Id2.16.840.1.113883.3.1937.99.61.20.10.15.1Effective Date2015‑11‑02 12:45:12
Statusdraft DraftVersion Label2.1
Namephcr-USRealmHeader-snapshotDisplay NamePHCR USRealmHeader v2.1 Snapshot
Description
This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents. Further specification, such as ClinicalDocument/code, are provided in document templates that conform to this template.  This is the version with all optional elements and includdes for PHCR 
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 6 templates
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.20.10.6Includedraft PHCR Document Body2015‑10‑30 05:51:33
2.16.840.1.113883.3.1937.99.61.20.10.14Includedraft PHCR ComponentOf Template2015‑11‑03
2.16.840.1.113883.3.1937.99.61.20.10.16Includedraft PHCR Documentation Of Template2015‑11‑03 21:56:01
2.16.840.1.113883.10.20.22.5.1.1Containmentdraft US Realm Person Name (PN.US.FIELDED) (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.5.2Containmentdraft US Realm Address (AD.US.FIELDED) (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.5.4Containmentdraft US Realm Date and Time (DTM.US.FIELDED) (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (2013‑01‑31)
ref
ccda-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
ref
ccda-
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
phcrdotsshot
cda:realmCode
1 … 1MSHALL contain exactly one [1..1] realmCode="US" (CONF:1198-16791).CONFdots6791
cda:typeId
1 … 1MSHALL contain exactly one [1..1] typeId (CONF:1198-5361).CONFdots5361
@root
uid1 … 1F2.16.840.1.113883.1.3CONFdots5250
 This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" (CONF:1198-5250).
@extension
st1 … 1FPOCD_HD000040CONFdots5251
 This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:1198-5251).
cda:templateId
1 … 1MSHALL contain exactly one [1..1] templateId (PHCR-2) such that itphcrdotsoc‑2
@root
uid1 … 1Fphcr-OIDphcrdotsoc‑2
@extension
st1 … 1F2015-08-01CONFdotsoc‑3
 SHALL contain exactly one [1..1] @extension="2015-11-3" (CONF:1198-32503).
 ConstraintWhen asserting this templateId, all document, section, and entry templates *SHALL* include a templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail.
cda:id
1 … 1MSHALL contain exactly one [1..1] id (CONF:1198-5363).CONFdots5363
 ConstraintThis id *SHALL* be a globally unique identifier for the document.
cda:code
CS1 … 1MSHALL contain exactly one [1..1] code (CONF:1198-5253).CONFdots5253
@code
CONF1 … 1F55751-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@displayName
1 … 1FPublic Health Case report
cda:title
ST1 … 1MSHALL contain exactly one [1..1] title (CONF:1198-5254).CONFdots5254
 CONF
element content shall be "Initial Public Health Case Report"
cda:effectiveTime
1 … 1MContains 2.16.840.1.113883.10.20.22.5.4 US Realm Date and Time (DTM.US.FIELDED) (2015‑08‑13)CONFdots5256
 ConstraintSHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1198-5256).
cda:confidentialityCode
1 … 1MSHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926 STATIC (CONF:1198-5259).CONFdots5259
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
cda:languageCode
1 … 1MSHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:1198-5372).CONFdots5372
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
cda:setId
0 … 1MAY contain zero or one [0..1] setId (CONF:1198-5261).CONFdots5261
 Schematron assertrolered error 
 test../cda:versionNumber 
 MessageIf setId is present versionNumber *SHALL* be present 
cda:versionNumber
0 … 1MAY contain zero or one [0..1] versionNumber (CONF:1198-5264).CONFdots5264
 Schematron assertrolered error 
 test../cda:setId 
 MessageIf versionNumber is present setId *SHALL* be present 
cda:recordTarget
1 … *MSHALL contain at least one [1..*] recordTarget (CONF:1198-5266).

The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element		CONFdots5266
cda:patientRole
1 … 1MContains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots5267
cda:id
1 … *MThis patientRole SHALL contain at least one [1..*] id (CONF:1198-5268).CONFdots5268
cda:telecom
1 … *MThis patientRole SHALL contain at least one [1..*] telecom (CONF:1198-5280).CONFdots5280
@use
set_cs0 … 1 Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-5375).CONFdots5375
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:patient
1 … 1MContains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)CONFdots5283
cda:administrativeGenderCode
1 … 1MThis patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1 DYNAMIC (CONF:1198-6394).CONFdots6394
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
cda:birthTime
1 … 1MThis patient SHALL contain exactly one [1..1] birthTime (CONF:1198-5298).

*MAY* be precise to the minute.		CONFdots5298
 Schematron assertrolered error 
 teststring-length(@value) >= 4 
 Message*SHALL* be precise to year. 
 Schematron assertroleorange warning 
 teststring-length(@value) >= 8 
 Message*SHOULD* be precise to day. 
sdtc:deceasedTime
0 … 1RThe subject SHOULD contain zero to one [O..1] sdtc:deceasedTime. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedTime element (phcr-doc-nn).

SHALL be precise to year

SHOULD be precise to day		phcrdotsc‑nn
 Schematron assertrolered error 
 teststring-length(@value) >= 4 
 MessageSHALL be precise to year 
 Schematron assertrolered error 
 teststring-length(@value) >= 8 
 MessageSHOULD be precise to day 
cda:maritalStatusCode
0 … 1RThis patient SHOULD contain zero or one [0..1] maritalStatusCode, which SHALL be selected from ValueSet Marital Status urn:oid:2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:1198-5303).CONFdots5303
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12212 Marital Status (DYNAMIC)
cda:religiousAffiliationCode
0 … 1This patient MAY contain zero or one [0..1] religiousAffiliationCode, which SHALL be selected from ValueSet Religious Affiliation urn:oid:2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:1198-5317).CONFdots5317
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19185 Religious Affiliation (DYNAMIC)
cda:raceCode
1 … 1MThis patient SHALL contain exactly one [1..1] raceCode, which SHALL be selected from ValueSet Race Category Excluding Nulls urn:oid:2.16.840.1.113883.3.2074.1.1.3 DYNAMIC (CONF:1198-5322).CONFdots5322
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.2074.1.1.3 Race Category Excluding Nulls (DYNAMIC)
sdtc:raceCode
0 … *This patient MAY contain zero or more [0..*] sdtc:raceCode, which SHALL be selected from ValueSet Race urn:oid:2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:1198-7263).CONFdots7263
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14914 Race (DYNAMIC)
 Schematron assertrolered error 
 testcount(../cda:raceCode)=1 
 MessageIf sdtc:raceCode is present, then the patient *SHALL* contain [[]1..1[]] raceCode. 
cda:ethnicGroupCode
1 … 1MThis patient SHALL contain exactly one [1..1] ethnicGroupCode, which SHALL be selected from ValueSet Ethnicity urn:oid:2.16.840.1.114222.4.11.837 DYNAMIC (CONF:1198-5323).CONFdots5323
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.837 Ethnicity (DYNAMIC)
sdtc:ethnicGroupCode
0 … *This patient MAY contain zero or more [0..*] sdtc:ethnicGroupCode, which SHALL be selected from ValueSet Detailed Ethnicity urn:oid:2.16.840.1.114222.4.11.877 DYNAMIC (CONF:1198-32901).CONFdots2901
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.877 Detailed Ethnicity (DYNAMIC)
cda:guardian
1 … *RThis patient SHALL contain guardian if available (PHCP-NN).

Contains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)		phcrdotsc‑nn
cda:code
0 … 1RThe guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-5326).CONFdots5326
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.12.1 Personal And Legal Relationship Role Type (DYNAMIC)
cda:telecom
1 … *RThe guardian, if present, SHOULD contain zero or more [0..*] telecom (CONF:1198-5382).CONFdots5382
@use
set_cs0 … 1 The telecom, if present, SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-7993).CONFdots7993
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:guardianPerson
1 … 1MContains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)CONFdots5385
cda:birthplace
0 … 1This patient MAY contain zero or one [0..1] birthplace (CONF:1198-5395).CONFdots5395
cda:place
1 … 1MThe birthplace, if present, SHALL contain exactly one [1..1] place (CONF:1198-5396).CONFdots5396
cda:addr
1 … 1MThis place SHALL contain exactly one [1..1] addr (CONF:1198-5397).CONFdots5397
cda:country
0 … 1RThis addr SHOULD contain zero or one [0..1] country, which SHALL be selected from ValueSet Country urn:oid:2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:1198-5404).CONFdots5404
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.63 Country (DYNAMIC)
cda:postalCode
0 … 1This addr MAY contain zero or one [0..1] postalCode, which SHALL be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 DYNAMIC (CONF:1198-5403).CONFdots5403
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.2 PostalCode (DYNAMIC)
 Schematron assertrolered error 
 testnot(ancestor::cda:patientRole/cda:addr[cda:country='US' or cda:country='USA']) or cda:state 
 MessageIf country is US, this addr *SHALL* contain exactly one [[]1..1[]] state, which *SHALL* be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* 
cda:languageCommunication
0 … *RThis patient SHOULD contain zero or more [0..*] languageCommunication (CONF:1198-5406).CONFdots5406
cda:languageCode
1 … 1MThe languageCommunication, if present, SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:1198-5407).CONFdots5407
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
cda:modeCode
0 … 1The languageCommunication, if present, MAY contain zero or one [0..1] modeCode, which SHALL be selected from ValueSet LanguageAbilityMode urn:oid:2.16.840.1.113883.1.11.12249 DYNAMIC (CONF:1198-5409).CONFdots5409
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
cda:proficiencyLevelCode
0 … 1RThe languageCommunication, if present, SHOULD contain zero or one [0..1] proficiencyLevelCode, which SHALL be selected from ValueSet LanguageAbilityProficiency urn:oid:2.16.840.1.113883.1.11.12199 DYNAMIC (CONF:1198-9965).CONFdots9965
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
cda:preferenceInd
0 … 1RThe languageCommunication, if present, SHOULD contain zero or one [0..1] preferenceInd (CONF:1198-5414).CONFdots5414
cda:providerOrganization
0 … 1Contains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots5416
cda:id
1 … *MThe providerOrganization, if present, SHALL contain at least one [1..*] id (CONF:1198-5417).CONFdots5417
@root
uid0 … 1F2.16.840.1.113883.4.6CONFdots6820
 Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-16820).
cda:name
1 … *MThe providerOrganization, if present, SHALL contain at least one [1..*] name (CONF:1198-5419).CONFdots5419
cda:telecom
1 … *MThe providerOrganization, if present, SHALL contain at least one [1..*] telecom (CONF:1198-5420).CONFdots5420
@use
set_cs0 … 1 Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-7994).CONFdots7994
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:author
1 … *MThe author element represents the creator of the clinical document. The author may be a device or a person.
NOTE: In a public health case report, the author may be software or may be a person in the role of 
infection control professional (ICP). In a population summary report, the author will be the 
software forming the message. The effect of the CDA Release 2.1 requirements is: 
An author element shall be present. The author element shall contain a time element that 
represents the time of authoring of the information, and an assignedAuthor element that 
represents the author of the information. The assignedAuthor element shall contain an id 
element. (from CDA R2) 
When the report author is vendor software, it can record the software installation id, an email 
address, and the vendor name

Contains 2.16.840.1.113883.10.20.22.5.4 US Realm Date and Time (DTM.US.FIELDED) (2015‑08‑13)		CONFdots5444
cda:assignedAuthor
1 … 1MContains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots5448
cda:id
1 … *MThis assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).CONFdots5449
cda:id
0 … 1RIf this assignedAuthor is an assignedPersonCONFdots2882
where [parent::cda:assignedPerson]
@nullFlavor
cs0 … 1FUNKCONFdots2883
 MAY contain zero or one [0..1] @nullFlavor="UNK" Unknown (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:1198-32883).
@root
uid1 … 1F2.16.840.1.113883.4.6CONFdots2884
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32884).
@extension
st0 … 1 SHOULD contain zero or one [0..1] @extension (CONF:1198-32885).CONFdots2885
cda:code
0 … 1RThis assignedAuthor SHOULD contain zero or one [0..1] code (CONF:1198-16787).

Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.		CONFdots6787
cda:telecom
1 … *MThis assignedAuthor SHALL contain at least one [1..*] telecom (CONF:1198-5428).CONFdots5428
@use
set_cs0 … 1 Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-7995).CONFdots7995
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:assignedPerson
0 … 1RContains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)CONFdots5430
 ConstraintThis assignedAuthor SHOULD contain zero or one [0..1] assignedPerson (CONF:1198-5430).
cda:assignedAuthoringDevice
0 … 1RCONFdots6783
 ConstraintThis assignedAuthor SHOULD contain zero or one [0..1] assignedAuthoringDevice (CONF:1198-16783).
cda:manufacturerModelName
1 … 1MThe assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] manufacturerModelName (CONF:1198-16784).CONFdots6784
cda:softwareName
1 … 1MThe assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] softwareName (CONF:1198-16785).CONFdots6785
 Schematron assertrolered error 
 testcda:assignedPerson |cda:assignedAuthoringDevice 
 MessageThere *SHALL* be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice. 
cda:dataEnterer
0 … 1MAY contain zero or one [0..1] dataEnterer (CONF:1198-5441).

The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.		CONFdots5441
cda:assignedEntity
1 … 1MContains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots5442
cda:id
1 … *MThis assignedEntity SHALL contain at least one [1..*] id (CONF:1198-5443).CONFdots5443
@root
uid0 … 1F2.16.840.1.113883.4.6CONFdots6821
 Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-16821).
cda:code
0 … 1This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32173).CONFdots2173
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)
cda:telecom
1 … *MThis assignedEntity SHALL contain at least one [1..*] telecom (CONF:1198-5466).CONFdots5466
@use
set_cs0 … 1 Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-7996).CONFdots7996
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:assignedPerson
1 … 1MContains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)CONFdots5469
cda:informant
0 … *MAY contain zero or more [0..*] informant (CONF:1198-8001) such that it

The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. 		CONFdots8001
where [cda:assignedEntity]
cda:assignedEntity
1 … 1MContains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots8002
cda:id
1 … *MThis assignedEntity SHALL contain at least one [1..*] id (CONF:1198-9945).CONFdots9945
 ConstraintIf assignedEntity/id is a provider then this id, *SHOULD* include zero or one [[]0..1[]] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier.
cda:code
0 … 1This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32174).CONFdots2174
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)
cda:assignedPerson
1 … 1MThis assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:1198-8221).
Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)		CONFdots8221
cda:informant
0 … *MAY contain zero or more [0..*] informant (CONF:1198-31355) such that it

The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. 		CONFdots1355
where [cda:relatedEntity]
cda:relatedEntity
1 … 1MSHALL contain exactly one [1..1] relatedEntity (CONF:1198-31356).CONFdots1356
cda:custodian
1 … 1MSHALL contain exactly one [1..1] custodian (CONF:1198-5519).

The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.		CONFdots5519
cda:assignedCustodian
1 … 1MThis custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:1198-5520).CONFdots5520
cda:representedCustodianOrganization
1 … 1MContains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots5521
cda:id
1 … *MThis representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:1198-5522).CONFdots5522
@root
uid0 … 1F2.16.840.1.113883.4.6CONFdots6822
 Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-16822).
cda:name
1 … 1MThis representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:1198-5524).CONFdots5524
cda:telecom
1 … 1MThis representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:1198-5525).CONFdots5525
@use
set_cs0 … 1 This telecom SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-7998).CONFdots7998
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:informationRecipient
0 … *MAY contain zero or more [0..*] informationRecipient (CONF:1198-5565).

The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.		CONFdots5565
cda:intendedRecipient
1 … 1MThe informationRecipient, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:1198-5566).CONFdots5566
cda:id
0 … *This intendedRecipient MAY contain zero or more [0..*] id (CONF:1198-32399).CONFdots2399
cda:informationRecipient
0 … 1Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)CONFdots5567
cda:receivedOrganization
0 … 1This intendedRecipient MAY contain zero or one [0..1] receivedOrganization (CONF:1198-5577).CONFdots5577
cda:name
1 … 1MThe receivedOrganization, if present, SHALL contain exactly one [1..1] name (CONF:1198-5578).CONFdots5578
cda:legalAuthenticator
0 … 1RThe legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
Contains 2.16.840.1.113883.10.20.22.5.4 US Realm Date and Time (DTM.US.FIELDED) (2015‑08‑13)		CONFdots5579
cda:signatureCode
1 … 1MThe legalAuthenticator, if present, SHALL contain exactly one [1..1] signatureCode (CONF:1198-5583).CONFdots5583
@code
1 … 1FSCONFdots5584
 This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: Participationsignature urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:1198-5584).
@code
CONF1 … 1FS
@codeSystem
1 … 1F2.16.840.1.113883.5.89
sdtc:signatureText
0 … 1The legalAuthenticator, if present, MAY contain zero or one [0..1] sdtc:signatureText (CONF:1198-30810).

The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.		CONFdots0810
cda:assignedEntity
1 … 1MContains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots5585
cda:id
1 … *MThis assignedEntity SHALL contain at least one [1..*] id (CONF:1198-5586).CONFdots5586
@root
uid0 … 1F2.16.840.1.113883.4.6CONFdots6823
 Such ids MAY contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-16823).
cda:code
0 … 1This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-17000).CONFdots7000
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)
cda:telecom
1 … *MThis assignedEntity SHALL contain at least one [1..*] telecom (CONF:1198-5595).CONFdots5595
@use
set_cs0 … 1 Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-7999).CONFdots7999
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:assignedPerson
1 … 1MContains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)CONFdots5597
cda:authenticator
0 … *The authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Contains 2.16.840.1.113883.10.20.22.5.4 US Realm Date and Time (DTM.US.FIELDED) (2015‑08‑13)		CONFdots5607
cda:signatureCode
1 … 1MSHALL contain exactly one [1..1] signatureCode (CONF:1198-5610).CONFdots5610
@code
1 … 1FSCONFdots5611
 This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: Participationsignature urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:1198-5611).
@code
CONF1 … 1FS
@codeSystem
1 … 1F2.16.840.1.113883.5.89
sdtc:signatureText
0 … 1MAY contain zero or one [0..1] sdtc:signatureText (CONF:1198-30811).

The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.		CONFdots0811
cda:assignedEntity
1 … 1MContains 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)CONFdots5612
cda:id
1 … *MThis assignedEntity SHALL contain at least one [1..*] id (CONF:1198-5613).CONFdots5613
@root
uid0 … 1F2.16.840.1.113883.4.6CONFdots6824
 Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-16824).
cda:code
0 … 1This assignedEntity MAY contain zero or one [0..1] code (CONF:1198-16825).CONFdots6825
cda:telecom
1 … *MThis assignedEntity SHALL contain at least one [1..*] telecom (CONF:1198-5622).CONFdots5622
@use
set_cs0 … 1 Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:1198-8000).CONFdots8000
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:assignedPerson
1 … 1MContains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)CONFdots5624
cda:participant
0 … *MAY contain zero or more [0..*] participant (CONF:1198-10003) such that it

The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). 		CONFdots0003
 ConstraintWhen participant/@typeCode is *IND*, associatedEntity/@classCode *SHOULD* be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30*
cda:time
0 … 1MAY contain zero or one [0..1] time (CONF:1198-10004).CONFdots0004
 Schematron assertrolered error 
 testcda:associatedPerson | cda:scopingOrganization 
 Message*SHALL* contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization. 
cda:inFulfillmentOf
0 … *MAY contain zero or more [0..*] inFulfillmentOf (CONF:1198-9952).

The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists’ report of an x-ray.		CONFdots9952
cda:order
1 … 1MThe inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:1198-9953).CONFdots9953
cda:id
1 … *MThis order SHALL contain at least one [1..*] id (CONF:1198-9954).CONFdots9954
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.20.10.16 PHCR Documentation Of Template (2015‑11‑03 21:56:01)
adding PHCR DocumentationOfConstraints
cda:documentationOf
1 … 1RSHALL contain 1 or more [1..*] documentationOf (CONF:PHCP-NN)

NOTE: For public health case reporting this element is used for documenting the trigger event code.		PHCP‑NN
cda:serviceEvent
1 … 1MThe documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:14836).phcp‑nn
@classCode
cs1 … 1FHCASEconfdots6819
cda:effectiveTime
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:14837).confdots4837
cda:low
1 … 1MThis effectiveTime SHALL contain exactly one [1..1] low (CONF:14838).confdots4838
cda:id
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] id (CONF:phcr-nn).

NOTE: This element is used to identify the trigger code row and table version.		phcr‑nn
cda:code
CD1 … 1MThis serviceEvent SHALL contain exactly one [1..1] (CONF:phcr-nn).

NOTE: This element is used to identify the trigger code. It SHALL contain the code and codeSystem and MAY contain the codeDescription and codeSystemName		CONFdotsr‑nn
@code
1 … 1Rphcp‑nn
@displayName
0 … 1 phcp‑nn
@codeSystem
1 … 1Rphcp‑nn
@codeSystemName
0 … 1 phcp‑nn
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.99.61.20.11.1 Trigger Code (DYNAMIC)
cda:authorization
0 … *MAY contain zero or more [0..*] authorization (CONF:1198-16792) such that it

The authorization element represents information about the patient’s consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ‘Privacy Consent’. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. 		CONFdots6792
cda:consent
1 … 1MSHALL contain exactly one [1..1] consent (CONF:1198-16793).CONFdots6793
cda:id
0 … *This consent MAY contain zero or more [0..*] id (CONF:1198-16794).CONFdots6794
cda:code
0 … 1This consent MAY contain zero or one [0..1] code (CONF:1198-16795).CONFdots6795
cda:statusCode
1 … 1MThis consent SHALL contain exactly one [1..1] statusCode (CONF:1198-16797).CONFdots6797
@code
CONF1 … 1Fcompleted
Included1 … 1M from 2.16.840.1.113883.3.1937.99.61.20.10.14 PHCR ComponentOf Template (2015‑11‑03)
adding PHCR ComponentOf Constraints
cda:componentOf
1 … 1MSHALL contain one [1..1] componentOf (phcr-nn).

NOTE: The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred (CDA R2). For the public health case report, the provider in charge of care and the facility in which care was provided when the case was triggered are contained within this element. 		phcr‑nn
cda:encompassingEncounter
1 … 1MThe componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:9956).conf‑9956
cda:id
1 … *MThis encompassingEncounter SHALL contain at least one [1..*] id (CONF:9959).

EH: will this be used as a local identifier for the case?		conf‑9959
cda:effectiveTime
1 … 1MThis encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:9958).

The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) 		conf‑9958
 Schematron assertrolered error 
 teststring-length(@value)>=8 
 MessageThe content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)  
cda:responsibleParty
1 … 1MThis encompassingEncounter SHALL contain at least one responsibleParty (phcr-nn).phcr‑nn
cda:assignedEntity
1 … 1MSuch responsibleParty SHALL contain exactly one [1..1] assignedEntity (phcr-nn).phcr‑nn
cda:id
1 … *RThis responsibleParty SHALL contain at least one [1..*] id (CONF:5268).conf‑5268
cda:addr
1 … *RThis responsibleParty SHALL contain at least one [1..*] addr (CONF:5271).

The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)		conf‑5271
 Schematron assertrolered error 
 testcda:streetAddressLine and cda:city and (cda:country!='US' or ((not(cda:country) or cda:country='US') and cda:state and cda:postalCode)) 
 MessageThe content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) 
cda:telecom
1 … *RThis responsibleParty SHALL contain at least one [1..*] telecom (CONF:5280).conf‑5280
@use
set_cs0 … 1 conf‑5375
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:assignedPerson
1 … 1MThis responsibleParty SHALL contain exactly one [1..1] patient (CONF:5283).conf‑5283
cda:name
1 … *RThis assignedPerson SHALL contain at least one [1..*] name (CONF:5284).

The content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1)		conf‑5284
 Schematron assertrolered error 
 testcda:given and cda:family 
 MessageThe content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1) 
cda:representedOrganization
1 … 1MThis assignedCustodian SHALL contain exactly one [1..1] representedOrganization (CONF:5521).conf‑5521
cda:name
1 … 1RThis representedOrganization SHALL contain exactly one [1..1] name (CONF:5524).conf‑5524
cda:addr
1 … 1RThis representedOrganization SHALL contain exactly one [1..1] addr (CONF:5559).

NOTE: The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)		conf‑5559
 Schematron assertrolered error 
 testcda:streetAddressLine and cda:city and ((not(cda:country) or cda:country!='US') or (cda:country='US' and cda:state and cda:postalCode)) 
 MessageThe content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) 
cda:location
1 … 1MThis encompassingEncounter SHALL contain at least one location (phcr-nn).phcr‑nn
cda:healthCareFacility
1 … 1MThe location SHALL contain one healthCareFacility (phcr-nn).phcr‑nn
cda:id
1 … *RThis healthCareFacility SHALL contain at least one [1..*] id (CONF:5268).conf‑5268
@root
uid0 … 1F2.16.840.1.113883.4.6confdots6822
cda:code
1 … 1RThis healthCareFacility SHALL contain at least one code (CONF:5268).conf‑5268
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.99.61.20.11.3 PHCR Service Directory Location Role Type (DYNAMIC)
cda:serviceProviderOrganization
1 … 1MThis assignedCustodian SHALL contain exactly one [1..1] serviceProviderOrganization (CONF:5521).conf‑5521
cda:name
1 … 1RThis representedOrganization SHALL contain exactly one [1..1] name (CONF:5524).conf‑5524
cda:telecom
1 … *RThis serviceProviderOrganization SHALL contain at least one [1..*] telecom (CONF:5280).conf‑5280
@use
set_cs0 … 1 conf‑5375
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 Telecom Use (US Realm Header) (DYNAMIC)
cda:addr
1 … 1RThis representedOrganization SHALL contain exactly one [1..1] addr (CONF:5559).

NOTE: The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)		conf‑5559
 Schematron assertrolered error 
 testcda:streetAddressLine and cda:city and ((not(cda:country) or cda:country!='US') or (cda:country='US' and cda:state and cda:postalCode)) 
 MessageThe content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) 
Included1 … 1M from 2.16.840.1.113883.3.1937.99.61.20.10.6 PHCR Document Body (2015‑10‑30 05:51:33)
adding list of Section Templates Based upon the CSTE Des
cda:component
1 … 1MphcrdotsBody
cda:structuredBody
1 … 1MphcrdotsBody
cda:component
1 … 1MContains 2.16.840.1.113883.3.1937.99.61.20.10.7 Encounters Section (entries required) (V3) (DYNAMIC)phcrdotsnt‑1
cda:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.20.10.8 History of Present Illness Section (DYNAMIC)phcrdotsnt‑2
cda:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.20.10.9 Medications Section (entries required) (V2) (DYNAMIC)phcrdotsnt‑3
cda:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.20.10.10 Problem Section (entries required) (V3) (DYNAMIC)phcrdotsnt‑4
cda:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.20.10.11 Reason for Visit Section (DYNAMIC)phcrdotsnt‑5
cda:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.20.10.12 Results Section (entries required) (V3) (DYNAMIC)phcrdotsnt‑6
cda:component
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.20.10.13 Social History Section (V3) (DYNAMIC)phcrdotsnt‑7