hl7:ClinicalDocument
|
|
|
|
|
(XeH der) |
@classCode
|
cs |
0 … 1 |
F |
DOCCLIN |
@moodCode
|
cs |
0 … 1 |
F |
EVN |
hl7:realmCode
|
CS |
0 … 1 |
R |
This attribute signals the imposition of
realm-specific constraints. The value of this attribute identifies the realm in question.
This element should not be used for identifying the originating country.
|
(XeHder) |
hl7:typeId
|
II |
1 … 1 |
R |
|
(XeHder) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.1.3 |
@extension
|
st |
1 … 1 |
F |
POCD_HD000040 |
hl7:templateId
|
II |
1 … 1 |
R |
|
(XeHder) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.3.1937.99.61.67.10.18 |
hl7:id
|
II |
1 … 1 |
R |
|
(XeHder) |
hl7:code
|
CE |
1 … 1 |
R |
The code specifying the particular kind of document (e.g. History and Physical, Discharge
Summary, Progress Note).
The value set is drawn from LOINC.
|
(XeHder) |
@codeSystem
|
CONF |
0 … 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
hl7:title
|
ST |
1 … 1 |
M |
Narrative title of the document, usually shown to the user.
|
(XeHder) |
xeh:documentStatus
|
CO |
0 … 1 |
|
|
(XeHder) |
hl7:effectiveTime
|
TS |
1 … 1 |
R |
The date/time of document creation.
Where the CDA document is transformed into another format, the ClinicalDocument.effectiveTime
of the original document is preserved.
|
(XeHder) |
hl7:confidentialityCode
|
CE |
1 … 1 |
R |
|
(XeHder) |
| |
CONF |
|
hl7:languageCode
|
CS (preferred) |
1 … 1 |
R |
|
(XeHder) |
| |
CONF |
|
hl7:setId
|
II |
1 … 1 |
R |
Common identifier to all revisions of the document
|
(XeHder) |
hl7:versionNumber
|
INT |
1 … 1 |
R |
|
(XeHder) |
| Included |
1 … * |
R |
from 2.16.840.1.113883.2.51.10.9 XeH CDA recordTarget (DYNAMIC)
The recordTarget represents the medical record that this document belongs to.
A clinical document typically has exactly one recordTarget participant. In the uncommon
case where a clinical document (such as a group encounter note) is placed into more
than one patient chart, more than one recordTarget participants can be stated.
|
hl7:recordTarget
|
|
1 … * |
R |
|
(XeHder) |
@typeCode
|
cs |
0 … 1 |
F |
RCT |
@contextControlCode
|
cs |
0 … 1 |
F |
OP |
| |
Example |
<recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole classCode="PAT">
<id root="1.2.3.999" extension="__example only__"/> <addr>
<streetAddressLine>HSE M CASSAR STR</streetAddressLine> <city>ISLA</city> <country>MT</country> </addr> <telecom use="HP" value="tel:+356124567891"/> <telecom use="WP" value="mailto:elif@foo.too.mt"/> <patient>
<name>
<family>BORG</family> <given>TANIA</given> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/> <birthTime value="19430130"/> <!-- Optional guardian information ; see example below-->
<!-- Optional languageCommunication information see example below -->
</patient> </patientRole></recordTarget> |
hl7:patientRole
|
|
1 … 1 |
M |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
PAT |
hl7:id
|
II |
1 … * |
R |
Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary
Patient Identifier (Social/Insurance Number)
|
(XeHder) |
hl7:addr
|
AD.IPS |
1 … * |
R |
The patient address. |
(XeHder) |
| |
Constraint |
When used for cross-border exchange the country address part has to be provided. |
| Included |
|
|
from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
|
@use
|
set_cs |
0 … 1 |
|
|
| |
CONF |
|
@nullFlavor
|
cs |
0 … 1 |
F |
NI |
| |
Constraint |
SHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
no address parts shall be present, otherwise there shall be no nullFlavor attribute,
and at least one of the address parts listed below shall be present.
|
| |
Schematron assert |
role |
 error
|
|
| |
test |
@nullFlavor or hl7:* |
|
| |
Message |
If addr is not nullflavored at least one sub element has to be provided |
|
hl7:streetAddressLine
|
ADXP |
0 … * |
C |
Subject's or Organization's Street Address Line |
(XeHder) |
| |
Schematron assert |
role |
error
|
|
| |
test |
hl7:streetAddressLine and (hl7:city or hl7:postalCode) |
|
| |
Message |
If the address line is included either the city or the zip code has to be provided |
|
hl7:city
|
ADXP |
0 … 1 |
C |
Subject's or Organization's City |
(XeHder) |
hl7:postalCode
|
ADXP |
0 … 1 |
C |
Subject's or Organization's Postal Code |
(XeHder) |
hl7:state
|
ADXP |
0 … 1 |
C |
Subject's or Organization's State or Province |
(XeHder) |
hl7:country
|
ADXP |
0 … 1 |
C |
Subject's Country. |
(XeHder) |
| |
Constraint |
The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2
urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3
2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO
Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
|
hl7:telecom
|
TEL |
1 … * |
R |
Patient’s telecom information : e.g. telephone number, e-mail address. |
(XeHder) |
@use
|
set_cs |
0 … 1 |
|
|
| |
CONF |
|
@nullFlavor
|
cs |
0 … 1 |
F |
NI |
| |
Constraint |
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute
shall not be present, and the "value" and "use" attributes shall be present.
|
| |
Example |
<telecom use="HP" value="tel:+356124567891"/> |
| |
Example |
<telecom use="WP" value="mailto:elif@foo.too.mt"/> |
| |
Example |
<telecom nullFlavor="NI"/> |
hl7:patient
|
|
1 … 1 |
M |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
PSN |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
| |
Example |
Japanese example (Person Name) <patient>
<name use="IDE">
<family>木村</family> <given>通男</given> </name> <name use="SYL">
<family>きむら</family> <given>みちお</given> </name> <name use="ABC">
<family>KIMURA</family> <given>MICHIO</given> </name> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/> <birthTime nullFlavor="UNK"/></patient> |
hl7:name
|
PN |
1 … * |
M |
Patient Name |
(XeHder) |
| |
Constraint |
The Alphabetic representation of the name SHALL be always provided |
hl7:family
|
|
1 … * |
R |
Patient's Family Name/Surname |
(XeHder) |
hl7:given
|
|
1 … * |
R |
Patient's Given Name |
(XeHder) |
hl7:administrativeGenderCode
|
CE.IPS |
1 … 1 |
R |
Patient's Gender |
(XeHder) |
@nullFlavor
|
cs |
0 … 1 |
F |
UNK |
| |
CONF |
|
| |
Example |
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
<translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode> |
hl7:birthTime
|
TS |
1 … 1 |
R |
Patient's Date of Birth. The patient date of birth may be a partial date such as only
the year.
|
(XeHder) |
hl7:guardian
|
|
0 … * |
R |
The guardians of a patient.
Other patient contacts are described using the /ClinicalDocument/participant structure.
The <associatedEntity> element defines the type of contact.
|
(XeHder) |
@classCode
|
cs |
1 … 1 |
F |
GUARD |
| |
Example |
<guardian classCode="GUARD">
<code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/> <addr nullFlavor="NI"/> <telecom use="MC" value="tel:+33-12345678"/> <guardianPerson>
<name>
<family>Curie</family> <given>Marie</given> </name> </guardianPerson></guardian> |
hl7:code
|
CD.IPS |
0 … 1 |
R |
The relationship between the patient and the guardian or other contact may be recorded
in the element.
|
(XeHder) |
| |
CONF |
|
hl7:addr
|
AD.IPS |
1 … * |
R |
|
(XeHder) |
| |
Constraint |
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
no address parts shall be present, otherwise there shall be no nullFlavor attribute,
and at least one of the address parts listed below shall be present.
|
| Included |
|
|
from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
|
@use
|
set_cs |
0 … 1 |
|
|
| |
CONF |
|
@nullFlavor
|
cs |
0 … 1 |
F |
NI |
| |
Constraint |
SHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
no address parts shall be present, otherwise there shall be no nullFlavor attribute,
and at least one of the address parts listed below shall be present.
|
| |
Schematron assert |
role |
error
|
|
| |
test |
@nullFlavor or hl7:* |
|
| |
Message |
If addr is not nullflavored at least one sub element has to be provided |
|
hl7:streetAddressLine
|
ADXP |
0 … * |
C |
Subject's or Organization's Street Address Line |
(XeHder) |
| |
Schematron assert |
role |
error
|
|
| |
test |
hl7:streetAddressLine and (hl7:city or hl7:postalCode) |
|
| |
Message |
If the address line is included either the city or the zip code has to be provided |
|
hl7:city
|
ADXP |
0 … 1 |
C |
Subject's or Organization's City |
(XeHder) |
hl7:postalCode
|
ADXP |
0 … 1 |
C |
Subject's or Organization's Postal Code |
(XeHder) |
hl7:state
|
ADXP |
0 … 1 |
C |
Subject's or Organization's State or Province |
(XeHder) |
hl7:country
|
ADXP |
0 … 1 |
C |
Subject's Country. |
(XeHder) |
| |
Constraint |
The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2
urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3
2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO
Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
|
hl7:telecom
|
TEL |
1 … * |
R |
Guardian’s telecom information: e.g. telephone number; e-mail address. |
(XeHder) |
@use
|
set_cs |
0 … 1 |
|
|
| |
CONF |
|
@nullFlavor
|
cs |
0 … 1 |
F |
NI |
| |
Constraint |
If there is no information, the nullFlavor attribute shall have a value of 'NI' and
the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute
shall not be present, and the "value" and "use" attributes shall be present.
|
hl7:guardianPerson
|
|
1 … 1 |
R |
|
(XeHder) |
hl7:name
|
PN |
1 … * |
R |
Patient Guardian's Name |
(XeHder) |
hl7:family
|
ENXP |
1 … * |
R |
Patient Guardian's Family Name/Surname |
(XeHder) |
hl7:given
|
ENXP |
1 … * |
R |
Patient Guardian's Given Name |
(XeHder) |
hl7:languageCommunication
|
|
0 … * |
R |
|
(XeHder) |
hl7:languageCode
|
CS |
1 … 1 |
R |
Patient’s language |
(XeHder) |
| |
Constraint |
The two characters form SHALL be used when available; otherwise the three characters representation
SHALL be adopted
|
| |
CONF |
|
| |
Example |
British English <languageCode code="en-GB"/> |
| |
Example |
Amurdak (Australia) <languageCode code="amg-AU"/> |
| |
Schematron assert |
role |
error
|
|
| |
test |
matches(@code,'[a-z]{2,3}-[A-Z]{2,3}') |
|
| |
Message |
The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47
(e.g. nn is the ISO language code; CC is ISO country code) |
|
| Included |
1 … * |
R |
from 2.16.840.1.113883.2.51.10.5 XeH CDA author (DYNAMIC)
Represents the humans and/or machines that authored the document.
The role of the author can also be recorded in the Author.functionCode or AssignedAuthor.code
attribute.
If either of these attributes is included, they should be equivalent to or further
specialize the role inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code
is simply "Physician Progress Note" and the value of Author.functionCode is "rounding
physician"), and shall not conflict with the role inherent in the ClinicalDocument.code,
as such a conflict would constitute an ambiguous situation.
|
hl7:author
|
|
1 … * |
R |
|
(XeHder) |
@typeCode
|
cs |
0 … 1 |
F |
AUT |
@contextControlCode
|
cs |
0 … 1 |
F |
OP |
| |
Example |
<author>
<time value="201212290600+0100"/> <assignedAuthor>
<id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/> <addr use="WP">
<streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country> </addr> <telecom use="WP" value="tel:+39-051-34343434"/> <assignedPerson>
<name>
<given>Paolo</given> <family>Rossi</family> </name> </assignedPerson> </assignedAuthor> <representedOrganization>
<!-- template 'IPS CDA Organization' (dynamic) -->
</representedOrganization></author> |
hl7:functionCode
|
CE.IPS |
0 … 1 |
R |
Function of the author (e.g. "Physician on duty", ...). Binding of this element is
left open and needs to be set according to project policies.
|
(XeHder) |
hl7:time
|
TS.IPS.TZ |
1 … 1 |
R |
The author/time element represents the start time of the author’s participation in
the creation of the clinical document.
|
(XeHder) |
| |
Example |
<time value="201212290600+0100"/> |
hl7:assignedAuthor
|
|
1 … 1 |
R |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
ASSIGNED |
hl7:id
|
II |
1 … * |
R |
Author Identifier(s) |
(XeHder) |
@nullFlavor
|
cs |
0 … 1 |
|
|
hl7:code
|
CE.IPS (extensible) |
0 … 1 |
R |
A code, which identifies the profession/competence/specialty of the author when it
is a person.
|
(XeHder) |
| |
CONF |
|
| |
Example |
<code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/> |
hl7:addr
|
AD.IPS |
1 … * |
R |
|
(XeHder) |
| |
Example |
<addr use="WP">
<streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country></addr> |
hl7:telecom
|
TEL.IPS |
1 … * |
R |
|
(XeHder) |
@use
|
set_cs |
0 … 1 |
|
|
| |
CONF |
|
@value
|
st |
0 … 1 |
|
|
| |
Example |
<telecom use="WP" value="tel:+39-051-34343434"/> |
| |
Example |
<telecom nullFlavor="NI"/> |
| Choice |
1 … 1 |
|
Elements to choose from:
|
hl7:assignedPerson
|
|
0 … 1 |
C |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
PSN |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … * |
R |
Name of the person (e.g. the Healthcare Professional) authoring this document |
(XeHder) |
| |
Example |
<name>
<given>John</given> <family>Español Smith</family></name> |
hl7:family
|
|
1 … * |
R |
|
(XeHder) |
hl7:given
|
|
1 … * |
R |
|
(XeHder) |
hl7:assignedAuthoringDevice
|
|
0 … 1 |
C |
Contains 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
|
(XeHder) |
| |
Example |
<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
<softwareName displayName="Turriano"/></assignedAuthoringDevice> |
hl7:representedOrganization
|
|
0 … 1 |
R |
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
|
(XeHder) |
| Included |
0 … 1 |
|
from 2.16.840.1.113883.2.51.10.7 XeH CDA dataEnterer (DYNAMIC)
|
hl7:dataEnterer
|
|
0 … 1 |
R |
|
(XeHder) |
hl7:time
|
TS.IPS.TZ |
1 … 1 |
R |
Time of entering the data into the originating system |
(XeHder) |
hl7:assignedEntity
|
|
0 … 1 |
R |
Represents the participant who has transformed a dictated note into text. A person
entering the data into the originating system.
|
(XeHder) |
hl7:id
|
|
0 … * |
R |
Unique identification of the data enterer |
(XeHder) |
hl7:addr
|
AD.IPS |
1 … * |
R |
|
(XeHder) |
hl7:telecom
|
TEL.IPS |
1 … * |
R |
|
(XeHder) |
hl7:assignedPerson
|
|
1 … 1 |
R |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
PSN |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … * |
M |
Name of the data enterer |
(XeHder) |
| |
Example |
<name>
<given>John</given> <family>Español Smith</family></name> |
hl7:family
|
|
1 … * |
R |
Family Name/Surname |
(XeHder) |
hl7:given
|
|
1 … * |
R |
Given Name |
(XeHder) |
hl7:representedOrganization
|
|
0 … 1 |
R |
Organization the data enterer is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
|
(XeHder) |
| Included |
0 … * |
|
from 2.16.840.1.113883.10.12.154 CDA Informant (DYNAMIC)
|
hl7:informant
|
|
0 … * |
|
|
(XeHder) |
@typeCode
|
|
0 … 1 |
F |
INF |
@contextControlCode
|
|
0 … 1 |
F |
OP |
| Choice |
1 … 1 |
|
Elements to choose from:
|
hl7:assignedEntity
|
|
|
|
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(XeHder) |
hl7:relatedEntity
|
|
|
|
Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)
|
(XeHder) |
| Included |
1 … 1 |
R |
from 2.16.840.1.113883.2.51.10.6 XeH CDA custodian (DYNAMIC)
Represents the organization that is in charge of maintaining the document.
The custodian is the steward that is entrusted with the care of the document.
|
hl7:custodian
|
|
1 … 1 |
R |
|
(XeHder) |
@typeCode
|
cs |
0 … 1 |
F |
CST |
| |
Example |
<custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
<!-- template 'IPS CDA Organization' (dynamic) -->
</representedCustodianOrganization> </assignedCustodian></custodian> |
hl7:assignedCustodian
|
|
1 … 1 |
R |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
ASSIGNED |
hl7:representedCustodianOrganization
|
|
1 … 1 |
R |
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
ORG |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
| Included |
0 … * |
|
from 2.16.840.1.113883.2.51.10.14 XeH Information Recipient (DYNAMIC)
Represents a recipient who should receive a copy of the document.
|
hl7:informationRecipient
|
|
0 … * |
|
|
(XeHder) |
hl7:templateId
|
II |
1 … 1 |
M |
|
(XeHder) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.2.51.10.14 |
hl7:templateId
|
II |
1 … 1 |
M |
|
(XeHder) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.3.1937.99.61.67.10.15 |
hl7:templateId
|
II |
0 … * |
R |
|
(XeHder) |
hl7:intendedRecipient
|
|
1 … 1 |
R |
|
(XeHder) |
hl7:id
|
II |
0 … * |
R |
|
(XeHder) |
hl7:addr
|
AD |
1 … * |
R |
|
(XeHder) |
hl7:telecom
|
TEL |
1 … * |
R |
|
(XeHder) |
hl7:informationRecipient
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)
|
(XeHder) |
hl7:receivedOrganization
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
|
(XeHder) |
| Included |
0 … 1 |
R |
from 2.16.840.1.113883.2.51.10.8 XeH CDA legalAuthenticator (DYNAMIC)
|
hl7:legalAuthenticator
|
|
0 … 1 |
R |
|
(XeHder) |
| |
Example |
<legalAuthenticator>
<time value="20111013150937-0800"/> <signatureCode code="S"/> <assignedEntity>
<id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/> <assignedPerson>
<name>
<given>John</given> <family>Español Smith</family> </name> </assignedPerson> <representedOrganization>
<name>Healthcare Facility's name</name> <addr>
<country>NL</country> <streetName>Duinweg</streetName> <houseNumber>23</houseNumber> <postalCode>7364 RX</postalCode> <city>Amsterdam</city> </addr> </representedOrganization> </assignedEntity></legalAuthenticator> |
hl7:time
|
TS.IPS.TZ |
1 … 1 |
M |
Time of signing the document |
(XeHder) |
hl7:signatureCode
|
CS |
1 … 1 |
R |
Signature code |
(XeHder) |
@code
|
CONF |
0 … 1 |
F |
S |
hl7:assignedEntity
|
|
0 … 1 |
R |
The entity that is responsible for the legal authentication of the CDA document |
(XeHder) |
hl7:id
|
|
1 … * |
R |
Unique identification of legal authenticator |
(XeHder) |
hl7:addr
|
AD.IPS |
1 … * |
R |
|
(XeHder) |
hl7:telecom
|
TEL.IPS |
1 … * |
R |
|
(XeHder) |
hl7:assignedPerson
|
|
1 … 1 |
R |
Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)
|
(XeHder) |
hl7:representedOrganization
|
|
1 … 1 |
M |
Organization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
|
(XeHder) |
| Included |
0 … * |
R |
from 2.16.840.1.113883.10.12.107 CDA authenticator (DYNAMIC)
|
hl7:authenticator
|
|
0 … * |
R |
|
(XeHder) |
@typeCode
|
|
0 … 1 |
F |
AUTHEN |
hl7:time
|
TS |
1 … 1 |
R |
|
(XeHder) |
hl7:signatureCode
|
CS |
1 … 1 |
R |
|
(XeHder) |
| |
CONF |
|
hl7:assignedEntity
|
|
1 … 1 |
|
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(XeHder) |
| Included |
0 … * |
|
from 2.16.840.1.113883.10.12.108 CDA participant (DYNAMIC)
|
hl7:participant
|
|
0 … * |
|
|
(XeHder) |
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
@contextControlCode
|
|
0 … 1 |
F |
OP |
hl7:functionCode
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(XeHder) |
hl7:associatedEntity
|
|
1 … 1 |
|
|
(XeHder) |
@classCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
hl7:id
|
II |
0 … * |
|
|
(XeHder) |
hl7:code
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
| shall be drawn from concept domain "RoleCode" |
|
hl7:addr
|
AD |
0 … * |
|
|
(XeHder) |
hl7:telecom
|
TEL |
0 … * |
|
|
(XeHder) |
hl7:associatedPerson
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)
|
(XeHder) |
hl7:scopingOrganization
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
|
(XeHder) |
| Included |
0 … * |
|
from 2.16.840.1.113883.10.12.109 CDA inFulfillmentOf (DYNAMIC)
|
hl7:inFulfillmentOf
|
|
0 … * |
|
|
(XeHder) |
@typeCode
|
|
0 … 1 |
F |
FLFS |
hl7:order
|
|
1 … 1 |
|
|
(XeHder) |
@classCode
|
|
0 … 1 |
F |
ACT |
@moodCode
|
|
1 … 1 |
F |
RQO |
hl7:id
|
II |
1 … * |
R |
|
(XeHder) |
hl7:code
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
| shall be drawn from concept domain "ActCode" |
|
hl7:priorityCode
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
| Included |
0 … * |
|
from 2.16.840.1.113883.10.12.110 CDA documentationOf (DYNAMIC)
|
hl7:documentationOf
|
|
0 … * |
|
|
(XeHder) |
@typeCode
|
|
1 … 1 |
F |
DOC |
hl7:serviceEvent
|
|
1 … 1 |
|
|
(XeHder) |
@classCode
|
|
1 … 1 |
F |
ACT |
@moodCode
|
|
1 … 1 |
F |
EVN |
hl7:id
|
II |
0 … * |
|
|
(XeHder) |
hl7:code
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
| shall be drawn from concept domain "ActCode" |
|
hl7:effectiveTime
|
IVL_TS |
0 … 1 |
|
|
(XeHder) |
hl7:performer
|
|
0 … * |
|
|
(XeHder) |
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
hl7:functionCode
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(XeHder) |
hl7:assignedEntity
|
|
1 … 1 |
|
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(XeHder) |
| Included |
0 … 2 |
R |
from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)
A reference to a ParentDocument representing the source of a document revision, addenda,
or transformation.
|
| |
Constraint |
|
hl7:relatedDocument
|
|
0 … 2 |
R |
|
(XeHder) |
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
hl7:parentDocument
|
|
1 … 1 |
R |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
DOCCLIN |
@moodCode
|
cs |
0 … 1 |
F |
EVN |
hl7:id
|
II |
1 … * |
R |
|
(XeHder) |
hl7:code
|
CD.IPS |
0 … 1 |
R |
|
(XeHder) |
@codeSystem
|
CONF |
0 … 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
hl7:text
|
ED |
0 … 1 |
R |
|
(XeHder) |
hl7:setId
|
II |
0 … 1 |
R |
|
(XeHder) |
hl7:versionNumber
|
INT |
0 … 1 |
R |
|
(XeHder) |
| Included |
0 … * |
|
from 2.16.840.1.113883.10.12.114 CDA Authorization (DYNAMIC)
|
hl7:authorization
|
|
0 … * |
|
|
(XeHder) |
@typeCode
|
|
0 … 1 |
F |
AUTH |
hl7:consent
|
|
1 … 1 |
|
|
(XeHder) |
@classCode
|
|
0 … 1 |
F |
CONS |
@moodCode
|
|
0 … 1 |
F |
EVN |
hl7:id
|
II |
0 … * |
|
|
(XeHder) |
hl7:code
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
| shall be drawn from concept domain "ActCode" |
|
hl7:statusCode
|
CS |
1 … 1 |
R |
|
(XeHder) |
@code
|
CONF |
0 … 1 |
F |
completed |
| Included |
0 … 1 |
|
from 2.16.840.1.113883.2.51.10.10 XeH ComponentOf (DYNAMIC)
A reference to the clinical encounter during which the documented act(s) or ServiceEvent
occurred. Documents are not necessarily generated during an encounter, such as when
a clinician, in response to an abnormal lab result, attempts to contact the patient
but can't, and writes a Progress Note.
|
hl7:componentOf
|
|
0 … 1 |
|
|
(XeHder) |
@typeCode
|
cs |
0 … 1 |
F |
COMP |
hl7:templateId
|
II |
1 … 1 |
M |
|
(XeHder) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.2.51.10.10 |
hl7:encompassingEncounter
|
|
1 … 1 |
R |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
ENC |
@moodCode
|
cs |
0 … 1 |
F |
EVN |
hl7:id
|
II |
1 … * |
R |
Identifier of the encounter (e.g. identifier of the hospital stay) |
(XeHder) |
hl7:code
|
CE (extensible) |
0 … 1 |
|
Code describing the kind of clinical encounter during which the documented act(s)
or ServiceEvent occurred.
|
(XeHder) |
| |
CONF |
|
hl7:effectiveTime
|
IVL_TS |
1 … 1 |
R |
|
(XeHder) |
hl7:low
|
IVXB_TS |
1 … 1 |
R |
Start date time of the encounter (e.g. date of admission) |
(XeHder) |
hl7:high
|
IVXB_TS |
1 … 1 |
R |
End date time of the encounter (e.g. date of discharge)
|
(XeHder) |
hl7:dischargeDispositionCode
|
CE (extensible) |
0 … 1 |
R |
Depict the disposition of the patient at the time of hospital discharge (e.g., discharged
to home, expired, against medical advice, etc.).
|
(XeHder) |
| |
CONF |
|
hl7:responsibleParty
|
|
0 … 1 |
|
The provider (person or organization) who has primary responsibility for the encounter.
The responsible provider is not necessarily present in an encounter, but is accountable
for the action through the power to delegate, and the duty to review actions with
the performing participant.
When the responsible party is an organization, the responsible party is reflected
by the presence of a scoping Organization, without a playing entity.
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(XeHder) |
@typeCode
|
cs |
0 … 1 |
F |
RESP |
hl7:encounterParticipant
|
|
0 … 1 |
R |
Admitter
|
(XeHder) |
@typeCode
|
cs |
1 … 1 |
F |
ADM |
hl7:time
|
IVL_TS |
0 … 1 |
|
The time when the participation occurred
|
(XeHder) |
hl7:assignedEntity
|
|
1 … 1 |
R |
The clinician assigned to the role (e.g. Admitter) by the scoping organization (e.g
the hospital)
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(XeHder) |
hl7:encounterParticipant
|
|
0 … 1 |
R |
Discharger
|
(XeHder) |
@typeCode
|
cs |
1 … 1 |
F |
DIS |
hl7:time
|
IVL_TS |
0 … 1 |
|
The time when the participation occurred
|
(XeHder) |
hl7:assignedEntity
|
|
1 … 1 |
R |
The clinician assigned to the role (e.g. Admitter) by the scoping organization (e.g
the hospital)
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(XeHder) |
hl7:encounterParticipant
|
|
0 … * |
R |
Other clinicians directly associated with the encounter.
|
(XeHder) |
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
hl7:time
|
IVL_TS |
0 … 1 |
|
The time when the participation occurred
|
(XeHder) |
hl7:assignedEntity
|
|
1 … 1 |
R |
The clinician assigned to the role (e.g. Admitter) by the scoping organization (e.g
the hospital)
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(XeHder) |
hl7:location
|
|
0 … 1 |
|
The location where the service is done. May be a static building (or room therein)
or a moving location (e.g., ambulance, helicopter, aircraft, train, truck, ship, etc.)
The setting of an encounter (e.g. cardiology clinic, primary care clinic, rehabilitation
hospital, skilled nursing facility) can be expressed in HealthCareFacility.code. Note
that setting and physical location are not the same.
|
(XeHder) |
@typeCode
|
cs |
0 … 1 |
F |
LOC |
hl7:healthCareFacility
|
|
1 … 1 |
R |
|
(XeHder) |
@classCode
|
cs |
0 … 1 |
F |
SDLOC |
hl7:id
|
II |
0 … * |
|
|
(XeHder) |
hl7:code
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
hl7:location
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)
|
(XeHder) |
hl7:serviceProviderOrganization
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
|
(XeHder) |
| Included |
1 … 1 |
R |
from 2.16.840.1.113883.10.12.112 CDA component (DYNAMIC)
|
hl7:component
|
|
1 … 1 |
R |
|
(XeHder) |
@typeCode
|
|
0 … 1 |
F |
COMP |
@contextConductionInd
|
bl |
0 … 1 |
F |
true |
| Choice |
1 … 1 |
|
Elements to choose from:
|
| Included |
|
|
from 2.16.840.1.113883.10.12.203 CDA NonXMLBody (DYNAMIC)
|
hl7:nonXMLBody
|
|
|
|
|
(XeHder) |
@classCode
|
|
0 … 1 |
F |
DOCBODY |
@moodCode
|
|
0 … 1 |
F |
EVN |
hl7:text
|
ED |
1 … 1 |
|
|
(XeHder) |
hl7:confidentialityCode
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
hl7:languageCode
|
CS |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
| Included |
|
|
from 2.16.840.1.113883.10.12.202 CDA StructuredBody (DYNAMIC)
|
hl7:structuredBody
|
|
|
|
|
(XeHder) |
@classCode
|
|
0 … 1 |
F |
DOCBODY |
@moodCode
|
|
0 … 1 |
F |
EVN |
hl7:confidentialityCode
|
CE |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
hl7:languageCode
|
CS |
0 … 1 |
|
|
(XeHder) |
| |
CONF |
|
hl7:component
|
|
1 … * |
|
Contains 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC)
|
(XeHder) |
@typeCode
|
|
0 … 1 |
F |
COMP |
@contextConductionInd
|
bl |
0 … 1 |
F |
true |
Template XeH Clinical Document
CDA Informant
IPS CDA relatedDocument (STU1)
