clinico draft MAIS-Conceptos
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
hl7:patientRole
1 … 1CDArdotsrget
@classCode
cs0 … 1FPAT
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.12.10.110 National Patient Identifier (DYNAMIC)
hl7:id
II.NL.BSN1 … 1RNatidotsfier
@root
uid1 … 1F2.16.840.1.113883.2.4.6.3
@extension
st1 … 1RBurgerservicenummer (National Patient Identifier)
hl7:patient
1 … 1RCDArdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
 Example<patient classCode="PSN" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>  <birthTime value="19620219"/></patient>
hl7:name
PN1 … *RCDArdotsrget
 
target
mais-dataelement-10draft Primer Nombre del Paciente draft MAIS-Conceptos
hl7:administrativeGenderCode
CE1 … 1RCDArdotsrget
 
target
mais-dataelement-40draft Género draft MAIS-Conceptos
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (HL7) (DYNAMIC)
hl7:birthTime
TS1 … 1RCDArdotsrget
 
target
mais-dataelement-30draft Fecha de Nacimiento draft MAIS-Conceptos
Included0 … * from 2.16.840.1.113883.3.1937.99.61.12.10.2002 CDA author (DYNAMIC)
hl7:author
0 … *M

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

CDAauthor
@typeCode
cs0 … 1FAUT
hl7:time
TS.DATE.MIN1 … 1MCDAauthor
hl7:assignedAuthor
1 … 1MCDAauthor
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … 1RCDAauthor
hl7:assignedPerson
0 … 1CDAauthor
Included from 2.16.840.1.113883.3.1937.99.61.12.10.900200 CDA Person Elements (2011‑12‑19)
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1MCDAPdotsents
hl7:representedOrganization
0 … 1CDAauthor
Included from 2.16.840.1.113883.3.1937.99.61.12.10.900201 CDA Organization Elements (DYNAMIC)
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *CDAOdotsents
hl7:name
ON1 … 1MCDAOdotsents
hl7:telecom
TEL0 … *CDAOdotsents
hl7:addr
AD0 … 1CDAOdotsents
Included0 … * from 2.16.840.1.113883.3.1937.99.61.12.10.2003 CDA custodian (DYNAMIC)
hl7:custodian
0 … *M

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

CDAcdotsdian
@typeCode
cs0 … 1FCST
hl7:assignedCustodian
1 … 1MCDAcdotsdian
@classCode
cs0 … 1FASSIGNED
hl7:representedCustodianOrganization
0 … 1CDAcdotsdian
Included from 2.16.840.1.113883.3.1937.99.61.12.10.900201 CDA Organization Elements (DYNAMIC)
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *CDAOdotsents
hl7:name
ON1 … 1MCDAOdotsents
hl7:telecom
TEL0 … *CDAOdotsents
hl7:addr
AD0 … 1CDAOdotsents
hl7:component
0 … *Minidotsment
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
 Example<!-- now for the study results: CDA body -->
<component typeCode="COMP" contextConductionInd="true">
  <!-- ... -->
</component>
hl7:structuredBody
0 … *Minidotsment
@classCode
cs0 … 1FDOCBODY
@moodCode
cs0 … 1FEVN
 Example<structuredBody classCode="DOCBODY" moodCode="EVN">
  <!-- ... -->
</structuredBody>
hl7:component
1 … 1MContains 2.16.840.1.113883.3.1937.99.61.12.10.3001 EKG impression (DYNAMIC)Minidotsment
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue