CDAR2 Implementation Guide 2012JUL

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CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL

HL7 Implementation Guide for CDA® Release 2:
IHE Health Story Consolidation, DSTU Release 1.1
(US Realm)
Draft Standard for Trial Use
July 2012

Publication of this draft standard for trial use and comment has been approved by
Health Level Seven International (HL7). This draft standard is not an accredited
American National Standard. The comment period for use of this draft standard shall
end 24 months from the date of publication. Suggestions for revision should be
submitted at http://www.hl7.org/dstucomments/index.cfm.
Following this 24 month evaluation period, this draft standard, revised as necessary,
will be submitted to a normative ballot in preparation for approval by ANSI as an
American National Standard. Implementations of this draft standard shall be viable
throughout the normative ballot process and for up to six months after publication of
the relevant normative standard.

Copyright © 2012 Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction
of this material in any form is strictly forbidden without the written permission of the publisher.
HL7 International and Health Level Seven are registered trademarks of Health Level Seven
International. Reg. U.S. Pat & TM Off.

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Following is a non-exhaustive list of third-party terminologies that may require a separate license:
Terminology
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Regenstrief Institute
World Health Organization (WHO)

Page 2
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Primary
Editor/
Co-Chair:

Brett Marquard
Lantana Consulting Group
brett.marquard@lantanagroup.com

Co-Editor:

Kanwarpreet (KP) Sethi
Deloitte Consulting LLP
ksethi@deloitte.com

Co-Chair:

Calvin Beebe
Mayo Clinic
cbeebe@mayo.edu

Co-Editor:

George Benny Varghese
Deloitte Consulting LLP
gvarghese@deloitte.com

Co-Chair:

Austin Kreisler
SAIC Consultant to CDC/NHSN
duz1@cdc.gov

Co-Editor:

Corey Spears
McKesson
Corey.Spears@McKesson.com

Primary
Editor/
Co-Chair:

Robert H. Dolin, MD
Lantana Consulting Group
bob.dolin@lantanagroup.com

Co-Editor:

Michael Tyburski
Social Security Administration
michael.tyburski@ssa.gov

Co-Chair:

Grahame Grieve
Kestral Computing Pty Ltd
grahame@kestral.com.au

Co-Editor:

Kevin Coonan, MD
Deloitte Consulting LLP
kcoonan@deloitte.com

Co-Editor:

Liora Alschuler
Lantana Consulting Group
liora.alschuler@lantanagroup.com

Co-Editor:

Ryan Murphy
Tenino Tek
teninotek@gmail.com

Co-Editor:

Dave Carlson
U.S. Department of Veterans Affairs
David.Carlson@va.gov

Co-Editor:

Bob Yencha
Lantana Consulting Group
bob.yencha@lantanagroup.com

Co-Editor:

Keith W. Boone
GE Healthcare
keith.boone@ge.com

Co-Editor:

Zabrina Gonzaga
Lantana Consulting Group
zabrina.gonzaga@lantanagroup.com

Co-Editor:

Pete Gilbert
Covisint
peterngilbert@gmail.com

Co-Editor:

Jingdong Li
Lantana Consulting Group
jingdong.li@lantanagroup.com

Co-Editor:

Gaye Dolin
Lantana Consulting Group
gaye.dolin@lantanagroup.com

Co-Editor:

Rick Geimer
Lantana Consulting Group
rick.geimer@lantanagroup.com

Co-Editor:

Rich Kernan
Deloitte Consulting LLP
rkernan@deloitte.com

Co-Editor:

Sean McIlvenna
Lantana Consulting Group
sean.mcilvenna@lantanagroup.com

Co-Editor:

David Parker
Evolvent Technologies, Inc.
david.parker@evolvent.com

Co-Editor:

Sean Muir
U.S. Department of Veterans Affairs
Sean.Muir@va.gov

Co-Editor:

Jas Singh
Deloitte Consulting LLP
jassingh3@deloitte.com

Technical
Editor:

Susan Hardy
Lantana Consulting Group
susan.hardy@lantanagroup.com

Technical
Editor:

Diana Wright
Lantana Consulting Group
diana.wright@lantanagroup.com

Current Work Group also includes all those who participated in the ONC S&I Framework
See the full list of participants (approximately 140) here:
http://wiki.siframework.org/CDA+Harmonization+WG

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 3
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

Acknowledgments
This guide was produced and developed through the joint efforts of Health Level
Seven (HL7), Integrating the Healthcare Environment (IHE), the Health Story
Project, and the Office of the National Coordinator (ONC) within the US
Department of Health and Human Services (HSS).
The project was carried out within the ONC’s Standards and Interoperability
(S&I) Framework as the Clinical Document Architecture (CDA) Consolidation
Project with a number of goals, one of which is providing a set of harmonized
CDA templates for the US Realm.
The co-editors appreciate the support and sponsorship of the HL7 Structured
Documents Working Group (SDWG) and all the volunteers, staff and contractors
participating in the S&I Framework.
The conformance requirements included here for review were generated from two
model-driven tools: the Model-Driven Health Tools (MDHT)—developed as on
open source tool under the auspices of the Veterans Administration, IBM, and
the ONC—and the Trifolia Template Database (Tdb)—developed initially for the
Centers for Disease Control and Prevention (CDC) and released by Lantana
Consulting Group under an open source license.
This material contains content from SNOMED CT®
(http://www.ihtsdo.org/snomed-ct/). SNOMED CT is a registered trademark of
the International Health Terminology Standard Development Organisation
(IHTSDO).
This material contains content from LOINC® (http://loinc.org). The LOINC table,
LOINC codes, and LOINC panels and forms file are copyright © 1995-2012,
Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and
Codes (LOINC) Committee and available at no cost under the license at
http://loinc.org/terms-of-use.

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HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Table of Contents
1

INTRODUCTION ........................................................................................................... 30
1.1

Audience .............................................................................................................. 30

1.2

Purpose ................................................................................................................ 30

1.3

Scope ................................................................................................................... 31

1.4

Approach ............................................................................................................. 31

1.5

Organization of This Guide ................................................................................... 32

1.6

Use of Templates .................................................................................................. 32

1.6.1

Originator Responsibilities: General Case.......................................................... 33

1.6.2

Recipient Responsibilities: General Case ........................................................... 33

1.7

Levels of Constraint .............................................................................................. 33

1.8

Conformance Conventions Used in This Guide ...................................................... 34

1.8.1

Templates and Conformance Statements .......................................................... 34

1.8.2

Open and Closed Templates ............................................................................. 36

1.8.3

Conformance Verbs (Keywords) ......................................................................... 36

1.8.4

Cardinality ....................................................................................................... 37

1.8.5

Optional and Required with Cardinality ............................................................ 38

1.8.6

Vocabulary Conformance.................................................................................. 38

1.8.7

Containment Relationships .............................................................................. 39

1.8.8

Null Flavor ....................................................................................................... 40

1.8.9

Unknown Information ...................................................................................... 42

1.8.10

Data Types ....................................................................................................... 43

1.9

2

XML Conventions Used in This Guide ................................................................... 44

1.9.1

XPath Notation ................................................................................................. 44

1.9.2

XML Examples and Sample Documents ............................................................ 44

1.10

UML Diagrams ..................................................................................................... 45

1.11

Content of the Package ......................................................................................... 45

GENERAL HEADER TEMPLATE .................................................................................... 46
2.1

Document Type Codes .......................................................................................... 46

2.2

US Realm Header ................................................................................................. 46

2.2.1

RecordTarget .................................................................................................... 48

2.2.2

Author ............................................................................................................. 58

2.2.3

DataEnterer ..................................................................................................... 60

2.2.4

Informant......................................................................................................... 62

2.2.5

Custodian ........................................................................................................ 63

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2.2.6

InformationRecipient ........................................................................................ 64

2.2.7

LegalAuthenticator ........................................................................................... 65

2.2.8

Authenticator ................................................................................................... 67

2.2.9

Participant (Support) ........................................................................................ 69

2.2.10

InFulfillmentOf ................................................................................................. 70

2.2.11

DocumentationOf/serviceEvent ........................................................................ 70

2.2.12

Authorization/consent...................................................................................... 72

2.2.13

ComponentOf ................................................................................................... 73

2.3

US Realm Address (AD.US.FIELDED) .................................................................... 73

2.4

US Realm Date and Time (DT.US.FIELDED) .......................................................... 74

2.5

US Realm Date and Time (DTM.US.FIELDED) ....................................................... 75

2.6

US Realm Patient Name (PTN.US.FIELDED) .......................................................... 75

2.7

US Realm Person Name (PN.US.FIELDED) ............................................................. 77

2.8

Rendering Header Information for Human Presentation ......................................... 77

DOCUMENT-LEVEL TEMPLATES .................................................................................. 79
3.1

Continuity of Care Document (CCD)/HITSP C32 ................................................... 84

3.1.1

Header Constraints Specific to CCD .................................................................. 84

3.1.2

CCD Body Constraints ..................................................................................... 86

3.2

Consultation Note ................................................................................................. 96

3.2.1

Consultation Note Header Constraints .............................................................. 96

3.2.2

Consultation Note Body Constraints ............................................................... 103

3.3

Diagnostic Imaging Report .................................................................................. 112

3.3.1

DIR Header Constraints .................................................................................. 113

3.3.2

DIR Body Constraints ..................................................................................... 124

3.4

Discharge Summary ........................................................................................... 130

3.4.1

Discharge Summary Header Constraints ........................................................ 130

3.4.2

Discharge Summary Body Constraints ............................................................ 134

3.5

History and Physical (H&P) Note ......................................................................... 146

3.5.1

H&P Note Header Constraints ......................................................................... 147

3.5.2

H&P Note Body Constraints ............................................................................ 150

3.6

Operative Note .................................................................................................... 160

3.6.1

Operative Note Header Constraints ................................................................. 160

3.6.2

Operative Note Body Constraints .................................................................... 165

3.7

Procedure Note ................................................................................................... 169

3.7.1

Procedure Note Header Constraints ................................................................ 169

3.7.2

Procedure Note Body Constraints ................................................................... 177

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July 2012

3.8
3.8.1

Progress Note Header Constraints ....................................................................188

3.8.2

Progress Note Body Constraints .......................................................................192

3.9

4

Progress Note ......................................................................................................188

Unstructured Document ......................................................................................197

3.9.1

Unstructured Document Header Constraints ...................................................198

3.9.2

Unstructured Document Body Constraints ......................................................199

SECTION-LEVEL TEMPLATES......................................................................................203
4.1

Advance Directives Section 42348-3.....................................................................210

4.2

Allergies Section 48765-2 ....................................................................................212

4.3

Anesthesia Section 59774-0 .................................................................................214

4.4

Assessment and Plan Section 51847-2 .................................................................215

4.5

Assessment Section 51848-0 ...............................................................................216

4.6

Chief Complaint and Reason for Visit Section 46239-0 .........................................217

4.7

Chief Complaint Section 10154-3 .........................................................................218

4.8

Complications Section 55109-3............................................................................219

4.9

DICOM Object Catalog Section - DCM 121181 .....................................................220

4.10

Discharge Diet Section 42344-2 ...........................................................................222

4.11

Encounters Section 46240-8 ................................................................................222

4.12

Family History Section 10157-6 ...........................................................................224

4.13

Findings Section (DIR) 18782-3 ...........................................................................226

4.14

Functional Status Section 47420-5 ......................................................................227

4.15

General Status Section 10210-3 ..........................................................................232

4.16

History of Past Illness Section 11348-0 ................................................................233

4.17

History of Present Illness Section 10164-2 ...........................................................234

4.18

Hospital Admission Diagnosis Section 46241-6 ....................................................235

4.19

Hospital Admission Medications Section 42346-7 (entries optional) ......................236

4.20

Hospital Consultations Section 18841-7 ..............................................................237

4.21

Hospital Course Section 8648-8 ...........................................................................237

4.22

Hospital Discharge Diagnosis Section 11535-2 .....................................................238

4.23

Hospital Discharge Instructions Section 8653-8 ...................................................239

4.24

Hospital Discharge Medications Section 10183-2 .................................................240

4.25

Hospital Discharge Physical Section 10184-0 .......................................................242

4.26

Hospital Discharge Studies Summary Section 11493-4 ........................................243

4.27

Immunizations Section 11369-6 ..........................................................................244

4.28

Instructions Section 69730-0 ...............................................................................247

4.29

Interventions Section 62387-6 .............................................................................248

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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5

4.30

Medical Equipment Section 46264-8 ................................................................... 249

4.31

Medical (General) History Section 11329-0 .......................................................... 250

4.32

Medications Administered Section 29549-3 ......................................................... 251

4.33

Medications Section 10160-0 .............................................................................. 252

4.34

Objective Section 61149-1 .................................................................................. 254

4.35

Operative Note Fluid Section 10216-0 ................................................................. 255

4.36

Operative Note Surgical Procedure Section 10223-6 ............................................ 256

4.37

Payers Section 48768-6 ...................................................................................... 257

4.38

Physical Exam Section 29545-1 .......................................................................... 259

4.39

Plan of Care Section 18776-5 .............................................................................. 260

4.40

Planned Procedure Section 59772-4 .................................................................... 262

4.41

Postoperative Diagnosis Section 10218-6 ............................................................ 263

4.42

Postprocedure Diagnosis Section 59769-0 ........................................................... 264

4.43

Preoperative Diagnosis Section 10219-4 .............................................................. 265

4.44

Problem Section 11450-4 .................................................................................... 266

4.45

Procedure Description Section 29554-3 ............................................................... 269

4.46

Procedure Disposition Section 59775-7 ............................................................... 270

4.47

Procedure Estimated Blood Loss Section 59770-8 ............................................... 270

4.48

Procedure Findings Section 59776-5 ................................................................... 271

4.49

Procedure Implants Section 59771-6 ................................................................... 272

4.50

Procedure Indications Section 59768-2 ............................................................... 273

4.51

Procedure Specimens Taken Section 59773-2...................................................... 274

4.52

Procedures Section 47519-4 ............................................................................... 275

4.53

Reason for Referral Section 42349-1 ................................................................... 278

4.54

Reason for Visit Section 29299-5 ........................................................................ 279

4.55

Results Section 30954-2 ..................................................................................... 280

4.56

Review of Systems Section 10187-3..................................................................... 282

4.57

Social History Section 29762-2 ........................................................................... 283

4.58

Subjective Section 61150-9 ................................................................................. 285

4.59

Surgical Drains Section 11537-8 ......................................................................... 286

4.60

Vital Signs Section 8716-3 .................................................................................. 287

ENTRY-LEVEL TEMPLATES ........................................................................................ 289
5.1

Admission Medication ......................................................................................... 289

5.2

Advance Directive Observation ............................................................................ 291

5.3

Age Observation ................................................................................................. 296

5.4

Allergy - Intolerance Observation ........................................................................ 298

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July 2012

5.5

Allergy Problem Act .............................................................................................306

5.6

Allergy Status Observation ...................................................................................309

5.7

Assessment Scale Observation .............................................................................310

5.8

Assessment Scale Supporting Observation ...........................................................314

5.9

Authorization Activity ..........................................................................................315

5.10

Boundary Observation .........................................................................................317

5.11

Caregiver Characteristics .....................................................................................318

5.12

Code Observations ...............................................................................................321

5.13

Cognitive Status Problem Observation..................................................................323

5.14

Cognitive Status Result Observation ....................................................................328

5.15

Cognitive Status Result Organizer ........................................................................331

5.16

Comment Activity ................................................................................................333

5.17

Coverage Activity .................................................................................................336

5.18

Deceased Observation .........................................................................................337

5.19

Discharge Medication ..........................................................................................339

5.20

Drug Vehicle .......................................................................................................341

5.21

Encounter Activities ............................................................................................343

5.22

Encounter Diagnosis ...........................................................................................346

5.23

Estimated Date of Delivery ...................................................................................348

5.24

Family History Death Observation ........................................................................349

5.25

Family History Observation ..................................................................................351

5.26

Family History Organizer .....................................................................................356

5.27

Functional Status Problem Observation ...............................................................360

5.28

Functional Status Result Observation ..................................................................363

5.29

Functional Status Result Organizer .....................................................................366

5.30

Health Status Observation ...................................................................................368

5.31

Highest Pressure Ulcer Stage ...............................................................................371

5.32

Hospital Admission Diagnosis ..............................................................................372

5.33

Hospital Discharge Diagnosis ...............................................................................373

5.34

Immunization Activity ..........................................................................................375

5.35

Immunization Medication Information ..................................................................381

5.36

Immunization Refusal Reason ..............................................................................384

5.37

Indication ............................................................................................................386

5.38

Instructions ........................................................................................................388

5.39

Medication Activity ..............................................................................................390

5.40

Medication Dispense ............................................................................................399

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5.41

Medication Information ....................................................................................... 402

5.42

Medication Supply Order .................................................................................... 404

5.43

Medication Use – None Known (deprecated) ......................................................... 407

5.44

Non-Medicinal Supply Activity ............................................................................ 408

5.45

Number of Pressure Ulcers Observation .............................................................. 410

5.46

Plan of Care Activity Act ...................................................................................... 412

5.47

Plan of Care Activity Encounter ........................................................................... 413

5.48

Plan of Care Activity Observation ........................................................................ 414

5.49

Plan of Care Activity Procedure ........................................................................... 416

5.50

Plan of Care Activity Substance Administration ................................................... 417

5.51

Plan of Care Activity Supply ................................................................................ 418

5.52

Policy Activity ..................................................................................................... 419

5.53

Postprocedure Diagnosis ..................................................................................... 430

5.54

Precondition for Substance Administration .......................................................... 431

5.55

Pregnancy Observation ....................................................................................... 432

5.56

Preoperative Diagnosis ........................................................................................ 434

5.57

Pressure Ulcer Observation ................................................................................. 436

5.58

Problem Concern Act (Condition) ......................................................................... 444

5.59

Problem Observation .......................................................................................... 446

5.60

Problem Status ................................................................................................... 451

5.61

Procedure Activity Act ......................................................................................... 452

5.62

Procedure Activity Observation ........................................................................... 460

5.63

Procedure Activity Procedure .............................................................................. 466

5.64

Procedure Context .............................................................................................. 472

5.65

Product Instance ................................................................................................ 473

5.66

Purpose of Reference Observation ....................................................................... 475

5.67

Quantity Measurement Observation .................................................................... 476

5.68

Reaction Observation .......................................................................................... 480

5.69

Referenced Frames Observation .......................................................................... 483

5.70

Result Observation ............................................................................................. 484

5.71

Result Organizer ................................................................................................. 488

5.72

Series Act ........................................................................................................... 490

5.73

Service Delivery Location .................................................................................... 493

5.74

Severity Observation ........................................................................................... 495

5.75

Smoking Status Observation ............................................................................... 497

5.76

Social History Observation .................................................................................. 500

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6

5.77

SOP Instance Observation ...................................................................................502

5.78

Study Act ............................................................................................................505

5.79

Text Observation .................................................................................................507

5.80

Tobacco Use ........................................................................................................510

5.81

Vital Sign Observation .........................................................................................512

5.82

Vital Signs Organizer ...........................................................................................515

REFERENCES .............................................................................................................518

APPENDIX A —

ACRONYMS AND ABBREVIATIONS ..........................................................520

APPENDIX B —

CHANGES FROM PREVIOUS GUIDES ......................................................522

New and Updated Templates ............................................................................................522
Cardinality Changes ........................................................................................................523
Section Code Changes .....................................................................................................524
Conformance Verbs .........................................................................................................525
Template ID Changes .......................................................................................................527
Consolidated Entries........................................................................................................535
Changes Within Sections .................................................................................................539
APPENDIX C —

TEMPLATE IDS IN THIS GUIDE ...............................................................557

APPENDIX D —

CODE SYSTEMS IN THIS GUIDE .............................................................563

APPENDIX E —

VALUE SETS IN THIS GUIDE ...................................................................565

APPENDIX F —

SINGLE-VALUE BINDINGS IN THIS GUIDE ..............................................568

APPENDIX G —

EXTENSIONS TO CDA R2 ........................................................................569

APPENDIX H — XDS-SD AND US REALM CLINICAL DOCUMENT HEADER
COMPARISON ..............................................................................................................571
APPENDIX I —

MIME MULTIPART/RELATED MESSAGES ...............................................573

MIME Multipart/Related Messages ...................................................................................573
RFC-2557 MIME Encapsulation of Aggregate Documents, Such as HTML (MHTML) ..........573
Referencing Supporting Files in Multipart/Related Messages ............................................573
Referencing Documents from Other Multiparts within the Same X12 Transactions ............574
APPENDIX J —

ADDITIONAL PHYSICAL EXAMINATION SUBSECTIONS ...........................575

APPENDIX K —

ADDITIONAL EXAMPLES .........................................................................577

Names Examples .............................................................................................................577
Addresses Examples ........................................................................................................577
Time Examples ................................................................................................................578
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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CD Examples .................................................................................................................. 578
APPENDIX L —

LARGE UML DIAGRAMS ......................................................................... 580

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Table of Figures
Figure 1: Constraints format example ........................................................................ 35
Figure 2: Constraints format – only one allowed......................................................... 37
Figure 3: Constraints format – only one like this allowed ........................................... 37
Figure 4: Binding to a single code .............................................................................. 38
Figure 5: XML expression of a single-code binding ..................................................... 39
Figure 6: Translation code example ........................................................................... 39
Figure 7: nullFlavor example ..................................................................................... 40
Figure 8: Attribute required....................................................................................... 41
Figure 9: Allowed nullFlavors when element is required (with xml examples) .............. 41
Figure 10: nullFlavor explicitly disallowed ................................................................. 41
Figure 11: Unknown medication example .................................................................. 42
Figure 12: Unknown medication use of anticoagulant drug example .......................... 43
Figure 13: No known medications example ................................................................ 43
Figure 14: XML document example ........................................................................... 44
Figure 15: XPath expression example ........................................................................ 44
Figure 16: ClinicalDocument example ....................................................................... 44
Figure 17: US Realm header example ........................................................................ 48
Figure 18: effectiveTime with time zone example ........................................................ 48
Figure 19: recordTarget example ............................................................................... 56
Figure 20: Person author example ............................................................................. 60
Figure 21: Device author example ............................................................................. 60
Figure 22: dataEnterer example ................................................................................ 62
Figure 23: Informant with assignedEntity example .................................................... 63
Figure 24: Custodian example ................................................................................... 64
Figure 25: informationRecipient example ................................................................... 65
Figure 26: legalAuthenticator example ....................................................................... 67
Figure 27: Authenticator example.............................................................................. 68
Figure 28: Participant example for a supporting person ............................................. 70
Figure 29: DocumentationOf example ........................................................................ 72
Figure 30: Procedure note consent example ............................................................... 73
Figure 31: CCD ClinicalDocument/templateId example ............................................. 84
Figure 32: CCD code example ................................................................................... 85
Figure 33: Consultation note ClinicalDocument/templateId example ......................... 97
Figure 34: Consultation note ClinicalDocument/code example ................................. 100

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Figure 35: Consultation note translation of local code example ................................ 100
Figure 36: Consultation note uncoordinated document type codes example .............. 101
Figure 37: Consultation note inFulfillmentOf example ............................................. 101
Figure 38: Consultation note componentOf example ................................................ 103
Figure 39: DIR ClinicalDocument/templateId example ............................................. 113
Figure 40: DIR ClinicalDocument/code example ...................................................... 115
Figure 41: DIR use of the translation element to include local codes for document type
....................................................................................................................... 115
Figure 42: DIR participant example ......................................................................... 116
Figure 43: DIR inFulfillmentOf example ................................................................... 117
Figure 44: DIR procedure context (CDA Header) illustration (non-normative) ............ 117
Figure 45: DIR documentationOf example................................................................ 118
Figure 46: DIR relatedDocument example ................................................................ 119
Figure 47: DIR componentOf example...................................................................... 121
Figure 48: Physician reading study performer example ............................................ 122
Figure 49: Physician of record participant example .................................................. 123
Figure 50: WADO reference using linkHtml example ................................................ 127
Figure 51: Fetus subject context example ................................................................ 128
Figure 52: Observer context example ....................................................................... 129
Figure 53: Discharge summary ClinicalDocument/templateId example .................... 130
Figure 54: Discharge summary ClinicalDocument/code example ............................ 131
Figure 55: Discharge summary componentOf example ............................................. 133
Figure 56: H&P ClinicalDocument/templateId example ............................................ 147
Figure 57: H&P ClinicalDocument/code example ................................................... 148
Figure 58: H&P use of translation to include local equivalents for document type ..... 148
Figure 59: H&P componentOf example .................................................................... 150
Figure 60: Operative note ClinicalDocument/templateId example ............................. 160
Figure 61: Operative note ClinicalDocument/code example ..................................... 162
Figure 62: Operative note serviceEvent example....................................................... 164
Figure 63: Operative note performer example ........................................................... 165
Figure 64: Procedure note ClinicalDocument/templateId category I example ............ 170
Figure 65: Procedure note ClinicalDocument/code example ..................................... 171
Figure 66: Procedure note serviceEvent example ...................................................... 176
Figure 67: Procedure note serviceEvent example with null value in width element .... 176
Figure 68: Procedure note performer example .......................................................... 177
Figure 69: Progress note ClinicalDocument/templateId example .............................. 188
Figure 70: Progress note ClinicalDocument/code example ...................................... 190
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Figure 71: Progress note serviceEvent example ........................................................ 191
Figure 72: Progress note componentOf example ....................................................... 192
Figure 73: nonXMLBody example with embedded content ........................................ 200
Figure 74: nonXMLBody example with referenced content ....................................... 200
Figure 75: nonXMLBody example with compressed content ..................................... 200
Figure 76: Unique file reference example ................................................................. 202
Figure 77: Advance directives section UML diagram ................................................. 210
Figure 78: Advance directives section example ......................................................... 211
Figure 79: Allergies section UML diagram ................................................................ 212
Figure 80: Allergies section example ........................................................................ 213
Figure 81: Anesthesia section example .................................................................... 215
Figure 82: Assessment and plan section example .................................................... 216
Figure 83: Assessment section example ................................................................... 217
Figure 84: Chief complaint and reason for visit section example ............................... 218
Figure 85: Chief complaint section example ............................................................. 218
Figure 86: Complications section example ............................................................... 219
Figure 87: DICOM object catalog section example .................................................... 221
Figure 88: Discharge diet section example ............................................................... 222
Figure 89: Encounters section UML diagram ........................................................... 223
Figure 90: Encounters section example ................................................................... 224
Figure 91: Family history section UML diagram ....................................................... 225
Figure 92: Family history section example ............................................................... 225
Figure 93: Findings section example ........................................................................ 226
Figure 94: Functional status section UML diagram .................................................. 227
Figure 95: Functional status section example .......................................................... 230
Figure 96: General status section example .............................................................. 232
Figure 97: History of past illness section example .................................................... 233
Figure 98: History of present illness section example ............................................... 234
Figure 99: Hospital admission diagnosis section example......................................... 235
Figure 100: Hospital admission medications section example ................................... 236
Figure 101: Hospital consultations section example ................................................. 237
Figure 102: Hospital course section example ........................................................... 238
Figure 103: Hospital discharge diagnosis section example ........................................ 239
Figure 104: Hospital discharge instructions section example ................................... 240
Figure 105: Hospital discharge medications section example.................................... 242
Figure 106: Hospital discharge physical section example ......................................... 243

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Figure 107: Hospital discharge studies summary section example ............................ 244
Figure 108: Immunization section* UML diagram .................................................... 244
Figure 109: Immunization section example .............................................................. 246
Figure 110: Instructions section example ................................................................ 248
Figure 111: Interventions section example ............................................................... 249
Figure 112: Medical equipment section UML diagram .............................................. 249
Figure 113: Medical equipment section example ...................................................... 250
Figure 114: Medical (general) history section example .............................................. 251
Figure 115: Medications administered section example ............................................ 252
Figure 116: Medications section UML diagram ......................................................... 252
Figure 117: Medications section entries example ..................................................... 254
Figure 118: Objective section example ..................................................................... 255
Figure 119: Operative Note fluid section example ..................................................... 256
Figure 120: Operative Note surgical procedure section example ............................... 256
Figure 121: Payers section UML diagram ................................................................. 257
Figure 122: Payers section example ......................................................................... 258
Figure 123: Physical exam section example ............................................................. 260
Figure 124: Plan of care section UML diagram ......................................................... 260
Figure 125: Plan of care section example ................................................................. 261
Figure 126: Planned procedure section example ...................................................... 263
Figure 127: Postoperative diagnosis section example................................................ 264
Figure 128: Postprocedure diagnosis section example .............................................. 265
Figure 129: Preoperative diagnosis section example ................................................. 266
Figure 130: Problem section UML diagram............................................................... 266
Figure 131: Problem section example ...................................................................... 268
Figure 132: Pressure ulcer on a problem list example .............................................. 268
Figure 133: Procedure description section example .................................................. 269
Figure 134: Procedure disposition section example .................................................. 270
Figure 135: Procedure estimated blood loss section example .................................... 271
Figure 136: Procedure findings section example ....................................................... 272
Figure 137: Procedure implants section example ..................................................... 273
Figure 138: Procedure indications section example .................................................. 274
Figure 139: Procedure specimens taken section example ......................................... 275
Figure 140: Procedures section UML diagram .......................................................... 275
Figure 141: Procedures section example .................................................................. 277
Figure 142: Reason for referral section example ....................................................... 278

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Figure 143: Reason for visit section example ........................................................... 279
Figure 144: Results section UML diagram................................................................ 280
Figure 145: Results section example ....................................................................... 282
Figure 146: Review of systems section example........................................................ 283
Figure 147: Social history section UML diagram ...................................................... 283
Figure 148: Social history section example .............................................................. 284
Figure 149: Subjective section example ................................................................... 285
Figure 150: Surgical drains section example ............................................................ 286
Figure 151: Vital signs section UML diagram ........................................................... 287
Figure 152: Vital signs section example ................................................................... 288
Figure 153: Admission medication entry example .................................................... 291
Figure 154: Advance directive observation example .................................................. 295
Figure 155: Age observation example ....................................................................... 298
Figure 156: Allergy - intolerance observation example .............................................. 305
Figure 157: Allergy problem act example ................................................................. 308
Figure 158: Allergy status observation example ....................................................... 310
Figure 159: Assessment scale observation example .................................................. 313
Figure 160: Assessment scale supporting observation example ................................ 315
Figure 161: Authorization activity example .............................................................. 317
Figure 162: Boundary observation example ............................................................. 318
Figure 163: Caregiver characteristics example with assertion ................................... 320
Figure 164: Caregiver characteristics example without assertion .............................. 320
Figure 165: Code observation example .................................................................... 323
Figure 166:Cognitive status problem observation example ....................................... 327
Figure 167: Cognitive status result observation example .......................................... 331
Figure 168 Cognitive status result organizer example .............................................. 333
Figure 169: Comment act example .......................................................................... 335
Figure 170: Coverage activity example ..................................................................... 337
Figure 171: Deceased observation example .............................................................. 339
Figure 172: Discharge medication entry example ..................................................... 341
Figure 173: Drug vehicle entry example ................................................................... 342
Figure 174: Encounter activities example ................................................................ 346
Figure 175: Encounter diagnosis act example .......................................................... 348
Figure 176: Estimated date of delivery example ....................................................... 349
Figure 177: Family history death observation example ............................................. 350
Figure 178: Family history observation scenario ...................................................... 353

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Figure 179: Family history observation example ...................................................... 354
Figure 180: Family history organizer example .......................................................... 359
Figure 181: Functional status problem observation example .................................... 363
Figure 182: Functional status result observation example ........................................ 366
Figure 183: Functional status result organizer example ........................................... 368
Figure 184: Health status observation example ........................................................ 370
Figure 185: Hospital admission diagnosis example .................................................. 373
Figure 186: Hospital discharge diagnosis act example .............................................. 375
Figure 187: Immunization activity example .............................................................. 381
Figure 188: Immunization medication information example ..................................... 384
Figure 189: Immunization refusal reason ................................................................ 385
Figure 190: Indication entry example ...................................................................... 387
Figure 191: Instructions entry example ................................................................... 389
Figure 192: Medication activity example .................................................................. 397
Figure 193: Medication dispense example ................................................................ 402
Figure 194: Medication information example ........................................................... 404
Figure 195: Medication supply order example .......................................................... 407
Figure 196: Medication use – none known example .................................................. 408
Figure 197: Non-medicinal supply activity example .................................................. 410
Figure 198: Number of pressure ulcers example ...................................................... 412
Figure 199: Plan of care activity act example ........................................................... 413
Figure 200: Plan of care activity encounter example ................................................. 414
Figure 201: Plan of care activity observation example .............................................. 416
Figure 202: Plan of care activity procedure example ................................................. 417
Figure 203: Plan of care activity substance administration example ......................... 418
Figure 204: Plan of care activity supply example ...................................................... 419
Figure 205: Policy activity example .......................................................................... 427
Figure 206: Postprocedure diagnosis example .......................................................... 431
Figure 207: Precondition for substance administration example ............................... 432
Figure 208: Pregnancy observation example ............................................................ 434
Figure 209: Preoperative diagnosis example ............................................................. 436
Figure 210: Pressure ulcer observation example ...................................................... 443
Figure 211: Problem concern act (condition) example ............................................... 445
Figure 212: Problem observation example ................................................................ 449
Figure 213: Problem observation with specific problem not observed ........................ 450
Figure 214: Problem observation for no known problems ......................................... 450

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Figure 215: NullFlavor example ............................................................................... 450
Figure 216: Problem status example ........................................................................ 452
Figure 217: Procedure activity act example .............................................................. 459
Figure 218: Procedure activity observation example ................................................. 465
Figure 219: Procedure activity procedure example ................................................... 471
Figure 220: Procedure context template example ..................................................... 473
Figure 221: Product instance example ..................................................................... 474
Figure 222: Purpose of reference example ................................................................ 476
Figure 223: Quantity measurement observation example ......................................... 479
Figure 224: Reaction observation example ............................................................... 483
Figure 225: Referenced frames observation example ................................................ 484
Figure 226: Result observation example .................................................................. 487
Figure 227: No evaluation procedures (e.g., labs/x-rays) performed example ............ 488
Figure 228: Local code example ............................................................................... 488
Figure 229: Result organizer example ...................................................................... 490
Figure 230: Series act example ................................................................................ 492
Figure 231: Service delivery location example .......................................................... 494
Figure 232: Severity observation example ................................................................ 497
Figure 233: Smoking status observation example .................................................... 499
Figure 234: Unknown if ever smoked ....................................................................... 499
Figure 235: Social history observation template example ......................................... 502
Figure 236: SOP instance observation example ........................................................ 504
Figure 237: Study act example ................................................................................ 507
Figure 238: Text observation example...................................................................... 510
Figure 239: Tobacco use entry example ................................................................... 512
Figure 240: Vital sign observation example .............................................................. 515
Figure 241: Vital signs organizer example ................................................................ 517
Figure 242: Correct use of name example 1 ............................................................. 577
Figure 243: Incorrect use of name example 1 - whitespace ....................................... 577
Figure 244: Incorrect use of Patient name example 2 - no tags ................................. 577
Figure 245: Correct use telecom address example .................................................... 577
Figure 246: Correct use postal address example ...................................................... 577
Figure 247: Correct use of IVL_TS example .............................................................. 578
Figure 248: Correct use of TS with precision to minute example .............................. 578
Figure 249: Correct use of TS with time zone offset example .................................... 578
Figure 250: Incorrect use of IVL_TS example ........................................................... 578

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Figure 251: Incorrect use of TS - insufficient precision example ............................... 578
Figure 252: Incorrect use of TS when time zone offset required example ................... 578
Figure 253: Incorrect use of time zone offset - not enough precision example ........... 578
Figure 254: Correct use of CD with no code example................................................ 578
Figure 255: Incorrect use of CD with no code - missing nullFlavor attribute example 579
Figure 256: Immunizations section UML diagram (larger copy) ................................. 580
Figure 257: Functional Status section UML diagram (larger copy) ............................ 580
Figure 258: Medications section UML diagram (larger copy) ..................................... 580
Figure 259: Plan of care section UML diagram (larger copy) ...................................... 580

Table of Tables
Table 1: Content of the Package ................................................................................ 45
Table 2: Basic Confidentiality Kind Value Set............................................................. 47
Table 3: Language Value Set (excerpt) ........................................................................ 47
Table 4: Telecom Use (US Realm Header) Value Set .................................................... 52
Table 5: Administrative Gender (HL7) Value Set ......................................................... 52
Table 6: Marital Status Value Set .............................................................................. 53
Table 7: Religious Affiliation Value Set (excerpt) ......................................................... 53
Table 8: Race Value Set (excerpt) ............................................................................... 54
Table 9: Ethnicity Value Set ...................................................................................... 54
Table 10: Personal Relationship Role Type Value Set (excerpt) .................................... 54
Table 11: State Value Set (excerpt) ............................................................................ 55
Table 12: Postal Code Value Set (excerpt)................................................................... 55
Table 13: Country Value Set (excerpt) ........................................................................ 55
Table 14: Language Ability Value Set ......................................................................... 56
Table 15: Language Ability Proficiency Value Set........................................................ 56
Table 16: IND Role classCode Value Set ..................................................................... 69
Table 17: PostalAddressUse Value Set ....................................................................... 74
Table 18: EntityNameUse Value Set ........................................................................... 76
Table 19: EntityPersonNamePartQualifier Value Set ................................................... 77
Table 20: Document Types and Required/Optional Sections with Structured Body ..... 80
Table 21: Template Containment for a CCD ............................................................... 88
Table 22: Consultation Note LOINC Document Codes ................................................ 98
Table 23: Invalid Codes for Consultation Note .......................................................... 100
Table 24: Template Containment for a Consultation Note ......................................... 105
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Table 25: DIR LOINC Document Type Codes ............................................................ 114
Table 26: Template Containment for Constrained DIR Sections ................................ 124
Table 27: DIR Section Type Codes ........................................................................... 125
Table 28: Discharge summary LOINC Document Codes ........................................... 131
Table 29: HL7 Discharge Disposition Codes ............................................................. 133
Table 30: Template Containment for a Discharge Summary ..................................... 137
Table 31: H&P LOINC Document Type Codes ........................................................... 148
Table 32: Template Containment for an H&P Note ................................................... 152
Table 33: Surgical Operation Note LOINC Document Codes ..................................... 161
Table 34: Provider Type Value Set (excerpt) .............................................................. 164
Table 35: Procedure Codes from SNOMED CT ......................................................... 164
Table 36: Template Containment for an Operative Note ............................................ 167
Table 37: Procedure Note LOINC Document Type Codes ........................................... 171
Table 38: Participant Scenario................................................................................. 172
Table 39: Healthcare Provider Taxonomy Value Set .................................................. 175
Table 40: Template Containment for a Procedure Note ............................................. 180
Table 41: Progress Note LOINC Document Codes ..................................................... 190
Table 42: Template Containment for a Progress Note ............................................... 194
Table 43: Supported File Formats Value Set (Unstructured Documents) ................... 200
Table 44: Sections and Required/Optional Document Types with Structured Body ... 204
Table 45: Advance Directives Section Contexts ........................................................ 210
Table 46: Allergies Section Contexts ........................................................................ 212
Table 47: Anesthesia Section Contexts .................................................................... 214
Table 48: Assessment and Plan Section Contexts ..................................................... 215
Table 49: Assessment Section Contexts ................................................................... 216
Table 50: Chief Complaint and Reason for Visit Section Contexts ............................. 217
Table 51: Chief Complaint Section Contexts ............................................................ 218
Table 52: Complications Section Contexts ............................................................... 219
Table 53: DICOM Object Catalog Section - DCM 121181 Contexts ........................... 220
Table 54: Discharge Diet Section Contexts ............................................................... 222
Table 55: Encounters Section Contexts ................................................................... 222
Table 56: Family History Section Contexts ............................................................... 224
Table 57: Findings Section Contexts ........................................................................ 226
Table 58: Functional Status Section Contexts .......................................................... 227
Table 59: Functional and Cognitive Status Problem Observation Examples .............. 228
Table 60: Functional and Cognitive Status Result Observation Examples ................. 229

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Table 61: General Status Section Contexts .............................................................. 232
Table 62: History of Past Illness Section Contexts .................................................... 233
Table 63: History of Present Illness Section Contexts ............................................... 234
Table 64: Hospital Admission Diagnosis Section Contexts ........................................ 235
Table 65: Hospital Admission Medications Section Contexts ..................................... 236
Table 66: Hospital Consultations Section Contexts .................................................. 237
Table 67: Hospital Course Section Contexts ............................................................. 237
Table 68: Hospital Discharge Diagnosis Section Contexts ......................................... 238
Table 69: Hospital Discharge Instructions Section Contexts ..................................... 239
Table 70: Hospital Discharge Medications Section Contexts ..................................... 240
Table 71: Hospital Discharge Physical Section Contexts ........................................... 242
Table 72: Hospital Discharge Studies Summary Section Contexts ............................ 243
Table 73: Immunizations Section Contexts .............................................................. 244
Table 74: Interventions Section Contexts ................................................................. 247
Table 75: Interventions Section Contexts ................................................................. 248
Table 76: Medical Equipment Section Contexts ........................................................ 249
Table 77: Medical (General) History Section Contexts ............................................... 250
Table 78: Medications Administered Section Contexts .............................................. 251
Table 79: Medications Section Contexts ................................................................... 252
Table 80: Objective Section Contexts ....................................................................... 254
Table 81: Operative Note Fluids Section Contexts .................................................... 255
Table 82: Operative Note Surgical Procedure Section Contexts ................................. 256
Table 83: Payers Section Contexts ........................................................................... 257
Table 84: Physical Exam Section Contexts ............................................................... 259
Table 86: Plan of Care Section Contexts................................................................... 260
Table 87: Planned Procedure Section Contexts......................................................... 262
Table 88: Postoperative Diagnosis Section Contexts ................................................. 263
Table 89: Postprocedure Diagnosis Section Contexts ................................................ 264
Table 90: Preoperative Diagnosis Section Contexts ................................................... 265
Table 91: Problem Section Contexts ......................................................................... 266
Table 92: Procedure Description Section Contexts ................................................... 269
Table 93: Procedure Disposition Section Contexts .................................................... 270
Table 94: Procedure Estimated Blood Loss Section Contexts .................................... 270
Table 95: Procedure Findings Section Contexts ........................................................ 271
Table 96: Procedure Implants Section Contexts ....................................................... 272
Table 97: Procedure Indications Section Contexts .................................................... 273

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Table 98: Procedure Specimens Taken Section Contexts .......................................... 274
Table 99: Procedures Section Contexts .................................................................... 275
Table 100: Reason for Referral Section Contexts ...................................................... 278
Table 101: Reason for Visit Section Contexts ........................................................... 279
Table 102: Results Section Contexts ........................................................................ 280
Table 103: Review of Systems Section Contexts ....................................................... 282
Table 104: Social History Section Contexts .............................................................. 283
Table 105: Subjective Section Contexts ................................................................... 285
Table 106: Surgical Drains Section Contexts ........................................................... 286
Table 107: Vital Signs Section Contexts ................................................................... 287
Table 108: Admission Medication Contexts .............................................................. 289
Table 109: Admission Medication Constraints Overview ........................................... 290
Table 110: Advance Directive Observation Contexts ................................................. 291
Table 111: Advance Directive Observation Constraints Overview .............................. 292
Table 112: Advance Directive Type Code Value Set .................................................. 295
Table 113: Age Observation Contexts ...................................................................... 296
Table 114: Age Observation Constraints Overview ................................................... 297
Table 115: AgePQ_UCUM Value Set ......................................................................... 298
Table 116: Allergy - Intolerance Observation Contexts ............................................. 298
Table 117: Allergy - Intolerance Observation Constraints Overview .......................... 299
Table 118: Allergy/Adverse Event Type Value Set .................................................... 303
Table 119: Medication Brand Name Value Set (excerpt) ............................................ 303
Table 120: Medication Clinical Drug Value Set (excerpt) ........................................... 304
Table 121: Medication Drug Class Value Set (excerpt) .............................................. 304
Table 122: Ingredient Name Value Set (excerpt) ....................................................... 305
Table 123: Allergy Problem Act Contexts .................................................................. 306
Table 124: Allergy Problem Act Constraints Overview ............................................... 307
Table 125: ProblemAct statusCode Value Set ........................................................... 308
Table 126: Allergy Status Observation Contexts ....................................................... 309
Table 127: Allergy Status Observation Constraints Overview .................................... 309
Table 128: HITSP Problem Status Value Set ............................................................ 310
Table 129: Assessment Scale Observation Contexts ................................................. 310
Table 130: Assessment Scale Observation Constraints Overview .............................. 311
Table 131: Assessment Scale Supporting Observation Contexts ............................... 314
Table 132: Assessment Scale Supporting Observation Constraints Overview ............ 314
Table 133: Authorization Activity Contexts .............................................................. 315

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Table 134: Authorization Activity Constraints Overview ........................................... 316
Table 135: Boundary Observation Contexts ............................................................. 317
Table 136: Boundary Observation Constraints Overview .......................................... 317
Table 137: Caregiver Characteristics Contexts ......................................................... 318
Table 138: Caregiver Characteristics Constraints Overview ...................................... 319
Table 139: Code Observations Contexts ................................................................... 321
Table 140: Code Observations Constraints Overview ................................................ 322
Table 141: Cognitive Status Problem Observation Contexts ...................................... 323
Table 142: Cognitive Status Problem Observation Constraints Overview ................... 324
Table 143: Problem type value set ........................................................................... 326
Table 144: Problem Value Set (excerpt) .................................................................... 326
Table 145: Cognitive Status Result Observation Contexts......................................... 328
Table 146: Cognitive Status Result Observation Constraints Overview ...................... 328
Table 147: Cognitive Status Result Organizer Contexts ............................................ 331
Table 148: Cognitive Status Result Organizer Constraints Overview ......................... 332
Table 149: Comment Activity Contexts .................................................................... 333
Table 150: Comment Activity Constraints Overview ................................................. 334
Table 151: Coverage Activity Contexts ..................................................................... 336
Table 152: Coverage Activity Constraints Overview .................................................. 336
Table 153: Deceased Observation Contexts .............................................................. 337
Table 154: Deceased Observation Constraints Overview ........................................... 338
Table 155: Discharge Medication Contexts ............................................................... 339
Table 156: Discharge Medication Constraints Overview............................................ 340
Table 157: Drug Vehicle Contexts ............................................................................ 341
Table 158: Drug Vehicle Constraints Overview ......................................................... 342
Table 159: Encounter Activities Contexts ................................................................. 343
Table 160: Encounter Activities Constraints Overview .............................................. 343
Table 161: Encounter Type Value Set ...................................................................... 345
Table 162: Encounter Diagnosis Contexts................................................................ 346
Table 163: Encounter Diagnosis Constraints Overview............................................. 347
Table 164: Estimated Date of Delivery Contexts ....................................................... 348
Table 165: Estimated Date of Delivery Constraints Overview .................................... 348
Table 166: Family History Death Observation Contexts ............................................ 349
Table 167: Family History Death Observation Constraints Overview ......................... 350
Table 168: Family History Observation Contexts ...................................................... 351
Table 169: Family History Observation Constraints Overview ................................... 351

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Table 170: Family History Organizer Contexts ......................................................... 356
Table 171: Family History Organizer Constraints Overview ...................................... 356
Table 172: Family History Related Subject Value Set (excerpt) ................................. 359
Table 173: Functional Status Problem Observation Contexts ................................... 360
Table 174: Functional Status Problem Observation Constraints Overview ................ 360
Table 175: Functional Status Result Observation Contexts ...................................... 363
Table 176: Functional Status Result Observation Constraints Overview ................... 364
Table 177: Functional Status Result Organizer Contexts .......................................... 366
Table 178: Functional Status Result Organizer Constraints Overview ....................... 367
Table 179: Health Status Observation Contexts ....................................................... 368
Table 180: Health Status Observation Constraints Overview .................................... 368
Table 181: HealthStatus Value Set .......................................................................... 369
Table 182: Highest Pressure Ulcer Stage Contexts ................................................... 371
Table 183: Highest Pressure Ulcer Stage Constraints Overview ................................ 371
Table 184: Hospital Admission Diagnosis Contexts .................................................. 372
Table 185: Hospital Admission Diagnosis Constraints Overview ............................... 372
Table 186: Hospital Discharge Diagnosis Contexts ................................................... 373
Table 187: Hospital Discharge Diagnosis Constraints Overview ................................ 374
Table 188: Immunization Activity Contexts .............................................................. 375
Table 189: Immunization Activity Constraints Overview ........................................... 376
Table 190: Immunization Medication Information Contexts ...................................... 381
Table 191: Immunization Medication Information Constraints Overview ................... 382
Table 192: Vaccine Administered (Hepatitis B) Value Set (excerpt) ............................ 383
Table 193: Immunization Refusal Reason Contexts .................................................. 384
Table 194: Immunization Refusal Reason Constraints Overview ............................... 384
Table 195: No Immunization Reason Value Set ........................................................ 385
Table 196: Indication Contexts ................................................................................ 386
Table 197: Indication Constraints Overview ............................................................. 386
Table 198: Instructions Contexts ............................................................................. 388
Table 199: Instructions Constraints Overview .......................................................... 388
Table 200: Patient Education Value Set ................................................................... 389
Table 201: Medication Activity Contexts .................................................................. 390
Table 202: Medication Activity Constraints Overview ............................................... 390
Table 203: MoodCodeEvnInt Value Set .................................................................... 395
Table 204: Medication Route FDA Value Set (excerpt) .............................................. 396
Table 205: Body Site Value Set (excerpt) .................................................................. 396

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Table 206: Medication Product Form Value Set (excerpt) .......................................... 397
Table 207: Unit of Measure Value Set (excerpt) ........................................................ 397
Table 208: Medication Dispense Contexts ................................................................ 399
Table 209: Medication Dispense Constraints Overview ............................................. 400
Table 210: Medication Fill Status Value Set ............................................................. 401
Table 211: Medication Information Contexts ............................................................ 402
Table 212: Medication Information Constraints Overview ......................................... 403
Table 213: Medication Supply Order Contexts ......................................................... 404
Table 214: Medication Supply Order Constraints Overview ...................................... 405
Table 215: Non-Medicinal Supply Activity Contexts .................................................. 408
Table 216: Non-Medicinal Supply Activity Constraints Overview ............................... 409
Table 217: Number of Pressure Ulcers Observation Contexts ................................... 410
Table 218: Number of Pressure Ulcers Observation Constraints Overview................. 410
Table 219: Plan of Care Activity Act Contexts ........................................................... 412
Table 220: Plan of Care Activity Act Constraints Overview ........................................ 412
Table 221: Plan of Care moodCode (Act/Encounter/Procedure) ................................ 413
Table 222: Plan of Care Activity Encounter Contexts ................................................ 413
Table 223: Plan of Care Activity Encounter Constraints Overview ............................. 414
Table 224: Plan of Care Activity Observation Contexts ............................................. 414
Table 225: Plan of Care Activity Observation Constraints Overview .......................... 415
Table 226: Plan of Care moodCode (Observation) Value Set ...................................... 415
Table 227: Plan of Care Activity Procedure Contexts ................................................ 416
Table 228: Plan of Care Activity Procedure Constraints Overview ............................. 416
Table 229: Plan of Care Activity Substance Administration Contexts ........................ 417
Table 230: Plan of Care Activity Substance Administration Constraints Overview ..... 417
Table 231: Plan of Care moodCode (SubstanceAdministration/Supply) Value Set ..... 418
Table 232: Plan of Care Activity Supply Contexts ..................................................... 418
Table 233: Plan of Care Activity Supply Constraints Overview .................................. 419
Table 234: Policy Activity Contexts .......................................................................... 419
Table 235: Policy Activity Constraints Overview ....................................................... 420
Table 236: Health Insurance Type Value Set (excerpt) .............................................. 426
Table 237: Coverage Type Value Set ........................................................................ 427
Table 238: Financially Responsible Party Value Set (excerpt) .................................... 427
Table 239: Postprocedure Diagnosis Contexts .......................................................... 430
Table 240: Postprocedure Diagnosis Constraints Overview ....................................... 430
Table 241: Precondition for Substance Administration Contexts ............................... 431

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Table 242: Precondition for Substance Administration Constraints Overview ............ 431
Table 243: Pregnancy Observation Contexts ............................................................ 432
Table 244: Pregnancy Observation Constraints Overview ......................................... 432
Table 245: Preoperative Diagnosis Contexts ............................................................. 434
Table 246: Preoperative Diagnosis Constraints Overview .......................................... 435
Table 247: Pressure Ulcer Observation Contexts ...................................................... 436
Table 248: Pressure Ulcer Observation Constraints Overview ................................... 436
Table 249 Pressure Ulcer Stage Value Set ................................................................ 440
Table 250: Pressure Point Value Set ........................................................................ 441
Table 251: Target Site Qualifiers Value Set .............................................................. 442
Table 252: Problem Concern Act (Condition) Contexts .............................................. 444
Table 253: Problem Concern Act (Condition) Constraints Overview ........................... 444
Table 254: Problem Observation Contexts ............................................................... 446
Table 255: Problem Observation Constraints Overview............................................. 446
Table 256: Problem Status Contexts ........................................................................ 451
Table 257: Problem Status Constraints Overview ..................................................... 451
Table 258: Procedure Activity Act Contexts .............................................................. 452
Table 259: Procedure Activity Act Constraints Overview ........................................... 454
Table 260: Procedure Act Status Code Value Set ...................................................... 458
Table 261: Act Priority Value Set ............................................................................. 458
Table 262: Procedure Activity Observation Contexts ................................................ 460
Table 263: Procedure Activity Observation Constraints Overview.............................. 460
Table 264: Procedure Activity Procedure Contexts.................................................... 466
Table 265: Procedure Activity Procedure Constraints Overview ................................. 466
Table 266: Procedure Context Contexts ................................................................... 472
Table 267: Procedure Context Constraints Overview ................................................ 472
Table 268: Product Instance Contexts ..................................................................... 473
Table 269: Product Instance Constraints Overview .................................................. 474
Table 270: Purpose of Reference Observation Contexts ............................................ 475
Table 271: Purpose of Reference Observation Constraints Overview ......................... 475
Table 272: DICOM Purpose of Reference Value Set .................................................. 476
Table 273: Quantity Measurement Observation Contexts ......................................... 476
Table 274: Quantity Measurement Observation Constraints Overview ...................... 477
Table 275: DIR Quantity Measurement Type Value Set ............................................ 478
Table 276: DICOM Quantity Measurement Type Value Set ....................................... 479
Table 277: Reaction Observation Contexts ............................................................... 480

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Table 278: Reaction Observation Constraints Overview ............................................ 480
Table 279: Referenced Frames Observation Constraints Overview ............................ 483
Table 280: Result Observation Contexts .................................................................. 484
Table 281: Result Observation Constraints Overview ............................................... 485
Table 282: Result Status Value Set .......................................................................... 487
Table 283: Result Organizer Contexts ...................................................................... 488
Table 284: Result Organizer Constraints Overview ................................................... 489
Table 285: Series Act Contexts ................................................................................ 490
Table 286: Series Act Constraints Overview ............................................................. 491
Table 287: Service Delivery Location Contexts ......................................................... 493
Table 288: Service Delivery Location Constraints Overview ...................................... 493
Table 289: HealthcareServiceLocation Value Set (excerpt) ........................................ 494
Table 290: Severity Observation Contexts ................................................................ 495
Table 291: Severity Observation Constraints Overview ............................................. 495
Table 292: Problem Severity Value Set ..................................................................... 496
Table 293: Smoking Status Observation Contexts .................................................... 497
Table 294: Smoking Status Observation Constraints Overview ................................. 498
Table 295: Smoking Status Value Set ...................................................................... 499
Table 296: Social History Observation Contexts ....................................................... 500
Table 297: Social History Observation Constraints Overview .................................... 500
Table 298: Social History Type Set Definition Value Set ........................................... 501
Table 299: SOP Instance Observation Contexts ........................................................ 502
Table 300: SOP Instance Observation Constraints Overview ..................................... 502
Table 301: Study Act Contexts ................................................................................ 505
Table 302: Study Act Constraints Overview ............................................................. 506
Table 303: Text Observation Contexts...................................................................... 507
Table 304: Text Observation Constraints Overview................................................... 508
Table 305: Tobacco Use Observation Contexts ......................................................... 510
Table 306: Tobacco Use Constraints Overview ......................................................... 511
Table 307: Tobacco Use Value Set ........................................................................... 512
Table 308: Vital Sign Observation Contexts ............................................................. 512
Table 309: Vital Sign Observation Constraints Overview .......................................... 513
Table 310: Vital Sign Result Type Value Set ............................................................. 514
Table 311: Vital Signs Organizer Contexts ............................................................... 515
Table 312: Vital Signs Organizer Constraints Overview ............................................ 516
Table 313: Templates Added and Updated in May 2012 Ballot ................................. 522

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Table 314: H&P Cardinality Updates ....................................................................... 523
Table 315: Consultation Note Cardinality Updates ................................................... 523
Table 316: Discharge Summary Cardinality Updates ............................................... 524
Table 317: Surgical Operative Codes Mapping to Generic Procedure Codes............... 524
Table 318: Consolidated Conformance Verb Matrix .................................................. 525
Table 319: Section Template Change Tracking ......................................................... 527
Table 320: Entry Change Tracking Table ................................................................. 535
Table 321: Result Section Changes .......................................................................... 539
Table 322: Problems Section Changes ..................................................................... 540
Table 323: Vital Signs Section Changes ................................................................... 543
Table 324: Procedures Section Changes .................................................................. 545
Table 325: Medications Section Changes ................................................................. 548
Table 326: Template Ids Alphabetically by Template Type ........................................ 557
Table 327: Code Systems in This Guide ................................................................... 563
Table 328: Value Sets in This Guide ........................................................................ 565
Table 329: Single-Value Bindings in This Guide....................................................... 568
Table 330: Comparison of XDS-SD and Clinical Document Header .......................... 571

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2

INTRODUCTION

2.1

Audience
The audiences for this implementation guide are the architects and developers of
healthcare information technology (HIT) systems in the US Realm that exchange
patient clinical data. This includes those exchanges that comply to the Health
Information Technology for Economic and Clinical Health (HITECH) provisions of
the American Recovery And Reinvestment Act of 2009, the Final Rules for Stage
1 Meaningful Use, and the 45 CFR Part 170 – Health Information Technology:
Initial Set of Standards, Implementation Specifications, and Certification Criteria
for Electronic Health Record Technology; Final Rule.1
Business analysts and policy managers can also benefit from a basic
understanding of the use of Clinical Document Architecture (CDA) templates
across multiple implementation use cases.

2.2

Purpose
This guide contains a library of CDA templates, incorporating and harmonizing
previous efforts from Health Level Seven (HL7), Integrating the Healthcare
Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It
represents harmonization of the HL7 Health Story guides, HITSP C32, related
components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care
(CCD), and it includes all required CDA templates in Final Rules for Stage 1
Meaningful Use and 45 CFR Part 170 – Health Information Technology: Initial
Set of Standards, Implementation Specifications, and Certification Criteria for
Electronic Health Record Technology; Final Rule.
This guide is a single source for implementing the following CDA documents (see
the References section for complete source listings):
Continuity of Care Document (CCD) (Release 1.1)
Consultation Notes (Release 1.1)
Discharge Summary (Release 1.1)
Imaging Integration, and DICOM Diagnostic Imaging Reports (DIR) (US
Realm - Release 1)
History and Physical (H&P) (Release 1.1)
Operative Note (Release 1.1)
Progress Note (Release 1.1)
Procedure Note (US Realm – Release 1)
Unstructured Documents (Release 1.1)

Many aspects of this guide were designed to meet the anticipated clinical document exchange
requirements of Stage 2 Meaningful Use. At the time of this publication, Stage 2 Meaningful Use
has not been published.
1

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The release 1.1 documents supersede existing release 1 publications. Procedure
Note and DIR are designated as release 1 because this guide is the first US
Realm release of these standards. The existing, separate Procedure Note and DIR
universal-realm guides are still valid for outside the US.

2.3

Scope
This document is scoped by the content of the eight Health Story Guides, CCD,
and additional constraints from IHE and HITSP. New conformance rules were
not introduced unless an ambiguity or conflict existed among the standards.
All CDA templates required for Final Rules for Stage 1 Meaningful Use2 are
included in this guide. All CDA templates required for Health Story compliance
to the section level are included, as well, of course, as the Health Story reuse of
Stage 1 Meaningful Use templates.
This guide fully specifies a compliant CDA R2 document for each document
type.
Additional optional CDA elements, not included here, can be included and the
result will be compliant with the documents in this standard.

2.4

Approach
In the development of this specification, the Consolidation Project team reviewed
the eight existing HL7 Health Story guides, CCD, and the additional constraints
from IHE, HITSP and Stage 1 Meaningful Use.
The Consolidation Project team members completed the analysis by creating a
fully compliant CCD document, then layering in the additional HITSP, IHE and
Stage 1 Meaningful Use constraints. When a new constraint introduced an
issue, conflict or ambiguity, the item was flagged for review with the full
consolidation team. The full analysis covered the CDA Header, section-level and
entry-level requirements sufficient for Stage 1 Meaningful Use. The Project also
reviewed document and section-level requirements for the full set of document
types.
All major template changes are summarized in the Change Appendix
All involved in the Consolidation Project recognize the critical need for an
intrinsic tie between the human-readable conformance requirements, the
computable expression of those requirements, the production of validation test
suites and application interfaces to facilitate adoption. To that end, the analysis
performed by the volunteers and staff of the Consolidation Project was the
prelude to data entry into a set of model-based tools.
Conformance requirements and value set tables published here are output from
the Template Database (Tdb), an open-source application first developed for the
Centers for Disease Control and Prevention and in active use by the National

http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf
Many aspects of this guide were designed to meet the anticipated clinical document exchange
requirements of Stage 2 Meaningful Use, which had not been released when this guide was
published
2

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Healthcare Safety Network3. The Tdb is the source for generation of platformindependent validation rules as Schematron 4 (compiled XPath). The Tdb is
available as the Trifolia Workbench (Consolidation Project Edition) on the HL7
website5.
The consolidation of templates developed across these organizations and their
publication in catalog form driven from model-based tools is a strong step
toward satisfying the full range of requirements for clinical information use and
reuse through templated CDA.

2.5

Organization of This Guide
This guide includes a set of CDA Templates and prescribes their use for a set of
specific document types. The main chapters are:
Chapter 2. General Header Template. This chapter defines a template for the
header constraints that apply across all of the consolidated document types.
Chapter 3. Document-Level Templates. This chapter defines each of the nine
document types. It defines header constraints specific to each and the sectionlevel templates (required and optional) for each.
Chapter 4. Section-Level Templates. This chapter defines the section templates
referenced within the document types described here. Sections are atomic units,
and can be reused by future specifications.
Chapter 5. Entry-Level Templates. This chapter defines entry-level templates,
called clinical statements. Machine processable data are sent in the entry
templates. The entry templates are referenced by one or more section templates.
Entry-level templates are always contained in section-level templates, and
section-level templates are always contained in a document.
Appendices. The Appendices include non-normative content to support
implementers. It includes a Change Appendix summary of previous and updated
templates.

2.6

Use of Templates
Template identifiers (templateId) are assigned at the document, section, and
entry level. When valued in an instance, the template identifier signals the
imposition of a set of template-defined constraints. The value of this attribute
(e.g. @root="2.16.840.1.113883.10.20.22.4.8") provides a unique identifier
for the template in question.
If a template is a specialization of another template, its first constraint indicates
the more general template. The general template is not always required. In all
cases where a more specific template conforms to a more general template,

http://www.lantanagroup.com/resources/tools/
http://www.schematron.com/
5 http://www.lantanagroup.com/newsroom/press-releases/trifolia-workbench/
You must be logged in as a member of HL7.org to access this resource:
http://www.hl7.org/login/singlesignon.cfm?next=/documentcenter/private/standards/cda/Trifo
lia_HL7_Consolidation_20110712-dist.zip
3
4

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asserting the more specific template also implies conformance to the more
general template.

2.6.1 Originator Responsibilities: General Case
An originator can apply a templateId if there is a desire to assert conformance
with a particular template.
In the most general forms of CDA exchange, an originator need not apply a
templateId for every template that an object in an instance document conforms
to. The implementation guide (IG) shall assert whenever templateIds are
required for conformance.

2.6.2 Recipient Responsibilities: General Case
A recipient may reject an instance that does not contain a particular
templateId (e.g., a recipient looking to receive only Procedure Note documents
can reject an instance without the appropriate templateId).
A recipient may process objects in an instance document that do not contain a
templateId (e.g., a recipient can process entries that contain Observation acts
within a Problems section, even if the entries do not have templateIds).

2.7

Levels of Constraint
The CDA standard describes conformance requirements in terms of three
general levels corresponding to three different, incremental types of conformance
statements:
Level 1 requirements impose constraints upon the CDA Header. The body
of a Level 1 document may be XML or an alternate allowed format. If
XML, it must be CDA-conformant markup.
Level 2 requirements specify constraints at the section level of a CDA
XML document: most critically, the section code and the cardinality of
the sections themselves, whether optional or required.
Level 3 requirements specify constraints at the entry level within a
section. A specification is considered “Level 3” if it requires any entrylevel templates.
Note that these levels are rough indications of what a recipient can expect in
terms of machine-processable coding and content reuse. They do not reflect the
level or type of clinical content, and many additional levels of reusability could
be defined.
In this consolidated guide, Unstructured Documents, by definition, are Level 1.
Stage 1 Meaningful Use of CCD requires certain entries and is therefore a Level
3 requirement. The balance of the document types can be implemented at any
level.
In all cases, required clinical content must be present. For example, a CDA
Procedure Note carrying the templateId that asserts conformance with Level 1
may use a PDF (portable document format) or HTML (hypertext markup

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language) format for the body of the document that contains the required
clinical content. Conformance, in this case, to the clinical content requirements
could not be validated without human review.
The section libraries for each document type list the required and optional
sections.

2.8

Conformance Conventions Used in This Guide

2.8.1 Templates and Conformance Statements
Conformance statements within this implementation guide are presented as
constraints from a Template Database (Tdb). An algorithm converts constraints
recorded in a Templates Database to a printable presentation. Each constraint is
uniquely identified by an identifier at or near the end of the constraint (e.g.,
CONF:7345). These identifiers are persistent but not sequential.
Bracketed information following each template title indicates the template type
(section, observation, act, procedure, etc.), the templateId, and whether the
template is open or closed.
Each section and entry template in the guide includes a context table. The "Used
By" column indicates which documents or sections use this template, and the
"Contains Entries" column indicates any entries that the template uses. Each
entry template also includes a constraint overview table to summarize the
constraints following the table.
The following figure shows a typical template explanation presented in this
guide. The next sections describe specific aspects of conformance statements—
open vs. closed statements, conformance verbs, cardinality, vocabulary
conformance, containment relationships, and null flavors.

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Figure 1: Constraints format example

Severity Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.8(open)]
Table xxx: Severity Observation Contexts
Used By:

Contains Entries:

Reaction Observation
Allergy - Intolerance Observation

This clinical statement represents the severity of the reaction to an agent. A
person may manifest many symptoms …
Table yyy: Severity Observation Contexts
Name

XPath

Green
Severity
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.8']

severity
Coded

Verb

Data
Type

CONF#

Fixed Value

@classCode

1..1

SHALL

7345

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

7346

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

code

1..1

SHALL

text

0..1

SHOULD

reference
/@value

0..1

SHOULD

statusCode

1..1

SHALL

CS

7352

2.16.840.1.113883.5.14 (ActStatus)
= completed

value

1..1

SHALL

CD

7356

2.16.840.1.113883.3.88.12.3221.6.8
(Problem Severity)

0..*

SHOULD

CE

9117

0..1

SHOULD

CE

9118

@root

severity
FreeText

Card.

interpretation
Code
code

SET

7347
10525

2.16.840.1.113883.10.20.22.4.8

CE

7349

2.16.840.1.113883.5.4 (ActCode) =
SEV

ED

7350
7351

2.16.840.1.113883.1.11.78
(Observation Interpretation (HL7))

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7345).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7346).
3. SHALL contain exactly one [1..1] templateId (CONF:7347) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.8" (CONF:10525).
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4. SHALL contain exactly one [1..1] code with @xsi:type="CE"="SEV" Severity
Observation (CodeSystem: ActCode 2.16.840.1.113883.5.4)
(CONF:7349).
5. SHOULD contain zero or one [0..1] text (CONF:7350).
a. The text, if present, SHOULD contain zero or one [0..1]
reference/@value (CONF:7351).
i.

This reference/@value SHALL begin with a '#' and SHALL point
to its corresponding narrative (using the approach defined in
CDA Release 2, section 4.3.5.1) (CONF:7378).

6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7352).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHALL be selected from ValueSet Problem Severity
2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC (CONF:7356).
8. SHOULD contain zero or more [0..*] interpretationCode (CONF:9117).
a. The interpretationCode, if present, SHOULD contain zero or one [0..1]
code with @xsi:type="CE", where the @code SHOULD be selected from
ValueSet Observation Interpretation (HL7)
2.16.840.1.113883.1.11.78 DYNAMIC (CONF:9118).

2.8.2 Open and Closed Templates
In open templates, all of the features of the CDA R2 base specification are
allowed except as constrained by the templates. By contrast, a closed template
specifies everything that is allowed and nothing further may be included.
Estimated Date of Delivery (templateId 2.16.840.1.113883.10.20.15.3.1) is
an example of a closed template in this guide.
Open templates allow HL7 implementers to develop additional structured
content not constrained within this guide. HL7 encourages implementers to
bring their use cases forward as candidate requirements to be formalized in a
subsequent version of the standard to maximize the use of shared semantics.

2.8.3 Conformance Verbs (Keywords)
The keywords SHALL, SHOULD, MAY, NEED NOT, SHOULD NOT, and SHALL NOT in this
document are to be interpreted as described in the HL7 Version 3 Publishing
Facilitator's Guide (http://www.hl7.org/v3ballot/html/help/pfg/pfg.htm):
SHALL:

an absolute requirement

SHALL NOT:

an absolute prohibition against inclusion

SHOULD/SHOULD NOT:

best practice or recommendation. There may be
valid reasons to ignore an item, but the full implications must be
understood and carefully weighed before choosing a different course

MAY/NEED NOT:

truly optional; can be included or omitted as the author
decides with no implications

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The keyword "SHALL" allows the use of nullFlavor unless the requirement is on
an attribute or the use of nullFlavor is explicitly precluded.
The Consolidated Conformance Verb Matrix table represents a matrix of the
conformance verbs used across the standards reviewed for the consolidation
guide.
The subject of a conformance verb (keyword) in a top-level constraint is the
template itself; for example, the subject of CONF:5249 is the ClinicalDocument
element. In nested constraints, the subject is the element in the containing
constraint. Top-level constraints are those that begin with a number and are not
indented.

2.8.4 Cardinality
The cardinality indicator (0..1, 1..1, 1..*, etc.) specifies the allowable occurrences
within a document instance. The cardinality indicators are interpreted with the
following format “m…n” where m represents the least and n the most:
0..1 zero or one
1..1 exactly one
1..* at least one
0..* zero or more
1..n at least one and not more than n
When a constraint has subordinate clauses, the scope of the cardinality of the
parent constraint must be clear. In the next figure, the constraint says exactly
one participant is to be present. The subordinate constraint specifies some
additional characteristics of that participant.
Figure 2: Constraints format – only one allowed
1. SHALL contain exactly one [1..1] participant (CONF:2777).
a. This participant SHALL contain exactly one [1..1] @typeCode="LOC"
(CodeSystem: 2.16.840.1.113883.5.90 HL7ParticipationType)
(CONF:2230).

In the next figure, the constraint says only one participant “like this” is to be
present. Other participant elements are not precluded by this constraint.
Figure 3: Constraints format – only one like this allowed
1. SHALL contain exactly one [1..1] participant (CONF:2777) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" (CodeSystem:
2.16.840.1.113883.5.90 HL7ParticipationType) (CONF:2230).

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2.8.5 Optional and Required with Cardinality
The terms optional and required describe the lower bound of cardinality as
follows:
Optional means that the number of allowable occurrences of an element may be
0; the cardinality will be expressed as [0..1] or [0..*] or similar. In these
cases, the element may not be present in the instance.
Required means that the number of allowable occurrences of an element must
be at least 1; the cardinality will be expressed as [m..n] where m >=1 and n
>=1 for example [1..1] or [1..*].. In these cases, the element must be
present in the instance. If an element is required, but is not known (and would
otherwise be omitted if it were optional), it must be represented by a nullFlavor.

2.8.6 Vocabulary Conformance
The templates in this document use terms from several code systems. These
vocabularies are defined in various supporting specifications and may be
maintained by other bodies, as is the case for the LOINC® and SNOMED CT®
vocabularies.
Note that value-set identifiers (e.g., ValueSet 2.16.840.1.113883.1.11.78
Observation Interpretation (HL7) DYNAMIC) do not appear in CDA
submissions; they tie the conformance requirements of an implementation guide
to the appropriate code system for validation.
Value-set bindings adhere to HL7 Vocabulary Working Group best practices,
and include both a conformance verb (SHALL, SHOULD, MAY, etc.) and an
indication of DYNAMIC vs. STATIC binding. Value-set constraints can be STATIC,
meaning that they are bound to a specified version of a value set, or DYNAMIC,
meaning that they are bound to the most current version of the value set. A
simplified constraint, used when the binding is to a single code, includes the
meaning of the code, as follows.
Figure 4: Binding to a single code

contain exactly one [1..1] code (CONF:15407).
a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem

... SHALL

List

(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15408) .

The notation conveys the actual code (11450-4), the code’s displayName
(Problem List), the OID of the codeSystem from which the code is drawn
(2.16.840.1.113883.6.1), and the codeSystemName (LOINC).
HL7 Data Types Release 1 requires the codeSystem attribute unless the
underlying data type is “Coded Simple” or “CS”, in which case it is prohibited.
The displayName and the codeSystemName are optional, but recommended, in
all cases.

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The above example would be properly expressed as follows.
Figure 5: XML expression of a single-code binding




A full discussion of the representation of vocabulary is outside the scope of this
document; for more information, see the HL7 V3 Normative Edition 2010 6
sections on Abstract Data Types and XML Data Types R1.
There is a discrepancy in the implementation of translation code versus the
original code between HL7 Data Types R1 and the convention agreed upon for
this specification. The R1 data type requires the original code in the root. This
implementation guide specifies the standard code in the root, whether it is
original or a translation. This discrepancy is resolved in HL7 Data Types R2.
Figure 6: Translation code example




2.8.7 Containment Relationships
Containment constraints between a section and its entry are indirect in this
guide, meaning that where a section asserts containment of an entry, that entry
can either be a direct child or a further descendent of that section.
For example, in the following constraint:
1. SHALL contain at least one [1..*] entry (CONF:8647) such that it
a. SHALL contain exactly one [1..1] Advance Directive Observation
(templateId:2.16.840.1.113883.10.20.22.4.48) (CONF:8801).
the Advance Directive Observation can be a direct child of the section (i.e.,
section/entry/AdvanceDirectiveObservation) or a further descendent of
that section (i.e., section/entry/…/AdvanceDirectiveObservation). Either of
these are conformant.

HL7 Version 3 Interoperability Standards, Normative Edition 2010.
http://www.hl7.org/memonly/downloads/v3edition.cfm - V32010
6

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All other containment relationships are direct, for example:
1. SHALL contain exactly one [1..1]
templateId/@root="2.16.840.1.113883.10.20.22.2.21" (CONF:7928).
The templateId must be a direct child of the section (i.e., section/templateId).

2.8.8 Null Flavor
Information technology solutions store and manage data, but sometimes data
are not available: an item may be unknown, not relevant, or not computable or
measureable. In HL7, a flavor of null, or nullFlavor, describes the reason for
missing data.
For example, if a patient arrives at an Emergency Department unconscious and
with no identification, we would use a null flavor to represent the lack of
information. The patient’s birth date would be represented with a null flavor of
“NAV”, which is the code for “temporarily unavailable”. When the patient regains
consciousness or a relative arrives, we expect to know the patient’s birth date.
Figure 7: nullFlavor example




Use null flavors for unknown, required, or optional attributes:
NI

No information. This is the most general and default null flavor.

NA

Not applicable. Known to have no proper value (e.g., last
menstrual period for a male).

UNK

Unknown. A proper value is applicable, but is not known.

ASKU

Asked, but not known. Information was sought, but not found
(e.g., the patient was asked but did not know).

NAV

Temporarily unavailable. The information is not available, but
is expected to be available later.

NASK

Not asked. The patient was not asked.

MSK

There is information on this item available but it has not been
provided by the sender due to security, privacy, or other
reasons. There may be an alternate mechanism for gaining
access to this information.

This above list contains those null flavors that are commonly used in clinical
documents. For the full list and descriptions, see the nullFlavor vocabulary
domain in the CDA normative edition7.
Any SHALL conformance statement may use nullFlavor, unless the attribute is
required or the nullFlavor is explicitly disallowed. SHOULD and MAY
conformance statement may also use nullFlavor.

HL7 Clinical Document Architecture (CDA Release 2)
http://www.hl7.org/implement/standards/cda.cfm
7

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Figure 8: Attribute required

contain exactly one [1..1] code (CONF:15407).
a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem

1. SHALL

List

(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15408) .

or
2. SHALL contain exactly one [1..1] effectiveTime/@value (CONF:5256).

Figure 9: Allowed nullFlavors when element is required (with xml examples)
1. SHALL contain at least one [1..*] id
2. SHALL contain exactly one [1..1] code
3. SHALL contain exactly one [1..1] effectiveTime




New Grading system




Spiculated mass grade 5




Figure 10: nullFlavor explicitly disallowed
1. SHALL contain exactly one [1..1] effectiveTime (CONF:5256).
a. SHALL NOT contain [0..0] nullFlavor (CONF:52580).

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2.8.9 Unknown Information
If a sender wants to state that a piece of information is unknown, the following
principles apply:
1. If the sender doesn’t know an attribute of an act, that attribute can be
null.
Figure 11: Unknown medication example

patient was given a medication but I do not know what it
was











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2. If the sender doesn’t know if an act occurred, the nullFlavor is on the
act (detail could include specific allergy, drug, etc.).
Figure 12: Unknown medication use of anticoagulant drug example


I do not know whether or not patient received an anticoagulant
drug










3. If the sender wants to state ‘no known’, a negationInd can be used on
the corresponding act (substanceAdministration, Procedure, etc.)
Figure 13: No known medications example


No known medications










Previously CCD, IHE, and HITSP recommended using specific codes to assert no
known content, for example 160244002 No known allergies or 160245001 No
current problems or disability. Specific codes are still allowed; however,
use of these codes is not recommended.

2.8.10 Data Types
All data types used in a CDA document are described in the CDA R2 normative
edition8. All attributes of a data type are allowed unless explicitly prohibited by
this specification.

HL7 Clinical Document Architecture (CDA Release 2).
http://www.hl7.org/implement/standards/cda.cfm
8

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2.9

XML Conventions Used in This Guide

2.9.1 XPath Notation
Instead of the traditional dotted notation used by HL7 to represent Reference
Information Model (RIM) classes, this document uses XML Path Language
(XPath) notation9 in conformance statements and elsewhere to identify the
Extended Markup Language (XML) elements and attributes within the CDA
document instance to which various constraints are applied. The implicit
context of these expressions is the root of the document. This notation provides
a mechanism that will be familiar to developers for identifying parts of an XML
document.
XPath statements appear in this document in a monospace font.
XPath syntax selects nodes from an XML document using a path containing the
context of the node(s). The path is constructed from node names and attribute
names (prefixed by a ‘@’) and catenated with a ‘/’ symbol.
Figure 14: XML document example


...

...



In the above example, the code attribute of the code could be selected with the
XPath expression in the next figure.
Figure 15: XPath expression example
author/assignedAuthor/code/@code

2.9.2 XML Examples and Sample Documents
Extended Mark-up Language (XML) examples appear in figures in this document
in this monospace font. Portions of the XML content may be omitted from the
content for brevity, marked by an ellipsis (...) as shown in the example below.
Figure 16: ClinicalDocument example

...


Within the narrative, XML element (code, assignedAuthor, etc.) and attribute
(SNOMED CT, 17561000, etc.) names also appear in this monospace font.

9

http://www.w3.org/TR/xpath/

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This publication package includes complete sample documents as listed in the
Content of the Package table below. These documents conform to the Level 1,
Level 2, and Level 3 constraints of this guide (see the Levels of Constraint
section).

2.10 UML Diagrams
Some sections may include a Unified Modeling Language (UML) class diagram to
provide further clarification. For example, a class diagram might describe the
generalization-specialization hierarchy of Act classes (see the Results section
UML Diagram figure.) The UML diagrams were output from the Model-Driven
Health Tools (MDHT) developed under the auspices of the Veterans
Administration and IBM with assistance from the ONC Standards &
Interoperability Framework10.

2.11 Content of the Package
The following files comprise the package:
Table 1: Content of the Package

10

Filename

Description

Standards
Applicability

CDAR2_IG_IHE_CONSOL_R1_U1_2012MAY

Implementation Guide

Normative

Consults.sample.xml

Consultation Note

Informative

DIR.sample.xml

Diagnostic Imaging Report

Informative

CCD.sample.xml

Continuity of Care
Document/C32

Informative

DS.sample.xml

Discharge Summary Report

Informative

HandP.sample.xml

History and Physical Report

Informative

OpNote.sample.xml

Operative Note

Informative

Procedure_Note.sample.xml

Procedure Note

Informative

Progress_Note.sample.xml

Progress Note

Informative

UD.sample.xml

Unstructured Document

Informative

cda.xsl

CDA stylesheet

Informative

Discharge_Summary_cda.xsl

Adds discharge disposition
to cda.xsl header

Informative

Consolidated CCD template hierarchy

Hierarchy of CCD sections
and entries

Informative

CDA_Schema_Files (folder)

Updated schema to validate
extensions to CDA R2
introduced in this guide

Informative

http://www.openhealthtools.org/charter/Charter-ModelingToolsForHealthcare.pdf

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3

GENERAL HEADER TEMPLATE
This template describes constraints that apply to the header for all documents
within the scope of this implementation guide. Header constraints specific to
each document type are described in the appropriate document-specific section
below.

3.1

Document Type Codes
CDA R2 states that LOINC is the preferred vocabulary for document type codes,
which specify the type of document being exchanged (e.g., History and Physical).
Each document type in this guide recommends a single preferred
clinicalDocument/code, with further specification provided by author or
performer, setting, or specialty.

3.2

US Realm Header
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.22.1.1(open)]
1. SHALL contain exactly one [1..1] realmCode="US" (CONF:16791).
2. SHALL contain exactly one [1..1] typeId (CONF:5361).
a. This typeId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.1.3" (CONF:5250).
b. This typeId SHALL contain exactly one [1..1]
@extension="POCD_HD000040" (CONF:5251).
3. SHALL contain exactly one [1..1] templateId (CONF:5252) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10036).
4. SHALL contain exactly one [1..1] id (CONF:5363).
a. This id SHALL be a globally unique identifier for the document
(CONF:9991).
5. SHALL contain exactly one [1..1] code (CONF:5253).
a. This code SHALL specify the particular kind of document (e.g. History
and Physical, Discharge Summary, Progress Note) (CONF:9992).
6. SHALL contain exactly one [1..1] title (CONF:5254).
a. Can either be a locally defined name or the display name
corresponding to clinicalDocument/code (CONF:5255).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:5256).
a. 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:16865).
8. SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be
selected from ValueSet HL7 BasicConfidentialityKind
2.16.840.1.113883.1.11.16926 STATIC 2010-04-21 (CONF:5259).

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9. SHALL contain exactly one [1..1] languageCode, which SHALL be selected from
ValueSet Language 2.16.840.1.113883.1.11.11526 DYNAMIC
(CONF:5372).
10. MAY contain zero or one [0..1] setId (CONF:5261).
a. If setId is present versionNumber SHALL be present (CONF:6380). 11
11. MAY contain zero or one [0..1] versionNumber (CONF:5264).
a. If versionNumber is present setId SHALL be present (CONF:6387). 12
Table 2: Basic Confidentiality Kind Value Set
Value Set: HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC 2010-04-21
Code System(s): Confidentiality Code 2.16.840.1.113883.5.25
Code

Code System

Print Name

N

Confidentiality Code

Normal

R

Confidentiality Code

Restricted

V

Confidentiality Code

Very Restricted

Table 3: Language Value Set (excerpt)
Value Set: Language 2.16.840.1.113883.1.11.11526 DYNAMIC
Code System(s): Internet Society Language 2.16.840.1.113883.1.11.11526
Description:

A value set of codes defined by Internet RFC 4646 (replacing RFC 3066).
Please see ISO 639 language code set maintained by Library of Congress for
enumeration of language codes
http://www.ietf.org/rfc/rfc4646.txt

Code

Code System

Print Name

en

Internet Society Language

english

fr

Internet Society Language

french

ar

Internet Society Language

arabic

en-US

Internet Society Language

English, US

es-US

Internet Society Language

Spanish, US

…

From CDA Normative Web edition: 4.2.1.7 ClinicalDocument.setId - Represents an identifier
that is common across all document revisions and “Document Identification, Revisions, and
Addenda” under 4.2.3.1 ParentDocument
12 From CDA Normative Web edition: 4.2.1.8 ClinicalDocument.versionNumber An integer value
used to version successive replacement documents
11

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Figure 17: US Realm header example















Figure 18: effectiveTime with time zone example




3.2.1 RecordTarget
The recordTarget records the patient whose health information is described by
the clinical document; each recordTarget must contain at least one
patientRole element.
12. SHALL contain at least one [1..*] recordTarget (CONF:5266).
a. Such recordTargets SHALL contain exactly one [1..1] patientRole
(CONF:5267).
i.

This patientRole SHALL contain at least one [1..*] id
(CONF:5268).

ii. This patientRole SHALL contain at least one [1..*] addr
(CONF:5271).
1. 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:10412).

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iii. This patientRole SHALL contain at least one [1..*] telecom
(CONF:5280).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:5375).

3.2.1.1 Patient
iv. This patientRole SHALL contain exactly one [1..1] patient
(CONF:5283).
1. This patient SHALL contain exactly one [1..1] name
(CONF:5284).
a. 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:10411).
2. This patient SHALL contain exactly one [1..1]
administrativeGenderCode, which SHALL be selected
from ValueSet Administrative Gender (HL7 V3)
2.16.840.1.113883.1.11.1 DYNAMIC (CONF:6394).
3. This patient SHALL contain exactly one [1..1]
birthTime (CONF:5298).
a. SHALL be precise to year (CONF:5299).
b. SHOULD be precise to day (CONF:5300).
4. This patient SHOULD contain zero or one [0..1]
maritalStatusCode, which SHALL be selected from
ValueSet HL7 MaritalStatus
2.16.840.1.113883.1.11.12212 DYNAMIC
(CONF:5303).
5. This patient MAY contain zero or one [0..1]
religiousAffiliationCode, which SHALL be selected
from ValueSet HL7 Religious Affiliation
2.16.840.1.113883.1.11.19185 DYNAMIC
(CONF:5317).
6. This patient MAY contain zero or one [0..1] raceCode,
which SHALL be selected from ValueSet Race
2.16.840.1.113883.1.11.14914 DYNAMIC
(CONF:5322).
7. This patient MAY contain zero or more [0..*]
sdwg:raceCode, where the @code SHALL be selected
from ValueSet Race 2.16.840.1.113883.1.11.14914
DYNAMIC (CONF:7263).
8. This patient MAY contain zero or one [0..1]
ethnicGroupCode, which SHALL be selected from
ValueSet Ethnicity Value

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2.16.840.1.114222.4.11.837 DYNAMIC
(CONF:5323).

3.2.1.2 Guardian
9. This patient MAY contain zero or more [0..*] guardian
(CONF:5325).
a. The guardian, if present, SHOULD contain zero
or one [0..1] code, which SHALL be selected
from ValueSet Personal Relationship Role
Type 2.16.840.1.113883.1.11.19563
DYNAMIC (CONF:5326).
b. The guardian, if present, SHOULD contain zero
or more [0..*] addr (CONF:5359).
i.

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:10413).

c. The guardian, if present, MAY contain zero or
more [0..*] telecom (CONF:5382).
i.

The telecom, if present, SHOULD contain
exactly one [1..1] @use, which SHALL be
selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20
DYNAMIC (CONF:7993).

d. The guardian, if present, SHALL contain exactly
one [1..1] guardianPerson (CONF:5385).
i.

This guardianPerson SHALL contain at
least one [1..*] name (CONF:5386).

1.

The content of name SHALL be a
conformant US Realm Person Name
(PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10414).

3.2.1.3 Birthplace
10. This patient MAY contain zero or one [0..1] birthplace
(CONF:5395).
a. The birthplace, if present, SHALL contain
exactly one [1..1] place (CONF:5396).
i.

This place SHALL contain exactly one
[1..1] addr (CONF:5397).

1.

This addr SHOULD contain zero or
one [0..1] country, where the @code
SHALL be selected from ValueSet

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CountryValueSet
2.16.840.1.113883.3.88.12.80.63
DYNAMIC (CONF:5404).
2.

This addr MAY contain zero or
one [0..1] postalCode, where the @code
SHALL be selected from ValueSet
PostalCodeValueSet
2.16.840.1.113883.3.88.12.80.2
DYNAMIC (CONF:5403).

3.

If country is US, this addr SHALL
contain exactly one [1..1] state, which
SHALL be selected from ValueSet
2.16.840.1.113883.3.88.12.80.1
StateValueSet DYNAMIC (CONF:5402).

3.2.1.4 LanguageCommunication
11. This patient SHOULD contain zero or more [0..*]
languageCommunication (CONF:5406).
a. The languageCommunication, if present, SHALL
contain exactly one [1..1] languageCode, which
SHALL be selected from ValueSet Language
2.16.840.1.113883.1.11.11526 DYNAMIC
(CONF:5407).
b. The languageCommunication, if present, MAY
contain zero or one [0..1] modeCode, which
SHALL be selected from ValueSet HL7
LanguageAbilityMode
2.16.840.1.113883.1.11.12249 DYNAMIC
(CONF:5409).
c. The languageCommunication, if present,
SHOULD contain zero or one [0..1]
proficiencyLevelCode, which SHALL be
selected from ValueSet
LanguageAbilityProficiency
2.16.840.1.113883.1.11.12199 DYNAMIC
(CONF:9965).
d. The languageCommunication, if present, MAY
contain zero or one [0..1] preferenceInd
(CONF:5414).

3.2.1.5 ProviderOrganization
v. This patientRole MAY contain zero or one [0..1]
providerOrganization (CONF:5416).
1. The providerOrganization, if present, SHALL contain at
least one [1..*] id (CONF:5417).

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a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National
Provider Identifier (CONF:16820).
2. The providerOrganization, if present, SHALL contain at
least one [1..*] name (CONF:5419).
3. The providerOrganization, if present, SHALL contain at
least one [1..*] telecom (CONF:5420).
a. Such telecoms SHOULD contain exactly one
[1..1] @use, which SHALL be selected from
ValueSet Telecom Use (US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7994).
4. The providerOrganization, if present, SHALL contain at
least one [1..*] addr (CONF:5422).
a. 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:10415).

3.2.1.6 RecordTarget Value Sets
Table 4: Telecom Use (US Realm Header) Value Set
Value Set: Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC
Code System(s): AddressUse 2.16.840.1.113883.5.1119
Code

Code System

Print Name

HP

AddressUse

primary home

WP

AddressUse

work place

MC

AddressUse

mobile contact

HV

AddressUse

vacation home

Table 5: Administrative Gender (HL7) Value Set
Value Set: Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC
Code System(s): AdministrativeGender 2.16.840.1.113883.5.1
Code

Code System

Print Name

F

AdministrativeGender

Female

M

AdministrativeGender

Male

UN

AdministrativeGender

Undifferentiated

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Table 6: Marital Status Value Set
Value Set: HL7 Marital Status 2.16.840.1.113883.1.11.12212 DYNAMIC
Code System(s): MaritalStatus 2.16.840.1.113883.5.2
Code

Code System

Print Name

A

MaritalStatus

Annulled

D

MaritalStatus

Divorced

I

MaritalStatus

Interlocutory

L

MaritalStatus

Legally Separated

M

MaritalStatus

Married

P

MaritalStatus

Polygamous

S

MaritalStatus

Never Married

T

MaritalStatus

Domestic partner

W

MaritalStatus

Widowed

Table 7: Religious Affiliation Value Set (excerpt)
Value Set: HL7 Religious Affiliation 2.16.840.1.113883.1.11.19185 DYNAMIC
Code System(s): ReligiousAffiliation 2.16.840.1.113883.5.1076
Description:

A value set of codes that reflect spiritual faith affiliation
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008

Code

Code System

Print Name

1026

ReligiousAffiliation

Judaism

1020

ReligiousAffiliation

Hinduism

1041

ReligiousAffiliation

Roman Catholic Church

…

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Table 8: Race Value Set (excerpt)
Value Set: Race 2.16.840.1.113883.1.11.14914 DYNAMIC
Code System(s): Race and Ethnicity - CDC 2.16.840.1.113883.6.238
Description:

A Value Set of codes for Classifying data based upon race.
Race is always reported at the discretion of the person for whom this attribute
is reported, and reporting must be completed according to Federal guidelines
for race reporting. Any code descending from the Race concept (1000-9) in
that terminology may be used in the exchange
http://phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.
1.113883.6.238&code=1000-9

Code

Code System

Print Name

1002-5

Race and Ethnicity- CDC

American Indian or Alaska Native

2028-9

Race and Ethnicity- CDC

Asian

2054-5

Race and Ethnicity- CDC

Black or African American

2076-8

Race and Ethnicity- CDC

Native Hawaiian or Other Pacific
Islander

2106-3

Race and Ethnicity- CDC

White

...

Table 9: Ethnicity Value Set
Value Set: Ethnicity Value Set 2.16.840.1.114222.4.11.837 DYNAMIC
Code System(s): Race and Ethnicity - CDC 2.16.840.1.113883.6.238
Code

Code System

Print Name

2135-2

Race and Ethnicity Code Sets

Hispanic or Latino

2186-5

Race and Ethnicity Code Sets

Not Hispanic or Latino

Table 10: Personal Relationship Role Type Value Set (excerpt)
Value Set: Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC
Code System(s): RoleCode 2.16.840.1.113883.5.111
Description:

A Personal Relationship records the role of a person in relation to another
person. This value set is to be used when recording the relationships between
different people who are not necessarily related by family ties, but also
includes family relationships.
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008

Code

Code System

Print Name

HUSB

RoleCode

husband

WIFE

RoleCode

wife

FRND

RoleCode

friend

SISINLAW

RoleCode

sister-in-law

…

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Table 11: State Value Set (excerpt)
Value Set: StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC
Code System(s): FIPS 5-2 (State) 2.16.840.1.113883.6.92
Description:

Codes for the Identification of the States, the District of Columbia and the
Outlying Areas of the United States, and Associated Areas Publication # 5-2,
May, 1987
http://www.itl.nist.gov/fipspubs/fip5-2.htm

Code

Code System

Print Name

AL

FIPS 5-2 (State Alpha Codes)

Alabama

AK

FIPS 5-2 (State Alpha Codes)

Alaska

AZ

FIPS 5-2 (State Alpha Codes)

Arizona

AR

FIPS 5-2 (State Alpha Codes)

Arkansas

…

Table 12: Postal Code Value Set (excerpt)
Value Set: PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC
Code System(s): US Postal Codes 2.16.840.1.113883.6.231
Description:

A value set of codes postal (ZIP) Code of an address in the United States.
http://zip4.usps.com/zip4/welcome.jsp

Code

Code System

Print Name

19009

US Postal Codes

Bryn Athyn, PA

92869-1736

US Postal Codes

Orange, CA

32830-8413

US Postal Codes

Lake Buena Vista, FL

…

Table 13: Country Value Set (excerpt)
Value Set: CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC
Code System(s): ISO 3166-1 Country Codes: 1.0.3166.1
Description:

A value set of codes for the representation of names of countries, territories
and areas of geographical interest.
Note: This table provides the ISO 3166-1 code elements available in the alpha2 code of ISO's country code standard
http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm

Code

Code System

Print Name

AW

ISO 3166-1 Country Codes

Aruba

IL

ISO 3166-1 Country Codes

Israel

KZ

ISO 3166-1 Country Codes

Kazakhstan

US

ISO 3166-1 Country Codes

United States

…

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Table 14: Language Ability Value Set
Value Set: HL7 LanguageAbilityMode 2.16.840.1.113883.1.11.12249 DYNAMIC
Code System(s): LanguageAbilityMode 2.16.840.1.113883.5.60
Description:

A value representing the method of expression of the language.

Code

Code System

Print Name

ESGN

LanguageAbilityMode

Expressed signed

ESP

LanguageAbilityMode

Expressed spoken

EWR

LanguageAbilityMode

Expressed written

RSGN

LanguageAbilityMode

Received signed

RSP

LanguageAbilityMode

Received spoken

RWR

LanguageAbilityMode

Received written

Table 15: Language Ability Proficiency Value Set
Value Set: LanguageAbilityProficiency 2.16.840.1.113883.1.11.12199 DYNAMIC
Code System(s): LanguageAbilityProficiency 2.16.840.1.113883.5.61
Description:

A value representing the level of proficiency in a language.

Code

Code System

Print Name

E

LanguageAbilityProficiency

Excellent

F

LanguageAbilityProficiency

Fair

G

LanguageAbilityProficiency

Good

P

LanguageAbilityProficiency

Poor

3.2.1.7 RecordTarget Example
Figure 19: recordTarget example











Mr.
Adam
Frankie

Everyman










17 Daws Rd.
Blue Bell
MA
02368
US




Ralph
Relative






MA
02368
US




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Good Health Clinic


21 North Ave
Burlington
MA
02368
US





3.2.2 Author
The author element represents the creator of the clinical document. The author
may be a device, or a person.
13. SHALL contain at least one [1..*] author (CONF:5444).
a. Such authors SHALL contain exactly one [1..1] time (CONF:5445).
i.

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:16866).

b. Such authors SHALL contain exactly one [1..1] assignedAuthor
(CONF:5448).
i.

This assignedAuthor SHALL contain exactly one [1..1] id
(CONF:5449) such that it
1. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:16786).

ii. This assignedAuthor SHOULD contain zero or one [0..1] code
(CONF:16787).
1. The code, if present, SHOULD contain exactly one [1..1]
@code, which SHOULD be selected from ValueSet
Healthcare Provider Taxonomy (NUCC - HIPAA)
2.16.840.1.114222.4.11.1066 DYNAMIC
(CONF:16788).
iii. This assignedAuthor SHALL contain at least one [1..*] addr
(CONF:5452).

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1. The content SHALL be a conformant US Realm Address
(AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
(CONF:16871).
iv. This assignedAuthor SHALL contain at least one [1..*] telecom
(CONF:5428).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7995).
v. This assignedAuthor SHOULD contain zero or one [0..1]
assignedPerson (CONF:5430).
1. The assignedPerson, if present, SHALL contain at least
one [1..*] name (CONF:16789).
a. The content SHALL be a conformant US Realm
Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:16872).
vi. This assignedAuthor SHOULD contain zero or one [0..1]
assignedAuthoringDevice (CONF:16783).
1. The assignedAuthoringDevice, if present, SHALL
contain exactly one [1..1] manufacturerModelName
(CONF:16784).
2. The assignedAuthoringDevice, if present, SHALL
contain exactly one [1..1] softwareName
(CONF:16785).
vii. There SHALL be exactly one assignedAuthor/assignedPerson or
exactly one assignedAuthor/assignedAuthoringDevice
(CONF:16790).

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Figure 20: Person author example





21 North Ave.
Burlington
MA
02368
US




Henry
Seven





Figure 21: Device author example





21 North Ave.
Burlington
MA
02368
US



Good Health Medical
Device
Good Health Report Generator




3.2.3 DataEnterer
The dataEnterer element represents the person who transferred the content,
written or dictated by someone else, into the clinical document. The guiding rule
of thumb is that an author provides the content found within the header or
body of the document, subject to their own interpretation, and the dataEnterer
adds that information to the electronic system. In other words, a dataEnterer

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transfers information from one source to another (e.g., transcription from paper
form to electronic system).
14. MAY contain zero or one [0..1] dataEnterer (CONF:5441).
a. The dataEnterer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:5442).
i.

This assignedEntity SHALL contain at least one [1..*] id
(CONF:5443).
1. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:16821).

ii. This assignedEntity SHALL contain at least one [1..*] addr
(CONF:5460).
1. 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:10417).
iii. This assignedEntity SHALL contain at least one [1..*] telecom
(CONF:5466).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7996).
iv. This assignedEntity SHALL contain exactly one [1..1]
assignedPerson (CONF:5469).
1. This assignedPerson SHALL contain at least one [1..*]
name (CONF:5470).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10418).
v. This assignedEntity MAY contain zero or one [0..1] code which
SHOULD be selected from coding system NUCC Health Care
Provider Taxonomy 2.16.840.1.113883.6.101 (CONF:9944).

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Figure 22: dataEnterer example




21 North Ave.
Burlington
MA
02368
US




Henry
Seven





3.2.4 Informant
The informant element describes the source of the information in a medical
document.
Assigned health care providers may be a source of information when a document
is created. (e.g., a nurse's aide who provides information about a recent
significant health care event that occurred within an acute care facility.) In these
cases, the assignedEntity element is used.
When the informant is a personal relation, that informant is represented in the
relatedEntity element. The code element of the relatedEntity describes the
relationship between the informant and the patient. The relationship between
the informant and the patient needs to be described to help the receiver of
the clinical document understand the information in the document.
15. MAY contain zero or more [0..*] informant (CONF:8001).
a. SHALL contain exactly one [1..1] assignedEntity OR exactly one [1..1]
relatedEntity (CONF:8002).
i.

SHOULD

contain at least one [1..*] addr (CONF:8220).

1. 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:10419).
ii. SHALL contain exactly one [1..1] assignedPerson OR exactly
one [1..1] relatedPerson (CONF:8221).
1. SHALL contain at least one [1..*] name (CONF:8222).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10420).
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iii. Ii. This assignedEntity MAY contain zero or one [0..1] code
which SHOULD be selected from coding system NUCC Health
Care Provider Taxonomy 2.16.840.1.113883.6.101
(CONF:9947).
iv. SHOULD contain zero or more [0..*] id (CONF:9945).
1. If 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
(CONF:9946).
Figure 23: Informant with assignedEntity example




21 North Ave.
Burlington
MA
02368
US




Henry
Seven





3.2.5 Custodian
The custodian element 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. Every CDA document has exactly one custodian. The
custodian participation satisfies the CDA definition of Stewardship. Because
CDA is an exchange standard and may not represent the original form of the
authenticated document (e.g., CDA could include scanned copy of original), 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.
16. SHALL contain exactly one [1..1] custodian (CONF:5519).
a. This custodian SHALL contain exactly one [1..1] assignedCustodian
(CONF:5520).
i.

This assignedCustodian SHALL contain exactly one [1..1]
representedCustodianOrganization (CONF:5521).
1. This representedCustodianOrganization SHALL contain
at least one [1..*] id (CONF:5522).

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a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National
Provider Identifier (CONF:16822).
2. This representedCustodianOrganization SHALL contain
exactly one [1..1] name (CONF:5524).
3. This representedCustodianOrganization SHALL contain
exactly one [1..1] telecom (CONF:5525).
a. This telecom SHOULD contain exactly one [1..1]
@use, which SHALL be selected from ValueSet
Telecom Use (US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7998).
4. This representedCustodianOrganization SHALL contain
at least one [1..*] addr (CONF:5559).
a. 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:10421).
Figure 24: Custodian example




Good Health Clinic


17 Daws Rd.
Blue Bell
MA
02368
US





3.2.6 InformationRecipient
The informationRecipient element records the intended recipient of the
information at the time the document is created. For example, in cases where
the intended recipient of the document is the patient's health chart, set the
receivedOrganization to be the scoping organization for that chart.
17. MAY contain zero or more [0..*] informationRecipient (CONF:5565).
a. The informationRecipient, if present, SHALL contain exactly one [1..1]
intendedRecipient (CONF:5566).
i.

This intendedRecipient MAY contain zero or one [0..1]
informationRecipient (CONF:5567).

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1. The informationRecipient, if present, SHALL contain at
least one [1..*] name (CONF:5568).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10427).
ii. This intendedRecipient MAY contain zero or one [0..1]
receivedOrganization (CONF:5577).
1. The receivedOrganization, if present, SHALL contain
exactly one [1..1] name (CONF:5578).
Figure 25: informationRecipient example




Henry
Seven



Good Health Clinic




3.2.7 LegalAuthenticator
The legalAuthenticator identifies the single person legally responsible for the
document and must be present if the document has been legally authenticated.
(Note that per the following section, there may also be one or more document
authenticators.)
Based on local practice, clinical documents may be released before legal
authentication. This implies that 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. 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.
18. SHOULD contain zero or one [0..1] legalAuthenticator (CONF:5579).
a. The legalAuthenticator, if present, SHALL contain exactly one [1..1]
time (CONF:5580).

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i.

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:16873).

b. The legalAuthenticator, if present, SHALL contain exactly one [1..1]
signatureCode (CONF:5583).
i.

This signatureCode SHALL contain exactly one [1..1]
@code="S" (CodeSystem: Participationsignature
2.16.840.1.113883.5.89) (CONF:5584).

c. The legalAuthenticator, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:5585).
i.

This assignedEntity SHALL contain at least one [1..*] id
(CONF:5586).
1. Such ids MAY contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:16823).

ii.

This assignedEntity MAY contain zero or one [0..1] code,
which SHOULD be selected from ValueSet Healthcare
Provider Taxonomy (NUCC - HIPAA)
2.16.840.1.114222.4.11.1066 (CONF:17000).

iii. This assignedEntity SHALL contain at least one [1..*] addr
(CONF:5589).
1. 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:10429).
iv. This assignedEntity SHALL contain at least one [1..*] telecom
(CONF:5595).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7999).
v. This assignedEntity SHALL contain exactly one [1..1]
assignedPerson (CONF:5597).
1. This assignedPerson SHALL contain at least one [1..*]
name (CONF:5598).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10430).

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Figure 26: legalAuthenticator example






21 North Ave.
Burlington
MA
02368
US




Henry
Seven





3.2.8 Authenticator
The authenticator identifies a participant or participants who attested to the
accuracy of the information in the document.
19. MAY contain zero or more [0..*] authenticator (CONF:5607).
a. The authenticator, if present, SHALL contain exactly one [1..1] time
(CONF:5608).
i.

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:16874).

b. The authenticator, if present, SHALL contain exactly one [1..1]
signatureCode (CONF:5610).
i.

This signatureCode SHALL contain exactly one [1..1]
@code="S" (CodeSystem: Participationsignature
2.16.840.1.113883.5.89) (CONF:5611).

c. The authenticator, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:5612).
i.

This assignedEntity SHALL contain at least one [1..*] id
(CONF:5613).
1. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:16824).

ii. This assignedEntity MAY contain zero or one [0..1] code
(CONF:16825).
1. The code, if present, MAY contain zero or one [0..1]
@code, which SHOULD be selected from ValueSet
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Healthcare Provider Taxonomy (NUCC - HIPAA)
2.16.840.1.114222.4.11.1066 (CONF:16826).
iii. This assignedEntity SHALL contain at least one [1..*] addr
(CONF:5616).
1. 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:10425).
iv. This assignedEntity SHALL contain at least one [1..*] telecom
(CONF:5622).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:8000).
v. This assignedEntity SHALL contain exactly one [1..1]
assignedPerson (CONF:5624).
1. This assignedPerson SHALL contain at least one [1..*]
name (CONF:5625).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10424).
Figure 27: Authenticator example






21 North Ave.
Burlington
MA
02368
US




Henry
Seven





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3.2.9 Participant (Support)
The participant element identifies other supporting participants, including
parents, relatives, caregivers, insurance policyholders, guarantors, and other
participants 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-ofkin)
20. MAY contain zero or more [0..*] participant (CONF:10003).
a. The participant, if present, MAY contain zero or one [0..1] time
(CONF:10004).
b. Such participants, if present, SHALL have an associatedPerson or
scopingOrganization element under participant/associatedEntity
(CONF:10006).
c. Unless otherwise specified by the document specific header
constraints, when participant/@typeCode is IND,
associatedEntity/@classCode SHALL be selected from ValueSet
2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
(CONF:10007).
Table 16: IND Role classCode Value Set
Value Set: INDRoleclassCodes 2.16.840.1.113883.11.20.9.33 STATIC 2011-09-30
Code System(s):
Code

RoleClass 2.16.840.1.113883.5.110
Code System

Print Name

PRS

RoleClass

personal relationship

NOK

RoleClass

next of kin

CAREGIVER

RoleClass

caregiver

AGNT

RoleClass

agent

GUAR

RoleClass

guarantor

ECON

RoleClass

emergency contact

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Figure 28: Participant example for a supporting person








17 Daws Rd.
Blue Bell
MA
02368
US




Mrs.
Martha
Mum





3.2.10 InFulfillmentOf
The inFulfillmentOf element represents orders that are fulfilled by this
document.
21. MAY contain zero or more [0..*] inFulfillmentOf (CONF:9952).
a. The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order
(CONF:9953).
i.

This order SHALL contain at least one [1..*] id (CONF:9954).

3.2.11 DocumentationOf/serviceEvent
A serviceEvent represents the main act, such as a colonoscopy or a cardiac
stress study, being documented. In a continuity of care document, CCD, the
serviceEvent is a provision of healthcare over a period of time. In a provision of
healthcare serviceEvent, the care providers, PCP or other longitudinal
providers, are recorded within the serviceEvent. If the document is about a
single encounter, the providers associated can be recorded in the
componentOf/encompassingEncounter.
22. MAY contain zero or more [0..*] documentationOf (CONF:14835).
a. The documentationOf, if present, SHALL contain exactly one [1..1]
serviceEvent (CONF:14836).
i.

This serviceEvent SHALL contain exactly one [1..1]
effectiveTime (CONF:14837).

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1. This effectiveTime SHALL contain exactly one [1..1] low
(CONF:14838).
ii. This serviceEvent SHOULD contain zero or more [0..*]
performer (CONF:14839).
1. The performer, if present, SHALL contain exactly one
[1..1] @typeCode="PRF" Participation physical
performer (CodeSystem: HL7ParticipationType
2.16.840.1.113883.5.90) (CONF:14840).
a. The performer participant represents clinicians
who actually and principally carry out the
serviceEvent. In a transfer of care this
represents the healthcare providers involved in
the current or pertinent historical care of the
patient. Preferably, the patient’s key healthcare
care team members would be listed,
particularly their primary physician and any
active consulting physicians, therapists, and
counselors (CONF:16753).
2. The performer, if present, MAY contain zero or one
[0..1] functionCode (CONF:16818).
a. The functionCode, if present, SHOULD contain
zero or one [0..1] @codeSystem, which SHOULD
be selected from CodeSystem
participationFunction
(2.16.840.1.113883.5.88) (CONF:16819).
3. The performer, if present, SHALL contain exactly one
[1..1] assignedEntity (CONF:14841).
a. This assignedEntity SHALL contain at least one
[1..*] id (CONF:14846).
i.

Such ids SHOULD contain zero or one
[0..1]
@root="2.16.840.1.113883.4.6"
National Provider Identifier
(CONF:14847).

b. This assignedEntity SHOULD contain zero or one
[0..1] code (CONF:14842).
i.

The code, if present, SHALL contain
exactly one [1..1] @code, which SHOULD
be selected from CodeSystem
NUCCProviderTaxonomy
(2.16.840.1.113883.6.101)
(CONF:14843).

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Figure 29: DocumentationOf example
















Matthew
Care
MD







3.2.12 Authorization/consent
The header can record information about the patient’s consent.
The type of consent (e.g., a consent to perform the related serviceEvent) 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’.
23. MAY contain zero or more [0..*] authorization (CONF:16792) such that it
a. SHALL contain exactly one [1..1] consent (CONF:16793).
i.

This consent MAY contain zero or more [0..*] id (CONF:16794).

ii. This consent MAY contain zero or one [0..1] code
(CONF:16795).
1. The type of consent (e.g., a consent to perform the
related serviceEvent) is conveyed in consent/code
(CONF:16796).

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iii. This consent SHALL contain exactly one [1..1] statusCode
(CONF:16797).
1. This statusCode SHALL contain exactly one [1..1]
@code="completed" Completed (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6)
(CONF:16798).
Figure 30: Procedure note consent example








3.2.13 ComponentOf
The componentOf element contains the encompassing encounter for this
document. The encompassing encounter represents the setting of the clinical
encounter during which the document act(s) or ServiceEvent occurred.
In order to represent providers associated with a specific encounter, they are
recorded within the encompassingEncounter as participants.
In a CCD the encompassingEncounter may be used when documenting a
specific encounter and its participants. All relevant encounters in a CCD may be
listed in the encounters section.
24. MAY contain zero or one [0..1] componentOf (CONF:9955).
a. The componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:9956).
i.

This encompassingEncounter SHALL contain at least one [1..*]
id (CONF:9959).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:9958).

3.3 US Realm Address (AD.US.FIELDED)
[addr: 2.16.840.1.113883.10.20.22.5.2(open)]
Reusable "address" template, designed for use in US Realm CDA Header.
1. SHOULD contain exactly one [1..1] @use, which SHALL be selected from
ValueSet PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC
2005-05-01 (CONF:7290).
2. SHOULD contain zero or one [0..1] country, where the @code SHALL be
selected from ValueSet CountryValueSet
2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:7295).

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3. SHOULD contain zero or one [0..1] state (ValueSet: StateValueSet
2.16.840.1.113883.3.88.12.80.1 DYNAMIC) (CONF:7293).
a. State is required if the country is US. If country is not specified, its
assumed to be US. If country is something other than US, the state
MAY be present but MAY be bound to different vocabularies
(CONF:10024).
4. SHALL contain exactly one [1..1] city (CONF:7292).
5. SHOULD contain zero or one [0..1] postalCode (ValueSet:
PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC)
(CONF:7294).
a. PostalCode is required if the country is US. If country is not specified,
its assumed to be US. If country is something other than US, the
postalCode MAY be present but MAY be bound to different
vocabularies (CONF:10025).
6. SHALL contain at least one and not more than 4 streetAddressLine
(CONF:7291).
7. SHALL NOT have mixed content except for white space 13 (CONF:7296).
Table 17: PostalAddressUse Value Set
Value Set: PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01
Code System(s):
Code

3.4

AddressUse 2.16.840.1.113883.5.1119
Code System

Print Name

BAD

AddressUse

bad address

DIR

AddressUse

direct

H

AddressUse

home address

HP

AddressUse

primary home

HV

AddressUse

vacation home

PHYS

AddressUse

physical visit address

PST

AddressUse

postal address

PUB

AddressUse

public

TMP

AddressUse

temporary

WP

AddressUse

work place

US Realm Date and Time (DT.US.FIELDED)
[effectiveTime: 2.16.840.1.113883.10.20.22.5.3(open)]
The US Realm Clinical Document Date and Time datatype flavor records date
and time information. If no time zone offset is provided, you can make no
assumption about time, unless you have made a local exchange agreement.
This data type uses the same rules as US Realm Date and Time
(DTM.US.FIELDED), but is used with the effectiveTime element.

For information on mixed content see Extensible Markup Language (XML)
(http://www.w3.org/TR/2008/REC-xml-20081126/#sec-mixed-content).
13

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1. SHALL be precise to the day (CONF:10078).
2. SHOULD be precise to the minute (CONF:10079).
3. MAY be precise to the second (CONF:10080).
4. If more precise than day, SHOULD include time-zone offset (CONF:10081).

3.5

US Realm Date and Time (DTM.US.FIELDED)
[time: 2.16.840.1.113883.10.20.22.5.4(open)]
The US Realm Clinical Document Date and Time datatype flavor records date
and time information. If no time zone offset is provided, you can make no
assumption about time, unless you have made a local exchange agreement.
This data type uses the same rules as US Realm Date and Time
(DT.US.FIELDED), but is used with the time element.
1. SHALL be precise to the day (CONF:10127).
2. SHOULD be precise to the minute (CONF:10128).
3. MAY be precise to the second (CONF:10129).
4. If more precise than day, SHOULD include time-zone offset (CONF:10130).

3.6 US Realm Patient Name (PTN.US.FIELDED)
[PN: templateId 2.16.840.1.113883.10.20.22.5.1 (open)]
The US Realm Patient Name datatype flavor is a set of reusable constraints that
can be used for the patient or any other person. It requires a first (given) and
last (family) name. If a patient or person has only one name part (e.g., patient
with first name only) place the name part in the field required by the
organization. Use the appropriate nullFlavor, "Not Applicable" (NA), in the
other field.
For information on mixed content see the Extensible Markup Language
reference (http://www.w3c.org/TR/2008/REC-xml-20081126/).
1. MAY contain zero or one [0..1] @use, which SHALL be selected from ValueSet
EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01
(CONF:7154).
2. SHALL contain exactly one [1..1] family (CONF:7159).
a. This family MAY contain zero or one [0..1] @qualifier, which SHALL
be selected from ValueSet EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7160).
3. SHALL contain at least one [1..*] given (CONF:7157).
a. Such givens MAY contain zero or one [0..1] @qualifier, which SHALL
be selected from ValueSet EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7158).
b. The second occurrence of given (given[2]) if provided, SHALL include
middle name or middle initial (CONF:7163).
4. MAY contain zero or more [0..*] prefix (CONF:7155).
a. The prefix, if present, MAY contain zero or one [0..1] @qualifier,
which SHALL be selected from ValueSet
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EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7156).
5. MAY contain zero or one [0..1] suffix (CONF:7161).
a. The suffix, if present, MAY contain zero or one [0..1] @qualifier,
which SHALL be selected from ValueSet
EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7162).
6. SHALL NOT have mixed content except for white space (CONF:7278).
Table 18: EntityNameUse Value Set
Value Set: EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01
Code System(s):

EntityNameUse 2.16.840.1.113883.5.45

Code

Code System

Print Name

A

EntityNameUse

Artist/Stage

ABC

EntityNameUse

Alphabetic

ASGN

EntityNameUse

Assigned

C

EntityNameUse

License

I

EntityNameUse

Indigenous/Tribal

IDE

EntityNameUse

Ideographic

L

EntityNameUse

Legal

P

EntityNameUse

Pseudonym

PHON

EntityNameUse

Phonetic

R

EntityNameUse

Religious

SNDX

EntityNameUse

Soundex

SRCH

EntityNameUse

Search

SYL

EntityNameUse

Syllabic

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Table 19: EntityPersonNamePartQualifier Value Set
Value Set: EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC
2011-09-30
Code System(s):
Code

3.7

EntityNamePartQualifier 2.16.840.1.113883.5.43
Code System

Print Name

AC

EntityNamePartQualifier

academic

AD

EntityNamePartQualifier

adopted

BR

EntityNamePartQualifier

birth

CL

EntityNamePartQualifier

callme

IN

EntityNamePartQualifier

initial

NB

EntityNamePartQualifier

nobility

PR

EntityNamePartQualifier

professional

SP

EntityNamePartQualifier

spouse

TITLE

EntityNamePartQualifier

title

VV

EntityNamePartQualifier

voorvoegsel

US Realm Person Name (PN.US.FIELDED)
[name: 2.16.840.1.113883.10.20.22.5.1.1(open)]
The US Realm Clinical Document Person Name datatype flavor is a set of
reusable constraints that can be used for Persons.
1. SHALL contain exactly one [1..1] name (CONF:9368).
a. The content of name SHALL be either a conformant Patient Name
(PTN.US.FIELDED), or a string (CONF:9371).
b. The string SHALL NOT contain name parts (CONF:9372).

3.8

Rendering Header Information for Human Presentation
Metadata carried in the header may already be available for rendering from
electronic medical records (EMRs) or other sources external to the document;
therefore, there is no strict requirement to render directly from the document.
An example of this would be a doctor using an EMR that already contains the
patient’s name, date of birth, current address, and phone number. When a CDA
document is rendered within that EMR, those pieces of information may not
need to be displayed since they are already known and displayed within the
EMR’s user interface.
Good practice would recommend that the following be present whenever the
document is viewed:
Document title and document dates
Service and encounter types, and date ranges as appropriate
Names of all persons along with their roles, participations, participation
date ranges, identifiers, address, and telecommunications information

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Names of selected organizations along with their roles, participations,
participation date ranges, identifiers, address, and telecommunications
information
Date of birth for recordTarget(s)
In Operative and Procedure Notes, the following information is typically
displayed in the electronic health record (EHR) and/or rendered directly in the
document:
The performers of the surgery or procedure, including any assistants
The surgery or procedure performed (serviceEvent)
The date of the surgery or procedure

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4

DOCUMENT-LEVEL TEMPLATES
Document-level templates describe the purpose and rules for constructing a
conforming CDA document. Document templates include constraints on the
CDA header and refer to section-level templates. The Document Types and
Required/Optional Sections table lists the sections used by each document type.
Each document-level template contains the following information:
Scope and intended use of the document type
Description and explanatory narrative.
Template metadata (e.g., templateId, etc.)
Header constraints: this includes a reference to the US Realm Clinical
Document Header template and additional constraints specific to each
document type
Required and optional section-level templates

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Table 20: Document Types and Required/Optional Sections with Structured Body
Required Sections

Optional Sections

CCD (Summarization of Episode
Note)
34133-9 (required)14
2.16.840.1.113883.10.20.22.1.2

Allergies
Medications
Problem List
Procedures15 (List of Surgeries)
(History of Procedures)
Results

Advance Directives
Encounters
Family History
Functional Status
Immunizations
Medical Equipment
Payers
Plan of Care
Social History
Vital Signs

Consultation Note
11488-4
2.16.840.1.113883.10.20.22.1.4

Assessment and
Plan/Assessment/Plan of
Care*

Allergies

Document Type
Preferred LOINC
templateId

Chief Complaint **

History of Present Illness

Chief Complaint and Reason
for Visit **

Physical Exam

Family History

Reason for Referral/Reason for
Visit16 **

General Status
History of Past Illness (Past
Medical History)
Immunizations
Medications
Problem List
Procedures (List of Surgeries)
(History of Procedures)
Results
Review of Systems
Social History
Vital Signs

14
15
16

CCD is the only document with a fixed clinicalDocument/code
Required only for inpatient settings
Either Reason for Referral or Reason for Visit must be present.

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Document Type

Required Sections

Optional Sections

DICOM Object Catalog

Addendum

Findings (Radiology Study
Observation)

Clinical Presentation

Preferred LOINC
templateId
Diagnostic Imaging Report
18748-4
2.16.840.1.113883.10.20.22.1.5

Complications
Conclusions
Current Imaging Procedure
Descriptions
Document Summary
Key Images
Medical (General) History
Prior Imaging Procedure
Descriptions
Radiology - Impression
Radiology Comparison Study Observation
Radiology Reason For Study
Radiology Study Recommendation
Requested Imaging Studies
Information

Discharge Summary (Discharge
Summarization Note)
18842-5
2.16.840.1.113883.10.20.22.1.8

Allergies

Chief Complaint **

Hospital Course
Hospital Discharge Diagnosis

Chief Complaint and Reason
for Visit **

Hospital Discharge Medications

Discharge Diet

Plan of Care

Family History
Functional Status
History of Past Illness (Past
Medical History)
History of Present Illness
Hospital Admissions Diagnosis
Hospital Consultations
Hospital Discharge
Instructions
Hospital Discharge Physical
Hospital Discharge Studies
Summary
Immunizations
Problem List
Procedures (List of Surgeries)
(History of Procedures)
Reason for Visit **
Review of Systems
Social History
Vital Signs

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Document Type

Required Sections

Optional Sections

Allergies

History of Present Illness

Assessment and
Plan/Assessment/Plan of
Care*

Immunizations

Chief Complaint **

Procedures (List of Surgeries)
(History of Procedures)

Preferred LOINC
templateId
History & Physical Note
34117-2
2.16.840.1.113883.10.20.22.1.3

Chief Complaint and Reason
for Visit **

Instructions
Problem List

Family History
General Status
History of Past Illness (Past
Medical History)
Medications
Physical Exam
Reason for Visit **
Results
Review of Systems
Social History
Vital Signs
Operative Note (Surgical
Operation Note)
11504-8
2.16.840.1.113883.10.20.22.1.7

Anesthesia
Complications
Postoperative Diagnosis
Preoperative Diagnosis
Procedure Estimated Blood
Loss
Procedure Findings
Procedure Specimens Taken
Procedure Description

Procedure Implants
Operative Note Fluids
Operative Note Surgical
Procedure
Plan of Care
Planned Procedure
Procedure Disposition
Procedure Indications
Surgical Drains

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Required Sections

Optional Sections

Procedure Note
28570-0
2.16.840.1.113883.10.20.22.1.6

Assessment and
Plan/Assessment/Plan of
Care*
Complications
Postprocedure Diagnosis
Procedure Description
Procedure Indications

Allergies
Anesthesia
Chief Complaint **
Chief Complaint and Reason
for Visit **
Family History
History of Past Illness
History of Present Illness
Medical (General) History
Medications
Medications Administered
Physical Exam
Planned Procedure
Procedure Disposition
Procedure Estimated Blood
Loss
Procedure Findings
Procedure Implants
Procedure Specimens Taken
Procedures (List of Surgeries)
(History of Procedures)
Reason for Visit **
Review of Systems
Social History

Progress Note (Subsequent
Evaluation Note)
11506-3
2.16.840.1.113883.10.20.22.1.9

Assessment and
Plan/Assessment/Plan of
Care*

Allergies
Chief Complaint
Instructions
Interventions
Medications
Objective
Physical Exam
Problem List
Results
Review of Systems
Subjective
Vital Signs

Unstructured Document
Non-preferred
2.16.840.1.113883.10.20.21.1.1
0

N/A

N/A

Document Type
Preferred LOINC
templateId

* Wherever referenced, intent is that either “Assessment and Plan” is present or both
“Assessment” and “Plan of Care”. Only these combinations should be used.
** Wherever referenced, intent is that either Chief Complaint/Reason for Visit Section is
present or Chief Complaint Section and/or Reason for Visit unique Sections should be
present.

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4.1

Continuity of Care Document (CCD)/HITSP C32
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.2(open)]
This section—Continuity of Care Document (CCD) Release 1.1—describes CDA
constraints in accordance with Stage 1 Meaningful Use. The CCD requirements
in this guide supersede CCD Release 1; in the near future, this guide could
supersede HITSP C3217.
The CCD is a core data set of the most relevant administrative, demographic,
and clinical information facts about a patient's healthcare, covering one or more
healthcare encounters. It provides a means for one healthcare practitioner,
system, or setting to aggregate all of the pertinent data about a patient and
forward it to another practitioner, system, or setting to support the continuity of
care. The primary use case for the CCD is to provide a snapshot in time
containing the pertinent clinical, demographic, and administrative data for a
specific patient18. More specific use cases, such as a Discharge Summary or
Progress Note, are available as alternative documents in this guide.

4.1.1 Header Constraints Specific to CCD
The Continuity of Care Document must conform to the US Realm Header. The
following sections include additional header constraints for conformant CCD.
1. SHALL contain exactly one [1..1] templateId (CONF:9441) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10037).

4.1.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of CCD as well as the templateId for the
US Realm Clinical Document Header template.
2. SHALL contain exactly one [1..1] templateId (CONF:8450) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.2" (CONF:10038).
Figure 31: CCD ClinicalDocument/templateId example





HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component;
(HITSP/C32); Versions 2.1, 2.2, 2.3, 2.5; December 13, 2007 - July 8, 2009
18 CCD was initially scoped to reflect the ASTM E2369-05 Standard Specification for Continuity of
Care Record (CCR). The requirements specified here, comply with Stage 1 Meaningful Use.
17

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4.1.1.2 ClinicalDocument/code
In accordance with the CDA specification, the ClinicalDocument/code element
must be present and specifies the type of the clinical document. CCD requires
the document type code 34133-9 "Summarization of Episode Note".
3. SHALL contain exactly one [1..1] code (CONF:17180).
a. This code SHALL contain exactly one [1..1] @code="34133-9"
Summarization of Episode Note (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:17181).
Figure 32: CCD code example


4.1.1.3 DocumentationOf/serviceEvent
The main activity being described by a CCD is the provision of healthcare over a
period of time. This is shown by setting the value of
ClinicalDocument/documentationOf/serviceEvent/@classCode to “PCPR”
(care provision) and indicating the duration over which care was provided in
ClinicalDocument/documentationOf/serviceEvent/effectiveTime.
Additional data from outside this duration may also be included if it is relevant
to care provided during that time range (e.g., reviewed during the stated time
range).
NOTE: Implementations originating a CCD should take care to discover what the
episode of care being summarized is. For example, when a patient fills out a
form providing relevant health history, the episode of care being documented
might be from birth to the present.
4. SHALL contain exactly one [1..1] documentationOf (CONF:8452).
a. This documentationOf SHALL contain exactly one [1..1] serviceEvent
(CONF:8480).
i. This serviceEvent SHALL contain exactly one [1..1]
@classCode="PCPR" Care Provision (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8453).
ii. This serviceEvent SHALL contain exactly one [1..1]
effectiveTime (CONF:8481).
1. This effectiveTime SHALL contain exactly one [1..1] low
(CONF:8454).
2. This effectiveTime SHALL contain exactly one [1..1]
high (CONF:8455).
iii. This serviceEvent SHOULD contain zero or more [0..*]
performer (CONF:8482).
1. serviceEvent/performer represents the healthcare
providers involved in the current or pertinent historical
care of the patient. Preferably, the patient’s key
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healthcare providers would be listed, particularly their
primary physician and any active consulting
physicians, therapists, and counselors (CONF:10026).
2. Such performers SHALL contain exactly one [1..1]
@typeCode="PRF" Participation physical performer
(CodeSystem: HL7ParticipationType
2.16.840.1.113883.5.90) (CONF:8458).
3. Such performers MAY contain zero or more [0..1]
assignedEntity (CONF:8459).
a. This assignedEntity SHALL contain at least one
[1..*] id (CONF:8460).
i.

include zero or one [0..1] id
where id/@root
="2.16.840.1.113883.4.6" National
Provider Identifier (CONF:10027).
SHOULD

b. This assignedEntity MAY contain zero or one
[0..1] code (CONF:8461).
i. The code MAY be the NUCC Health Care
Provider Taxonomy (CodeSystem:
2.16.840.1.113883.6.101). (See
http://www.nucc.org) (CONF:8462).

4.1.1.4 Author
5. CCD SHALL contain at least one [1..*] author (CONF:9442)
a. SHALL contain exactly one [1..1] assignedAuthor (CONF:9443)
i.

contain exactly one [1..1] assignedPerson or exactly one
[1..1] representedOrganization. (CONF:8456).
SHALL

ii. If assignedAuthor has an associated representedOrganization
with no assignedPerson or assignedAuthoringDevice, then the
value for
"ClinicalDocument/author/assignedAuthor/id/@NullFlavor"
SHALL be "NA" "Not applicable" 2.16.840.1.113883.5.1008
NullFlavor STATIC. (CONF:8457).

4.1.2 CCD Body Constraints
The Continuity of Care Document supports both narrative sections and sections
requiring coded clinical statements. The required and optional sections are listed
in the Document Types and Required/Optional Sections table. The table below
the constraints shows all templates including entries within each section.
1. The component/structuredBody SHALL conform to the section constraints
below (CONF:9536).
a. SHALL contain exactly one [1..1] Allergies Section(entries
required) (templateId:2.16.840.1.113883.10.20.22.2.6.1)
(CONF:9445).

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b. SHALL contain exactly one [1..1] Medications Section (entries
required) (templateId:2.16.840.1.113883.10.20.22.2.1.1)
(CONF:9447).
c. SHALL contain exactly one [1..1] Problem Section (entries
required) (templateId:2.16.840.1.113883.10.20.22.2.5.1)
(CONF:9449).
d. SHOULD contain exactly one [1..1] Procedures Section (entries
required) (templateId:2.16.840.1.113883.10.20.22.2.7.1)
(CONF:9451).
e. SHALL contain exactly one [1..1] Results Section (entries
required) (templateId:2.16.840.1.113883.10.20.22.2.3.1)
(CONF:9453).
f.

contain zero or one [0..1] Advance Directives Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.21) (CONF:9455).
MAY

g. MAY contain zero or one [0..1] Encounters Section (entries
optional) (templateId:2.16.840.1.113883.10.20.22.2.22)
(CONF:9457).
h. MAY contain zero or one [0..1] Family History Section
(templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:9459).
i.

MAY

contain zero or one [0..1] Functional Status Section
(templateId:2.16.840.1.113883.10.20.22.2.14) (CONF:9461).

j.

MAY

contain zero or one [0..1] Immunizations Section (entries
optional) (templateId:2.16.840.1.113883.10.20.22.2.2)
(CONF:9463).

k. MAY contain zero or one [0..1] Medical Equipment Section
(templateId:2.16.840.1.113883.10.20.22.2.23) (CONF:9466).
l.

contain zero or one [0..1] Payers Section
(templateId:2.16.840.1.113883.10.20.22.2.18) (CONF:9468).
MAY

m. MAY contain zero or one [0..1] Plan of Care Section
(templateId:2.16.840.1.113883.10.20.22.2.10) (CONF:9470).
n. MAY contain zero or one [0..1] Social History Section
(templateId:2.16.840.1.113883.10.20.22.2.17) (CONF:9472).
o. MAY contain zero or one [0..1] Vital Signs Section (entries
optional) (templateId:2.16.840.1.113883.10.20.22.2.4)
(CONF:9474).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 87
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

The following table shows relationships among the templates in the body of a
CCD.
Table 21: Template Containment for a CCD
Template Title

Template
Type

templateId

Continuity of Care Document (CCD)

document

2.16.840.1.113883.10.20.22.1.2

section

2.16.840.1.113883.10.20.22.2.21

entry

2.16.840.1.113883.10.20.22.4.48

section

2.16.840.1.113883.10.20.22.2.6.1

entry

2.16.840.1.113883.10.20.22.4.30

entry

2.16.840.1.113883.10.20.22.4.7

Allergy Status Observation

entry

2.16.840.1.113883.10.20.22.4.28

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Advance Directives Section (entries
optional)
Advance Directive Observation
Allergies Section (entries required)
Allergy Problem Act
Allergy Observation

Page 88
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Template Title

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.22

entry

2.16.840.1.113883.10.20.22.4.49

entry

2.16.840.1.113883.10.20.22.4.80

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

Medication Dispense

Severity Observation
Severity Observation
Encounters Section (entries optional)
Encounter Activities
Encounter Diagnosis
Problem Observation

entry

2.16.840.1.113883.10.20.22.4.6

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

section

2.16.840.1.113883.10.20.22.2.15

entry

2.16.840.1.113883.10.20.22.4.45

entry

2.16.840.1.113883.10.20.22.4.46

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Family History Death Observation

entry

2.16.840.1.113883.10.20.22.4.47

Family History Section
Family History Organizer
Family History Observation

Functional Status Section

section

2.16.840.1.113883.10.20.22.2.14

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Cognitive Status Problem Observation

entry

2.16.840.1.113883.10.20.22.4.73

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 89
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

Template Title

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.74

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.75

entry

2.16.840.1.113883.10.20.22.4.74

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.68

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.67

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.66

entry

2.16.840.1.113883.10.20.22.4.67

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

section

2.16.840.1.113883.10.20.22.2.2

entry

2.16.840.1.113883.10.20.22.4.52

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Immunization Refusal Reason

entry

2.16.840.1.113883.10.20.22.4.53

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Non-Medicinal Supply Activity
Product Instance
Cognitive Status Result Observation

Product Instance
Cognitive Status Result Organizer
Cognitive Status Result Observation

Product Instance
Functional Status Problem Observation

Product Instance
Functional Status Result Observation

Product Instance
Functional Status Result Organizer
Functional Status Result Observation

Product Instance
Non-Medicinal Supply Activity
Product Instance
Immunizations Section (entries optional)
Immunization Activity

Page 90
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Template Title

Template
Type

templateId

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Medication Supply Order

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 91
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

Template Title

Template
Type

templateId

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.23

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

section

2.16.840.1.113883.10.20.22.2.1.1

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Severity Observation
Medical Equipment Section
Non-Medicinal Supply Activity
Product Instance
Medications Section (entries required)
Medication Activity

Page 92
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Template Title

Template
Type

templateId

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.18

Coverage Activity

entry

2.16.840.1.113883.10.20.22.4.60

Policy Activity

entry

2.16.840.1.113883.10.20.22.4.61

section

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

entry

2.16.840.1.113883.10.20.22.4.43

section

2.16.840.1.113883.10.20.22.2.5.1

entry

2.16.840.1.113883.10.20.22.4.3

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

section

2.16.840.1.113883.10.20.22.2.7.1

entry

2.16.840.1.113883.10.20.22.4.12

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Procedure Activity Procedure

Severity Observation
Payers Section

Plan of Care Section

Problem Section (entries required)
Problem Concern Act (Condition)
Problem Observation

Procedures Section (entries required)
Procedure Activity Act

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 93
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

Template Title

Template
Type

templateId

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

Severity Observation
Service Delivery Location
Procedure Activity Observation

entry

2.16.840.1.113883.10.20.22.4.13

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

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Template Title

Template
Type

templateId

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

Procedure Activity Procedure

Severity Observation

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.8

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

section

2.16.840.1.113883.10.20.22.2.3.1

entry

2.16.840.1.113883.10.20.22.4.1

Severity Observation

Results Section (entries required)
Result Organizer

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Template Title

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.2

section

2.16.840.1.113883.10.20.22.2.17

entry

2.16.840.1.113883.10.20.15.3.8

Estimated Date of Delivery

entry

2.16.840.1.113883.10.20.15.3.1

Smoking Status Observation

entry

2.16.840.1.113883.10.22.4.78

Social History Observation

entry

2.16.840.1.113883.10.20.22.4.38

section

2.16.840.1.113883.10.20.22.2.4

entry

2.16.840.1.113883.10.20.22.4.26

entry

2.16.840.1.113883.10.20.22.4.27

Result Observation
Social History Section
Pregnancy Observation

Vital Signs Section (entries optional)
Vital Signs Organizer
Vital Sign Observation

4.2

Consultation Note
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.4(open)]
For the purpose of this Implementation Guide, a consultation visit is defined by
the evaluation and management guidelines for a consultation established by the
Centers for Medicare and Medicaid Services (CMS). According to those
guidelines, a Consultation Note must be generated as a result of a physician or
nonphysician practitioner's (NPP) request for an opinion or advice from another
physician or NPP. Consultations must involve face-to-face time with the patient
or fall under guidelines for telemedicine visits.
A Consultation Note must be provided to the referring physician or NPP and
must include the reason for the referral, history of present illness, physical
examination, and decision-making component (Assessment and Plan).
An NPP is defined as any licensed medical professional as recognized by the
state in which the professional practices, including, but not limited to, physician
assistants, nurse practitioners, clinical nurse specialists, social workers,
registered dietitians, physical therapists, and speech therapists.
Reports on visits requested by a patient, family member, or other third party are
not covered by this specification. Second opinions, sometimes called
"confirmatory consultations," also are not covered here. Any question on use of
the Consultation Note defined here should be resolved by reference to CMS or
American Medical Association (AMA) guidelines.

4.2.1 Consultation Note Header Constraints
The Consultation Note must conform to the US Realm Clinical Document
Header. The following sections include additional header constraints for
conformant Consultation Notes.
1. SHALL contain exactly one [1..1] templateId (CONF:9477) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10039)

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4.2.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of a Consultation Note as well as the
templateId for the US Realm Clinical Document Header template.
2. SHALL contain exactly one [1..1] templateId (CONF:8375) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.4" (CONF:10040).
Figure 33: Consultation note ClinicalDocument/templateId example




4.2.1.2 ClinicalDocument/code
The Consultation Note limits document type codes to those codes listed in the
Consultation Note LOINC Document Codes table (invalid codes are listed in a
separate table). Implementation may use translation elements to specify a local
code that is equivalent to a document type (see the Consultation Note
translation of local code figure).
The Consultation Note recommends use of a single document type code, 114884 "Consultation Note", with further specification provided by author or
performer, setting, or specialty. The specialized codes in the Consultation Note
LOINC Document Codes table are pre-coordinated with the practice setting or
the training or professional level of the author. Use of these codes is not
recommended, as this duplicates information that may be present in the header.
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, a Cardiology Consultation Note would
not be authored by an Obstetrician.
3. SHALL contain exactly one [1..1] code (CONF:17176).
a. This code SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet ConsultDocumentType
2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:17177).

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Table 22: Consultation Note LOINC Document Codes
Value Set: ConsultDocumentType 2.16.840.1.113883.11.20.9.31 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC Code

Type of Service
(“Component”)

Setting
(“System”)

Specialty/ Training/
Professional Level
(“Method”)

Root Level Document Type Code
11488-4

Consultation Note

{Provider}

Specialized by Setting
34100-8

Consultation Note

Critical care unit

{Provider}

34104-0

Consultation Note

Hospital

{Provider}

51845-6

Consultation Note

Outpatient

{Provider}

51853-0

Consultation Note

Inpatient

{Provider}

51846-4

Consultation Note

Emergency
Dept.

{Provider}

Specialized by Setting and Specialty
34101-6

Consultation Note

Outpatient

General medicine

34749-2

Consultation Note

Outpatient

Anesthesia

34102-4

Consultation Note

Hospital

Psychiatry

Specialized by Specialty19

19

34099-2

Consultation Note

Cardiology

34756-7

Consultation Note

Dentistry

34758-3

Consultation Note

Dermatology

34760-9

Consultation Note

Diabetology

34879-7

Consultation Note

Endocrinology

34761-7

Consultation Note

Gastroenterology

34764-1

Consultation Note

General medicine

34771-6

Consultation Note

General surgery

34776-5

Consultation Note

Gerontology

34777-3

Consultation Note

Gynecology

34779-9

Consultation Note

Hematology+Oncology

34781-5

Consultation Note

Infectious disease

34783-1

Consultation Note

Kinesiotherapy

34785-6

Consultation Note

Mental health

34795-5

Consultation Note

Nephrology

34797-1

Consultation Note

Neurology

34798-9

Consultation Note

Neurosurgery

34800-3

Consultation Note

Nutrition+Dietetics

34803-7

Consultation Note

Occupational health

34855-7

Consultation Note

Occupational therapy

34805-2

Consultation Note

Oncology

Use of these codes is not recommended, as it duplicates information that may be present in the header

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Value Set: ConsultDocumentType 2.16.840.1.113883.11.20.9.31 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC Code

Type of Service
(“Component”)

Setting
(“System”)

Specialty/ Training/
Professional Level
(“Method”)

34807-8

Consultation Note

Ophthalmology

34810-2

Consultation Note

Optometry

34812-8

Consultation Note

Oromaxillofacial surgery

34814-4

Consultation Note

Orthopedics

34816-9

Consultation Note

Otorhinolaryngology

34820-1

Consultation Note

Pharmacy

34822-7

Consultation Note

Physical medicine and
rehabilitation

34824-3

Consultation Note

Physical therapy

34826-8

Consultation Note

Plastic surgery

34828-4

Consultation Note

Podiatry

34788-0

Consultation Note

Psychiatry

34791-4

Consultation Note

Psychology

34103-2

Consultation Note

Pulmonary

34831-8

Consultation Note

Radiation oncology

34833-4

Consultation Note

Recreational therapy

34835-9

Consultation Note

Rehabilitation

34837-5

Consultation Note

Respiratory therapy

34839-1

Consultation Note

Rheumatology

34841-7

Consultation Note

Social work

34845-8

Consultation Note

Speech
therapy+Audiology

34847-4

Consultation Note

Surgery

34849-0

Consultation Note

Thoracic surgery

34851-6

Consultation Note

Urology

34853-2

Consultation Note

Vascular surgery

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Table 23: Invalid Codes for Consultation Note20
LOINC Code

Type of Service
(“Component”)

Setting
(“System”)

Specialty/ Training/
Professional Level
(“Method”)

18841-7

Hospital consultations

8647-0

Hospital consultations

33720-4

Blood bank consult

24611-6

Confirmatory consultation
note

47040-1

Confirmatory consultation
note

47041-9

Confirmatory consultation
note

28569-2

Subsequent evaluation note

Consulting physician

18763-3

Initial evaluation note

Consulting physician

(scale = nom)
Outpatient

{Provider}
{Provider}

Inpatient

{Provider}

Figure 34: Consultation note ClinicalDocument/code example


Figure 35: Consultation note translation of local code example




20

The Invalid Codes for Consultation Note are from the original Consultation Note DSTU.

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Figure 36: Consultation note uncoordinated document type codes example

...


...



...

...


...


...







4.2.1.3 InFulfillmentOf
The inFulfillmentOf element describes the prior orders that are fulfilled (in
whole or part) by the service events described in the Consultation Note. For
example, the prior order might be for the consultation being reported in the
Note.
4. SHALL contain at least one [1..*] inFulfillmentOf (CONF:8382).
a. This inFulfillmentOf SHOULD contain exactly one
[1..1] order (CONF:8385).
i.

This order SHALL contain at least one [1..*] id (CONF:9102).

Figure 37: Consultation note inFulfillmentOf example






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4.2.1.4 ComponentOf
A Consultation Note is always associated with an encounter; the componentOf
element must be present and the encounter must be identified.
CDA R2 requires encompasingEncounter and the id element of the
encompassingEncounter is required to be present and represents the identifier
for the encounter.
The encounterParticipant elements may be present. If present, they represent
only those participants in the encounter, not necessarily the entire episode of
care (see related information under Participant above).
The responsibleParty element may be present. If present, it represents only
the party responsible for the encounter, not necessarily the entire episode of
care.
5. SHALL contain exactly one [1..1] componentOf (CONF:8386).
a. This componentOf SHALL contain exactly one [1..1]
encompassingEncounter (CONF:8387).
i.

This encompassingEncounter SHALL contain exactly one [1..1]
id (CONF:8388).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:8389).
1. This effectiveTime SHALL contain exactly one [1..1] US
Realm Date and Time (DT.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.3)
(CONF:10132).
iii. This encompassingEncounter MAY contain zero or one [0..1]
responsibleParty (CONF:8391).
1. The responsibleParty element records only the party
responsible for the encounter, not necessarily the
entire episode of care. (CONF:8393).
2. The responsibleParty element, if present, SHALL
contain an assignedEntity element which SHALL
contain an assignedPerson element, a
representedOrganization element, or both.
(CONF:8394).
iv. This encompassingEncounter MAY contain zero or more [0..*]
encounterParticipant (CONF:8392).
1. The encounterParticipant element, if present, records
only participants in the encounter, not necessarily in
the entire episode of care. (CONF:8395).
2. An encounterParticipant element, if present, SHALL
contain an assignedEntity element which SHALL
contain an assignedPerson element, a
representedOrganization element, or both.
(CONF:8396).

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Figure 38: Consultation note componentOf example





...



4.2.2 Consultation Note Body Constraints
The Consultation Note supports both narrative sections and sections requiring
coded clinical statements. The required and optional sections are listed in the
Document Types and Required/Optional Sections table. The table below the
constraints shows all templates including entries within each section.
1. SHALL contain exactly one [1..1] component (CONF:8397).
a. A Consultation Note can have either a structuredBody or a
nonXMLBody. (CONF:8398).
i.

A Consultation 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
2.16.840.1.113883.10.20.22.1.4), coded entries are optional.
(CONF:8399).

b. If structuredBody, the component/structuredBody SHALL conform to
the section constraints below. (CONF:9503).
i.

include an Assessment and Plan Section, or an
Assessment Section and a Plan Section. (CONF:9501).
SHALL

ii. SHALL NOT include an Assessment/Plan Section when an
Assessment Section and a Plan of Care Section are present.
(CONF:10028)
iii. MAY contain zero or one [0..1] Assessment Section
(templateId:2.16.840.1.113883.10.20.22.2.8)
(CONF:9487).
iv. MAY contain zero or one [0..1] Plan of Care Section
(templateId:2.16.840.1.113883.10.20.22.2.10)
(CONF:9489).
v. MAY contain zero or one [0..1] Assessment and Plan
Section (templateId:2.16.840.1.113883.10.20.22.2.9)
(CONF:9491).

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vi. SHALL contain exactly one [1..1] History of Present
Illness Section (templateId:
1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:9493).
vii. SHOULD contain exactly one [1..1] Physical Exam Section
(templateId:2.16.840.1.113883.10.20.2.10)
(CONF:9495).
viii. SHALL include a Reason for Referral or Reason for Visit section
(CONF:9504).
ix. MAY contain zero or one [0..1] Reason for Referral
Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.1)
(CONF:9498).
x. MAY contain zero or one [0..1] Reason for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.12)
(CONF:9500).
xi. MAY contain zero or one [0..1] Allergies Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.6)
(CONF:9507).
xii. SHALL NOT include a combined Chief Complaint and Reason
for Visit Section with either a Chief Complaint Section or a
Reason for Visit Section. (CONF:10029).
xiii. MAY contain zero or one [0..1] Chief Complaint Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
(CONF:9509).
xiv. MAY contain zero or one [0..1] Chief Complaint and Reason
for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.13)
(CONF:9511).
xv. MAY contain zero or one [0..1] Family History Section
(templateId:2.16.840.1.113883.10.20.22.2.15)
(CONF:9513).
xvi. MAY contain zero or one [0..1] General Status Section
(templateId:2.16.840.1.113883.10.20.2.5)
(CONF:9515).
xvii. MAY contain zero or one [0..1] History of Past Illness
Section
(templateId:2.16.840.1.113883.10.20.22.2.20)
(CONF:9517).
xviii. MAY contain zero or one [0..1] Immunizations Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.2)
(CONF:9519).
xix. MAY contain zero or one [0..1] Medications Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.1)
(CONF:9521).

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xx. MAY contain zero or one [0..1] Problem Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.5)
(CONF:9523).
xxi. MAY contain zero or one [0..1] Procedures Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.7)
(CONF:9525).
xxii. MAY contain zero or one [0..1] Results Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.3)
(CONF:9527).
xxiii. MAY contain zero or one [0..1] Review of Systems
Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18)
(CONF:9529).
xxiv. MAY contain zero or one [0..1] Social History Section
(templateId:2.16.840.1.113883.10.20.22.2.17)
(CONF:9531).
xxv. MAY contain zero or one [0..1] Vital Signs Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.4)
(CONF:9533).
The following table shows relationships among the templates in the body of a
Consultation Note.
Table 24: Template Containment for a Consultation Note
Template Title

Template
Type

templateId

Consultation Note

document

2.16.840.1.113883.10.20.22.1.4

section

2.16.840.1.113883.10.20.22.2.6

entry

2.16.840.1.113883.10.20.22.4.30

entry

2.16.840.1.113883.10.20.22.4.7

Allergy Status Observation

entry

2.16.840.1.113883.10.20.22.4.28

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

entry

2.16.840.1.113883.10.20.22.4.54

Allergies Section (entries optional)
Allergy Problem Act
Allergy - Intolerance Observation

Immunization Medication
Information

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Type

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Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.9

entry

2.16.840.1.113883.10.20.22.4.39

section

2.16.840.1.113883.10.20.22.2.8

Severity Observation
Severity Observation
Assessment and Plan Section
Plan of Care Activity Act
Assessment Section

Page 106
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July 2012

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Chief Complaint and Reason for Visit
Section

section

2.16.840.1.113883.10.20.22.2.13

Chief Complaint Section

section

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

Family History Section

section

2.16.840.1.113883.10.20.22.2.15

entry

2.16.840.1.113883.10.20.22.4.45

entry

2.16.840.1.113883.10.20.22.4.46

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Family History Death Observation

entry

2.16.840.1.113883.10.20.22.4.47

General Status Section

section

2.16.840.1.113883.10.20.2.5

History of Past Illness Section

section

2.16.840.1.113883.10.20.22.2.20

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

History of Present Illness Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.4

Immunizations Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.2

entry

2.16.840.1.113883.10.20.22.4.52

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Immunization Refusal Reason

entry

2.16.840.1.113883.10.20.22.4.53

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

Family History Organizer
Family History Observation

Problem Observation

Immunization Activity

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Medication Supply Order

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Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

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Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.1

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Severity Observation
Medications Section (entries optional)
Medication Activity

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.8

Physical Exam Section

Severity Observation

section

2.16.840.1.113883.10.20.2.10

Plan of Care Section

section

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

entry

2.16.840.1.113883.10.20.22.4.43

section

2.16.840.1.113883.10.20.22.2.5

Problem Section (entries optional)

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entry

2.16.840.1.113883.10.20.22.4.3

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

section

2.16.840.1.113883.10.20.22.2.7

entry

2.16.840.1.113883.10.20.22.4.12

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

Problem Concern Act (Condition)
Problem Observation

Procedures Section (entries optional)
Procedure Activity Act

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.13

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Procedure Activity Procedure

Severity Observation
Service Delivery Location
Procedure Activity Observation

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2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Medication Activity

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.8

Service Delivery Location

Severity Observation

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

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Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.8

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Reason for Referral Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.1

Reason for Visit Section

section

2.16.840.1.113883.10.20.22.2.12

Results Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.3

entry

2.16.840.1.113883.10.20.22.4.1

Severity Observation

Result Organizer

entry

2.16.840.1.113883.10.20.22.4.2

Review of Systems Section

Result Observation

section

1.3.6.1.4.1.19376.1.5.3.1.3.18

Social History Section

section

2.16.840.1.113883.10.20.22.2.17

entry

2.16.840.1.113883.10.20.15.3.8

Estimated Date of Delivery

entry

2.16.840.1.113883.10.20.15.3.1

Smoking Status Observation

entry

2.16.840.1.113883.10.22.4.78

Social History Observation

entry

2.16.840.1.113883.10.20.22.4.38

section

2.16.840.1.113883.10.20.22.2.4

entry

2.16.840.1.113883.10.20.22.4.26

entry

2.16.840.1.113883.10.20.22.4.27

Pregnancy Observation

Vital Signs Section (entries optional)
Vital Signs Organizer
Vital Sign Observation

4.3

Diagnostic Imaging Report
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.5(open)]
A Diagnostic Imaging Report (DIR) is a document that contains a consulting
specialist’s interpretation of image data. It conveys the interpretation to the
referring (ordering) physician and becomes part of the patient’s medical record.
It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

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4.3.1 DIR Header Constraints
The DIR must conform to the US Realm Clinical Document Header. The
following sections include additional header constraints for conformant DIR
Notes.
1. SHALL contain exactly one [1..1] templateId (CONF:9405) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10041).

4.3.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of a DIR as well as the templateId for the
U.S. Realm CDA Header Constraints template.
2. SHALL contain exactly one [1..1] templateId (CONF:8404) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.5" (CONF:10042).
Figure 39: DIR ClinicalDocument/templateId example





4.3.1.2 ClinicalDocument/id
3. The ClinicalDocument/id/@root attribute SHALL be a syntactically correct
OID, and SHALL NOT be a UUID. (CONF:8405).
a. OIDs SHALL be represented in dotted decimal notation, where each
decimal number is either 0 or starts with a nonzero digit. More
formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+
(CONF:8406).
b. OIDs SHALL be no more than 64 characters in length. (CONF:8407).

4.3.1.3 ClinicalDocument/code
Given that DIR documents may be transformed from established collections of
imaging reports already stored with their own type codes, there is no static set of
Document Type codes. The set of LOINC codes listed in the DIR LOINC
Document Type Codes table may be extended by additions to LOINC and
supplemented by local codes as translations.
The DIR document recommends use of a single document type code, 18748-4
"Diagnostic Imaging Report", with further specification provided by author
or performer, setting, or specialty. Some of these codes in the DIR LOINC
Document Type Codes table are pre-coordinated with either the imaging
modality, body part examined, or specific imaging method such as the view. Use

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of these codes is not recommended, as this duplicates information potentially
present with the header. 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. This table is drawn
from LOINC Version 2.36, June 30, 2011, and consists of codes whose scale is
DOC and that refer to reports for diagnostic imaging procedures.
4. SHALL contain exactly one [1..1] code (CONF:14833).
a. This code SHOULD contain zero or one [0..1] @code, which SHOULD be
selected from ValueSet DIRDocumentTypeCode
2.16.840.1.113883.11.20.9.32 DYNAMIC (CONF:14834).
Table 25: DIR LOINC Document Type Codes
Value Set: DIRDocumentTypeCodes 2.16.840.1.113883.11.20.9.32 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC
Code

DIR
‘Modality’

Common
DIR
Display
Name

Type of
Service
‘Component’

Setting
‘System’

Specialty/
Training/
Professional Level
‘Method_Type’

Diagnositic
Imaging
Report

Study Report

Diagnostic Imaging

Preferred Code
18748-4

Any

Additional Codes
18747-6

Computed
Tomography

CT Report

Study

CT

18755-9

Magnetic
Resonance
Imaging

MRI Report

Study report

MRI

18760-9

Ultrasound

Ultrasound
Report

Study

US

18757-5

Nuclear
Medicine

Nuclear
Medicine
Report

Study report

RadNuc

18758-3

Positron
Emission
Tomography

PET Scan
Report

Study

Pet scan

18745-0

Cardiac
Radiography
/Fluoroscopy

Cardiac
Catheteriza
tion Report

Study report

Heart

Cardiac
catheterization

11522-0

Cardiac
Ultrasound

Echocardio
graphy
Report

Study report

Heart

Cardiac echo

18746-8

Colonoscopy

Colonoscopy
Report

Study report

Lower GI
tract

Colonoscopy

18751-8

Endoscopy

Endoscopy
Report

Study report

Upper GI
tract

Endoscopy

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Value Set: DIRDocumentTypeCodes 2.16.840.1.113883.11.20.9.32 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC
Code

DIR
‘Modality’

Common
DIR
Display
Name

Type of
Service
‘Component’

Setting
‘System’

Specialty/
Training/
Professional Level
‘Method_Type’

11525-3

Ultrasound

Obstetrical
Ultrasound
Report

Study report

Pelvis+Fe
tus

OB US

Figure 40: DIR ClinicalDocument/code example


Figure 41: DIR use of the translation element to include local codes for document
type







Amanda
Assigned
MD





4.3.1.6 InFulfillmentOf
An inFulfillmentOf element represents the Placer Order that is either a group
of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders &
Observations domain) or a single order item (modeled as ObservationRequest
in the same RMIM). This optionality reflects two major approaches to the
grouping of procedures as implemented in the installed base of imaging
information systems. These approaches differ in their handling of grouped
procedures and how they are mapped to identifiers in the Digital Imaging and
Communications in Medicine (DICOM) image and structured reporting data.
The example of a CT examination covering chest, abdomen, and pelvis will be
used in the discussion below.
In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis
CT each represent a Requested Procedure, and all three procedures are grouped
under a single Filler Order. The Filler Order number maps directly to the
DICOM Accession Number in the DICOM imaging and report data.
A widely deployed alternative approach maps the requested procedure identifiers
directly to the DICOM Accession Number. The Requested Procedure ID in such
implementations may or may not be different from the Accession Number, but is
of little identifying importance because there is only one Requested Procedure
per Accession Number. There is no identifier that formally connects the
requested procedures ordered in this group.

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In both cases, inFulfillmentOf/order/id is mapped to the DICOM Accession
Number in the imaging data.
Figure 43: DIR inFulfillmentOf example







4.3.1.7 DocumentationOf
Each documentationOf/serviceEvent indicates an imaging procedure that the
provider describes and interprets in the content of the DIR. The main activity
being described by this document is the interpretation of the imaging procedure.
This is shown by setting the value of the @classCode attribute of the
serviceEvent element to ACT, and indicating the duration over which care was
provided in the effectiveTime element. Within each documentationOf
element, there is one serviceEvent element. This event is the unit imaging
procedure corresponding to a billable item. The type of imaging procedure may
be further described in the serviceEvent/code element. This guide makes no
specific recommendations about the vocabulary to use for describing this event.
Figure 44: DIR procedure context (CDA Header) illustration (non-normative)

ClinicalDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title*: ST [1..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)

0..* serviceEvent

documentationOf
typeCode*: <= DOC

ServiceEvent
classCode*: <= ACT
moodCode*: <= EVN
id: SET [0..*]
code: CE CWE [0..1]
effectiveTime: IVL [0..1]

performer
typeCode*: <= x_ServiceEventPerformer
functionCode: CE CWE [0..1] <= ParticipationFunction
time: IVL [0..1]

0..* assignedEntity

0..1 representedOrganization
AssignedEntity
0..1 assignedPerson

In IHE Scheduled Workflow environments, one serviceEvent/id element
contains the DICOM Study Instance UID from the Modality Worklist, and the
second serviceEvent/id element contains the DICOM Requested Procedure ID
from the Modality Worklist. These two ids are in a single serviceEvent.
The effectiveTime for the serviceEvent covers the duration of the imaging
procedure being reported. This event should have one or more performers, which
may participate at the same or different periods of time.
Service events map to DICOM Requested Procedures. That is,
documentationOf/serviceEvent/id is the ID of the Requested Procedure.
8. SHALL contain exactly one [1..1] documentationOf (CONF:8416) such that it
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a. SHALL contain exactly one [1..1] serviceEvent (CONF:8431).
i.

This serviceEvent SHALL contain exactly one [1..1]
@classCode="ACT" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6) (CONF:8430).

ii. This serviceEvent SHOULD contain zero or more [0..*] id
(CONF:8418).
iii. This serviceEvent SHALL contain exactly one [1..1] code
(CONF:8419).
1. The value of serviceEvent/code SHALL NOT conflict with
the ClininicalDocument/code. When transforming
from DICOM SR documents that do not contain a
procedure code, an appropriate nullFlavor SHALL be
used on serviceEvent/code. (CONF:8420).
iv. This serviceEvent SHOULD contain zero or more [0..*]
Physician Reading Study Performer
(templateId:2.16.840.1.113883.10.20.6.2.1)
(CONF:8422).
Figure 45: DIR documentationOf example

















Christine
Cure
MD







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4.3.1.8 RelatedDocument
A DIR may have three types of parent document:
A superseded version that the present document wholly replaces
(typeCode = RPLC). DIRs may go through stages of revision prior to
being legally authenticated. Such early stages may be drafts from
transcription, those created by residents, or other preliminary versions.
Policies not covered by this specification may govern requirements for
retention of such earlier versions. Except for forensic purposes, the
latest version in a chain of revisions represents the complete and
current report.
An original version that the present document appends (typeCode =
APND). When a DIR is legally authenticated, it can be amended by a
separate addendum document that references the original.
A source document from which the present document is transformed
(typeCode = XFRM). A DIR may be created by transformation from a
DICOM Structured Report (SR) document or from another DIR. An
example of the latter case is the creation of a derived document for
inclusion of imaging results in a clinical document.

9. MAY contain zero or one [0..1] relatedDocument (CONF:8432) such that it
a. When a Diagnostic Imaging Report has been transformed from a
DICOM SR document, relatedDocument/@typeCode SHALL be XFRM,
and relatedDocument/parentDocument/id SHALL contain the SOP
Instance UID of the original DICOM SR document. (CONF:8433).
10. The relatedDocument/id/@root attribute SHALL be a syntactically correct
OID, and SHALL NOT be a UUID. (CONF:10030).
a. OIDs SHALL be represented in dotted decimal notation, where each
decimal number is either 0 or starts with a nonzero digit. More
formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+
(CONF:10031).
b. OIDs SHALL be no more than 64 characters in length. (CONF:10032).
Figure 46: DIR relatedDocument example








4.3.1.9 ComponentOf
The id element of the encompassingEncounter represents the identifier for the
encounter. When the diagnostic imaging procedure is performed in the context

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of a hospital stay or an outpatient visit for which there is an Encounter Number,
that number should be present as the ID of the encompassingEncounter.
The effectiveTime represents the time interval or point in time in which the
encounter took place. The encompassing encounter might be that of the hospital
or office visit in which the diagnostic imaging procedure was performed. If the
effective time is unknown, a nullFlavor attribute can be used.
11. MAY contain zero or one [0..1] componentOf (CONF:8434).
a. This componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:8449).
i.

This encompassingEncounter SHALL contain at least one [1..*]
id (CONF:8435).
1. In the case of transformed DICOM SR documents, an
appropriate null flavor MAY be used if the id is
unavailable. (CONF:8436).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:8437).
1. This effectiveTime SHALL contain exactly one [1..1] US
Realm Date and Time (DT.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.3) (CONF:10133).
iii. This encompassingEncounter MAY contain zero or more [0..1]
responsibleParty (CONF:8438).
1. This responsibleParty, if present, SHALL contain exactly
one [1..1] assignedEntity (CONF:9407).
a. SHOULD contain zero or one [0..1]
assignedPerson OR contain zero or one [0..1]
representedOrganization (CONF:8439).
iv. This encompassingEncounter SHOULD contain zero or one
[0..1] Physician of Record Participant
(templateId:2.16.840.1.113883.10.20.6.2.2)
(CONF:8448).

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Figure 47: DIR componentOf example













Dr.
Fay 
Family







4.3.1.10 Physician Reading Study Performer
[performer: templateId 2.16.840.1.113883.10.20.6.2.1(open)]
This participant is the Physician Reading Study Performer defined in
documentationOf/serviceEvent and is usually different from the attending
physician. The reading physician interprets the images and evidence of the
study (DICOM Definition)
1. SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8424).
2. SHALL contain exactly one [1..1]
templateId/@root="2.16.840.1.113883.10.20.6.2.1" (CONF:8423).
3. MAY contain zero or one [0..1] time (CONF:8425).
a. This time SHALL contain exactly one [1..1] US Realm Date and Time
(DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
(CONF:10134).
4. SHALL contain exactly one [1..1] assignedEntity (CONF:8426).
a. This assignedEntity SHALL contain at least one [1..*] id
(CONF:10033).
i.

The id SHOULD include zero or one [0..1] id where id/@root
="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:10034).

b. This assignedEntity SHALL contain exactly one [1..1] code
(CONF:8427).

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i.

contain a valid DICOM personal identification code
sequence (@codeSystem is 1.2.840.10008.2.16.4) or an
appropriate national health care provider coding system (e.g.,
NUCC in the U.S., where @codeSystem is
2.16.840.1.113883.6.101). (CONF:8428).
SHALL

c. Every assignedEntity element SHALL have at least one assignedPerson
or representedOrganization. (CONF:8429).
Figure 48: Physician reading study performer example









Christine
Cure
MD





4.3.1.11 Physician of Record Participant
[encounterParticipant: templateId
2.16.840.1.113883.10.20.6.2.2(open)]
This encounterParticipant is the attending physician and is usually different
from the Physician Reading Study Performer defined in
documentationOf/serviceEvent.
1. SHALL contain exactly one [1..1] @typeCode="ATND" Attender (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:8881).
2. SHALL contain exactly one [1..1]
templateId/@root="2.16.840.1.113883.10.20.6.2.2" (CONF:8440).
3. SHALL contain exactly one [1..1] assignedEntity (CONF:8886).
a. This assignedEntity SHALL contain at least one [1..*] id (CONF:8887).
i.

The id SHOULD include zero or one [0..1] id where id/@root
="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:10035).

b. This assignedEntity SHALL contain exactly one [1..1] code
(CONF:8888).

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i.

contain a valid DICOM Organizational Role from
DICOM CID 745221 (Value Set
1.2.840.10008.6.1.516)(@codeSystem is
1.2.840.10008.2.16.4) or an appropriate national health
care provider coding system (e.g., NUCC in the U.S., where
@codeSystem is 2.16.840.1.113883.6.101) (CONF:8889).
SHALL

c. This assignedEntity SHOULD contain zero or one [0..1] name
(CONF:8890).
Figure 49: Physician of record participant example









Dr.
Fay
Family





DICOM Part 16 (NEMA PS3.16), page 631 in the 2011 edition. See
ftp://medical.nema.org/medical/dicom/2011/11_16pu.pdf
21

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4.3.2 DIR Body Constraints
The DIR supports both narrative sections and sections requiring coded clinical
statements. The required and optional sections are listed in the Document Types
and Required/Optional Sections table.
The following table shows relationships among the constrained templates in the
body of a DIR report.
Table 26: Template Containment for Constrained DIR Sections
Template Title

Template
Type

templateId

Diagnostic Imaging Report

document

2.16.840.1.113883.10.20.22.1.5

Fetus Subject Context

section

2.16.840.1.113883.10.20.6.2.3

Findings Section (DIR)

section

2.16.840.1.113883.10.20.6.1.2

Observer Context

section

2.16.840.1.113883.10.20.6.2.4

Physician of Record Participant

unspecified

2.16.840.1.113883.10.20.6.2.2

Physician Reading Study Performer

unspecified

2.16.840.1.113883.10.20.6.2.1

Procedure Context

entry

2.16.840.1.113883.10.20.6.2.5

DICOM Object Catalog Section - DCM
121181

section

2.16.840.1.113883.10.20.6.1.1

entry

2.16.840.1.113883.10.20.6.2.6

entry

2.16.840.1.113883.10.20.22.4.63

entry

2.16.840.1.113883.10.20.6.2.8

Purpose of Reference Observation

entry

2.16.840.1.113883.10.20.6.2.9

Referenced Frames Observation

entry

2.16.840.1.113883.10.20.6.2.10

entry

2.16.840.1.113883.10.20.6.2.11

Study Act
Series Act
SOP Instance Observation

Boundary Observation

4.3.2.1 DIR Section Constraints
The Section Type codes used by DIR are described below in the DIR Section Type
Codes table. All section codes shown in this table describe narrative document
sections22. The column headings of this table are:

22

DCM Code:

The code of the section in DICOM (Context
Group CID 7001)

DCM Code Meaning:

The display name of the section in DICOM
(Context Group CID 7001)

LOINC Code:

The code of the section in LOINC

LOINC Component Name:

The display name of the section in LOINC

SCALE_TYP = 'NAR' in the LOINC tables.

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Use:

The use column indicates that a section in
a Diagnostic Imaging Report is:
R – required
C – conditionally required
O – optional
Table 27: DIR Section Type Codes

DICOM Code

DICOM Code Meaning

LOINC Code

LOINC Code Meaning

Use

121181

DICOM Object Catalog

N/A

N/A

C

121060

History

11329-0

HISTORY GENERAL

O

121062

Request

55115-0

REQUESTED IMAGING
STUDIES INFORMATION

O

121064

Current Procedure
Descriptions

55111-9

CURRENT IMAGING
PROCEDURE DESCRIPTIONS

O

121066

Prior Procedure
Descriptions

55114-3

PRIOR IMAGING PROCEDURE
DESCRIPTIONS

O

121068

Previous Findings

18834-2

RADIOLOGY COMPARISON
STUDY - OBSERVATION

O

121070

Findings (DIR)

18782-3

RADIOLOGY STUDY
OBSERVATION

R

121072

Impressions

19005-8

RADIOLOGY - IMPRESSION

O

121074

Recommendations

18783-1

RADIOLOGY STUDY RECOMMENDATION

O

121076

Conclusions

55110-1

CONCLUSIONS

O

121078

Addendum

55107-7

ADDENDUM

O

121109

Indications for
Procedure

18785-6

RADIOLOGY REASON FOR
STUDY

O

121110

Patient Presentation

55108-5

CLINICAL PRESENTATION

O

121113

Complications

55109-3

COMPLICATIONS

O

121111

Summary

55112-7

DOCUMENT SUMMARY

O

121180

Key Images

55113-5

KEY IMAGES

O

For Level 2 conformance, all section elements that are present in the Body of
the document must have a code and some nonblank text or one or more
subsections, even if the purpose of the text is only to indicate that information is
unknown.
There is no equivalent to section/title in DICOM SR, so for a CDA to SR
transformation, the section/code will be transferred and the title element
will be dropped.
1. SHALL contain exactly one [1..1] component (CONF:14907).
a. A Diagnostic Imaging Report can have either a structuredBody or a
nonXMLBody (CONF:14908).
i.

A Diagnostic Imaging Report can conform to CDA Level 1
(nonXMLBody), CDA Level 2 (structuredBody with sections
that contain a narrative block), or CDA Level 3

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(structuredBody containing sections that contain a narrative
block and coded entries). In this template (templateId
2.16.840.1.113883.10.20.22.1.5), coded entries are optional
(CONF:14909).
b. If structuredBody, the component/structuredBody SHALL conform to
the section constraints below (CONF:14910).
i.

The DICOM Object Catalog section (templateId
2.16.840.1.113883.10.20.6.1.1), if present, SHALL be the first
section in the document Body (CONF:9408).

ii. SHALL contain exactly one [1..1] Findings Section (DIR)
(templateId:2.16.840.1.113883.10.20.6.1.2)
(CONF:9484).
iii. SHOULD contain zero or one [0..1] DICOM Object Catalog
Section - DCM 121181
(templateId:2.16.840.1.113883.10.20.6.1.1)
(CONF:15141).
iv. With the exception of the DICOM Object Catalog (templateId
2.16.840.1.113883.10.20.6.1.1), all sections within the
Diagnostic Imaging Report content SHOULD contain a title
element (CONF:9409).
v. The section/code SHOULD be selected from LOINC or DICOM
for sections not listed in the DIR Section Type Codes table
(CONF:9410).
1. Descriptions for sections is under development in
DICOM in cooperation with the RSNA reporting
initiative (CONF:9423).
vi. All sections defined in the DIR Section Type Codes table SHALL
be top-level sections (CONF:9411).
vii. A section element SHALL have a code element, which SHALL
contain a LOINC code or DCM code for sections that have no
LOINC equivalent. This only applies to sections described in
the DIR Section Type Codes table (CONF:9412).
viii. Apart from the DICOM Object Catalog (templateId
2.16.840.1.113883.10.20.6.1.1), all other instances of section
SHALL contain at least one text element or one or more
component elements (CONF:9413).
ix. All text or component elements SHALL contain content. text
elements SHALL contain PCDATA or child elements, and
component elements SHALL contain child elements
(CONF:9414).
x. The text elements (and their children) MAY contain Web Access
to DICOM Persistent Object (WADO) references to DICOM
objects by including a linkHtml element where @href is a valid
WADO URL and the text content of linkHtml is the visible text
of the hyperlink (CONF:9415).

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xi. If clinical statements are present, the section/text SHALL
represent faithfully all such statements and MAY contain
additional text (CONF:9416).
xii. MAY contain zero or more [0..*] Procedure Context
(templateId:2.16.840.1.113883.10.20.6.2.5)
(CONF:9417).
1. If the service context of a section is different from the
value specified in documentationOf/serviceEvent, then
the section SHALL contain one or more entries
containing Procedure Context (templateId
2.16.840.1.113883.10.20.6.2.5), which will reset the
context for any clinical statements nested within those
elements (CONF:9418).
xiii. MAY contain zero or more [0..*] Fetus Subject Context
(templateId:2.16.840.1.113883.10.20.6.2.3)
(CONF:9419).
1. If the subject of a section is a fetus, the section SHALL
contain a subject element containing a Fetus Subject
Context (templateId 2.16.840.1.113883.10.20.6.2.3)
(CONF:9420).
xiv. MAY contain zero or more [0..*] Observer Context
(templateId:2.16.840.1.113883.10.20.6.2.4)
(CONF:9421).
1. : If the author of a section is different from the
author(s) listed in the Header, an author element
SHALL be present containing Observer Context
(templateId 2.16.840.1.113883.10.20.6.2.4)
(CONF:9422).
Figure 50: WADO reference using linkHtml example

...

Source of Measurement
Chest
_PA

...


4.3.2.2 Fetus Subject Context
[relatedSubject: templateId 2.16.840.1.113883.10.20.6.2.3(open)]
For reports on mothers and their fetus(es), information on a mother is mapped
to recordTarget, PatientRole, and Patient. Information on the fetus is mapped to
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subject, relatedSubject, and SubjectPerson at the CDA section level. Both
context information on the mother and fetus must be included in the document
if observations on fetus(es) are contained in the document.
1. SHALL contain exactly one [1..1] templateId (CONF:9189) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.3" (CONF:10535).
2. SHALL contain exactly one [1..1] code="121026" (CodeSystem: DCM
1.2.840.10008.2.16.4) (CONF:9190).
3. SHALL contain exactly one [1..1] subject (CONF:9191).
4. SHALL contain exactly one [1..1] name (CONF:9192).
a. The name element is used to store the DICOM fetus ID, typically a
pseudonym such as fetus_1 (CONF:9193).
Figure 51: Fetus subject context example




fetus_1



4.3.2.3 Observer Context
[assignedAuthor: templateId 2.16.840.1.113883.10.20.6.2.4(open)]
The Observer Context is used to override the author specified in the CDA
Header. It is valid as a direct child element of a section.
1. SHALL contain exactly one [1..1] templateId (CONF:9194) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.4" (CONF:10536).
2. SHALL contain exactly one [1..1] assignedAuthor (CONF:9195).
3. SHALL contain at least one [1..*] id (CONF:9196).
a. The id element contains the author's id or the DICOM device observer
UID (CONF:9197).
4. Either assignedPerson or assignedAuthoringDevice SHALL be present
(CONF:9198).

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Figure 52: Observer context example





Richard
Blitz
MD




4.3.2.4 DIR Clinical Statements
A Diagnostic Imaging Report may contain CDA entries that represent, in coded
form findings, image references, annotation, and numeric measurements based
on DICOM Basic Diagnostic Imaging Report (Template 2000) and Transcribed
Diagnostic Imaging Report (Template 2005). Most of the constraints for this
document have been inherited from the DICOM PS 3.20 “Transformation of
DICOM to and from HL7 Standards”.
This document type and the companion DICOM PS 3.20 “Transformation of
DICOM to and from HL7 Standards” guide further constrain the transformation
because image Spatial Coordinates region of interest (SCOORD) for linear, area,
and volume measurements are not encoded in the CDA document. If it is
desired to show images with such graphical annotations, the annotations should
be encoded in DICOM Softcopy Presentation State objects that reference the
image. Report applications that display referenced images and annotation
should retrieve a rendered image using a WADO reference, including the image
and Presentation State, or other DICOM retrieval and rendering methods. This
approach avoids the risks of errors in registering a region of interest annotation
with DICOM images.
DICOM Template 2000 defines imaging report documents that are comprised of
a number of optional sections, including those defined above in DIR Section
Type Codes Each section contains:
Text Observations (Text Elements in DICOM SR), optionally inferred from
Quantity Measurement Observation or Image references
Code Observations (Code Elements in DICOM SR), optionally inferred
from Quantity Measurement Observation or Image references
Quantity Measurement Observation (Numeric Elements in DICOM SR)
with a coded measurement type, optionally inferred from an image
reference
Service Object Pair (SOP) Instance Observations containing image
references
The number or order of the observations and image references in the above
bullet points are not constrained in a section.
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4.4 Discharge Summary
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.8(open)]
The Discharge Summary is a document that is a synopsis of a patient's
admission to a hospital; it provides pertinent information for the continuation of
care following discharge. The Joint Commission requires the following
information to be included in the Discharge Summary23:
The reason for hospitalization
The procedures performed
The care, treatment, and services provided
The patient’s condition and disposition at discharge
Information provided to the patient and family
Provisions for follow-up care

4.4.1 Discharge Summary Header Constraints
The Discharge Summary must conform to the US Realm Clinical Document
Header. The following sections include additional header constraints for
conformant Discharge Summaries.
1. SHALL contain exactly one [1..1] templateId (CONF:9479) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10043).

4.4.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of a Discharge Summary as well as the
templateId for the US Realm Clinical Document Header template.
2. SHALL contain exactly one [1..1] templateId (CONF:8463) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.8" (CONF:10044).
Figure 53: Discharge summary ClinicalDocument/templateId example





Joint Commission Requirements for Discharge Summary (JCAHO IM.6.10 EP7). See
http://www.jointcommission.org/NR/rdonlyres/C9298DD0-6726-4105-A007FE2C65F77075/0/CMS_New_Revised_HAP_FINAL_withScoring.pdf..
23

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4.4.1.2 ClinicalDocument/code
The Discharge Summary LOINC Document Codes table shows the LOINC codes
suitable for Discharge Summary, as of publication of this implementation guide.
This is a dynamic value set meaning that these codes may be added to or
deprecated by LOINC.
The Discharge Summary recommends use of a single document type code,
18842-5 "Discharge Summarization Note", with further specification
provided by author or performer, setting, or specialty. Some of the LOINC codes
listed here pre-coordinate the practice setting or the training or professional
level of the author. Use of these codes is not recommended, as this duplicates
information that may be present in the header. If used, the pre-coordinated
codes must be consistent with the LOINC document type code.
3. SHALL contain exactly one [1..1] code (CONF:17178).
a. This code SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet DischargeSummaryDocumentTypeCode
2.16.840.1.113883.11.20.4.1 DYNAMIC (CONF:17179).
Table 28: Discharge summary LOINC Document Codes
Value Set: DischargeSummaryDocumentTypeCode 2.16.840.1.113883.11.20.4.1 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC Code

Type of Service
‘Component’

Setting
‘System’

Specialty/Training/Professional
Level ‘Method_Type’

Discharge summarization
note

{Setting}

{Provider}

Preferred Code
18842-5

Additional Codes
11490-0

Discharge summarization
note

{Setting}

Physician

28655-9

Discharge summarization
note

{Setting}

Attending physician

29761-4

Discharge summarization
note

{Setting}

Dentistry

34745-0

Discharge summarization
note

{Setting}

Nursing

34105-7

Discharge summarization
note

Hospital

{Provider}

34106-5

Discharge summarization
note

Hospital

Physician

Figure 54: Discharge summary ClinicalDocument/code example


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4.4.1.3 Participant
The participant element in the Discharge Summary header follows the General
Header Constraints for participants. Discharge Summary does not specify any
use for functionCode for participants. Local policies will determine how this
element should be used in implementations.

4.4.1.4 ComponentOf
The Discharge Summary is always associated with a Hospital Admission using
the encompassingEncounter element in the header.
The dischargeDispositionCode records the disposition of the patient at time
of discharge. Access to the National Uniform Billing Committee (NUBC) code
system requires a membership. The following conformance statement aligns with
HITSP C80 requirements.
The responsibleParty element represents only the party responsible for the
encounter, not necessarily the entire episode of care.
The encounterParticipant elements represent only those participants in the
encounter, not necessarily the entire episode of care.
The admission date is recorded in the
componnentOf/encompassingEncounter/
effectiveTime/low.
4. SHALL contain exactly one [1..1] componentOf (CONF:8471).
a. This componentOf SHALL contain exactly one [1..1]
encompassingEncounter (CONF:8472).
i.

This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime/low (CONF:8473).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime/high (CONF:8475).
iii. The dischargeDispositionCode SHALL be present where the
value of code SHOULD be selected from ValueSet NUBC UB-04
FL17-Patient Status 2.16.840.1.113883.3.88.12.80.33
DYNAMIC (http://www.nubc.org) (CONF:8476).
1. The dischargeDispositionCode, @displayName, or
NUBC UB-04 Print Name, SHALL be displayed when the
document is rendered. (CONF:8477).
iv. The responsibleParty element MAY be present. If present, the
responsibleParty/assignedEntity element SHALL have at least
one assignedPerson or representedOrganization element
present. (CONF:8479).
v. The encounterParticipant elements MAY be present. If present,
the encounterParticipant/assignedEntity element SHALL have
at least one assignedPerson or representedOrganization
element present. (CONF:8478).

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Table 29: HL7 Discharge Disposition Codes
Code System: HL7 Discharge Disposition 2.16.840.1.113883.12.112
Code

Print Name

01

Discharged to home or self care (routine discharge)

02

Discharged/transferred to another short-term general hospital for inpatient
care

03

Discharged/transferred to skilled nursing facility (SNF)

04

Discharged/transferred to an intermediate-care facility (ICF)

05

Discharged/transferred to another type of institution for inpatient care or
referred for outpatient services to another institution

06

Discharged/transferred to home under care of organized home health service
organization

07

Left against medical advice or discontinued care

08

Discharged/transferred to home under care of Home IV provider

09

Admitted as an inpatient to this hospital

10 …19

Discharge to be defined at state level, if necessary

20

Expired (i.e., dead)

21 ... 29

Expired to be defined at state level, if necessary

30

Still patient or expected to return for outpatient services (i.e., still a patient)

31 … 39

Still patient to be defined at state level, if necessary (i.e., still a patient)

40

Expired (i.e., died) at home

41

Expired (i.e., died) in a medical facility; e.g., hospital, SNF, ICF, or freestanding hospice

42

Expired (i.e., died) - place unknown

Figure 55: Discharge summary componentOf example











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4.4.2 Discharge Summary Body Constraints
The Discharge Summary supports both narrative sections and sections requiring
code clinical statements. The required and optional sections are listed in the
Document Types and Required/Optional Sections table. The table below the
constraints shows all templates including entries within each section.
1. SHALL contain exactly one [1..1] component (CONF:9539).
a. A Discharge Summary can have either a structuredBody or a
nonXMLBody. (CONF:9537).
i.

A Discharge Summary 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
2.16.840.1.113883.10.20.22.1.8), coded entries are optional.
(CONF:9538).

b. If structuredBody, the component/structuredBody SHALL conform to
the section constraints below. (CONF:9540).
i.

contain exactly one [1..1] Allergies Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.6)
(CONF:9542).
SHALL

ii. SHALL contain exactly one [1..1] Hospital Course Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.3.5)
(CONF:9544).
iii. SHALL contain exactly one [1..1] Hospital Discharge
Diagnosis Section
(templateId:2.16.840.1.113883.10.20.22.2.24)
(CONF:9546).
iv. SHALL contain exactly one [1..1] Hospital Discharge
Medications Section (entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.11)
(CONF:9548).
v. SHALL contain exactly one [1..1] Plan of Care Section
(templateId:2.16.840.1.113883.10.20.22.2.10)
(CONF:9550).
vi. SHALL NOT include a Chief Complaint and Reason for Visit
Section with either a Chief Complaint Section or a Reason for
Visit Section. (CONF:10055)
vii. MAY contain zero or one [0..1] Chief Complaint Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
(CONF:9554).
viii. MAY contain zero or one [0..1] Chief Complaint and Reason
for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.13)
(CONF:9556).

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ix. MAY contain zero or one [0..1] Discharge Diet Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.3.33)
(CONF:9558).
x. MAY contain zero or one [0..1] Family History Section
(templateId:2.16.840.1.113883.10.20.22.2.15)
(CONF:9560).
xi. MAY contain zero or one [0..1] Functional Status Section
(templateId:2.16.840.1.113883.10.20.22.2.14)
(CONF:9562).
xii. MAY contain zero or one [0..1] History of Past Illness
Section
(templateId:2.16.840.1.113883.10.20.22.2.20)
(CONF:9564).
xiii. MAY contain zero or one [0..1] History of Present Illness
Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.4)
(CONF:9566).
xiv. MAY contain zero or one [0..1] Hospital Admission
Diagnosis Section
(templateId:2.16.840.1.113883.10.20.22.2.43)
(CONF:9928).
xv. MAY contain zero or one [0..1] Hospital Admission
Medications Section (entries optional)
(2.16.840.1.113883.10.20.22.2.44) (CONF:10111).
xvi. MAY contain zero or one [0..1] Hospital Consultations
Section
(templateId:2.16.840.1.113883.10.20.22.2.42)
(CONF:9924).
xvii. MAY contain zero or one [0..1] Hospital Discharge
Instructions Section
(templateId:2.16.840.1.113883.10.20.22.2.41)
(CONF:9926).
xviii. MAY contain zero or one [0..1] Hospital Discharge
Physical Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.3.26)
(CONF:9568).
xix. MAY contain zero or one [0..1] Hospital Discharge Studies
Summary Section
(templateId:2.16.840.1.113883.10.20.22.2.16)
(CONF:9570).
xx. MAY contain zero or one [0..1] Immunizations Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.2)
(CONF:9572).
xxi. MAY contain zero or one [0..1] Problem Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.5)
(CONF:9574).

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xxii. MAY contain zero or one [0..1] Procedures Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.7)
(CONF:9576).
xxiii. MAY contain zero or one [0..1] Reason for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.12)
(CONF:9578).
xxiv. MAY contain zero or one [0..1] Review of Systems
Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18)
(CONF:9580).
xxv. MAY contain zero or one [0..1] Social History Section
(templateId:2.16.840.1.113883.10.20.22.2.17)
(CONF:9582).
xxvi. MAY contain zero or one [0..1] Vital Signs Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.4)
(CONF:9584).

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The following table shows relationships among the templates in the body of a
Discharge Summary.
Table 30: Template Containment for a Discharge Summary
Template Title
Discharge Summary

Template
Type

templateId

document

2.16.840.1.113883.10.20.22.1.8

section

2.16.840.1.113883.10.20.22.2.6

entry

2.16.840.1.113883.10.20.22.4.30

entry

2.16.840.1.113883.10.20.22.4.7

Allergy Status Observation

entry

2.16.840.1.113883.10.20.22.4.28

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

entry

2.16.840.1.113883.10.20.22.4.54

Allergies Section (entries optional)
Allergy Problem Act
Allergy - Intolerance Observation

Immunization Medication
Information

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Template Title

Template
Type

templateId

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.8

Chief Complaint and Reason for Visit
Section

section

2.16.840.1.113883.10.20.22.2.13

Chief Complaint Section

section

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

Discharge Diet Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.33

Family History Section

section

2.16.840.1.113883.10.20.22.2.15

entry

2.16.840.1.113883.10.20.22.4.45

entry

2.16.840.1.113883.10.20.22.4.46

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Family History Death Observation

entry

2.16.840.1.113883.10.20.22.4.47

Severity Observation
Severity Observation

Family History Organizer
Family History Observation

Functional Status Section

section

2.16.840.1.113883.10.20.22.2.14

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Cognitive Status Problem Observation

entry

2.16.840.1.113883.10.20.22.4.73

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

Product Instance
Cognitive Status Result Observation

entry

2.16.840.1.113883.10.20.22.4.74

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.75

Product Instance
Cognitive Status Result Organizer

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Template Title
Cognitive Status Result Observation

Template
Type

templateId

entry

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Assessment Scale Observation

entry

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Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

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Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Functional Status Problem
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entry

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Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

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Assessment Scale Observation

entry

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Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.66

entry

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Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

entry

2.16.840.1.113883.10.20.22.4.50

entry

2.16.840.1.113883.10.20.22.4.37

section

2.16.840.1.113883.10.20.22.2.20

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

Product Instance
Functional Status Result Observation

Product Instance
Functional Status Result Organizer
Functional Status Result
Observation

Product Instance
Non-Medicinal Supply Activity
Product Instance
History of Past Illness Section
Problem Observation

entry

2.16.840.1.113883.10.20.22.4.6

History of Present Illness Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.4

Hospital Admission Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.43

entry

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entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

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Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

section

2.16.840.1.113883.10.20.22.2.44

entry

2.16.840.1.113883.10.20.22.4.36

Hospital Admission Diagnosis
Problem Observation

Hospital Admission Medications Section
(entries optional)
Admission Medication

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Template Title
Medication Activity

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.8

Hospital Consultations Section

Severity Observation

section

2.16.840.1.113883.10.20.22.2.42

Hospital Course Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.5

Hospital Discharge Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.24

entry

2.16.840.1.113883.10.20.22.4.33

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

Hospital Discharge Diagnosis
Problem Observation

entry

2.16.840.1.113883.10.20.22.4.6

Hospital Discharge Instructions Section

section

2.16.840.1.113883.10.20.22.2.41

Hospital Discharge Medications Section
(entries optional)

section

2.16.840.1.113883.10.20.22.2.11

Discharge Medication

entry

2.16.840.1.113883.10.20.22.4.35

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

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Type

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Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

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Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

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Immunization Medication
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entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

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Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

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Product Instance

entry

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Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

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Hospital Discharge Physical Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.26

Hospital Discharge Studies Summary
Section

section

2.16.840.1.113883.10.20.22.2.16

Immunizations Section (entries
optional)

section

2.16.840.1.113883.10.20.22.2.2

entry

2.16.840.1.113883.10.20.22.4.52

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Immunization Medication
Information

entry

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Immunization Refusal Reason

entry

2.16.840.1.113883.10.20.22.4.53

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

entry

2.16.840.1.113883.10.20.22.4.54

Procedure Activity Procedure

Severity Observation

Immunization Activity

Immunization Medication
Information

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Template
Type

templateId

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

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Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

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Template
Type

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Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

entry

2.16.840.1.113883.10.20.22.4.43

section

2.16.840.1.113883.10.20.22.2.5

entry

2.16.840.1.113883.10.20.22.4.3

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

section

2.16.840.1.113883.10.20.22.2.7

entry

2.16.840.1.113883.10.20.22.4.12

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

entry

2.16.840.1.113883.10.20.22.4.24

Severity Observation
Plan of Care Section

Problem Section (entries optional)
Problem Concern Act (Condition)
Problem Observation

Procedures Section (entries optional)
Procedure Activity Act

Drug Vehicle

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Template
Type

templateId

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

Severity Observation
Service Delivery Location
Procedure Activity Observation

entry

2.16.840.1.113883.10.20.22.4.13

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

entry

2.16.840.1.113883.10.20.22.4.54

Immunization Medication
Information

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Type

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Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

Procedure Activity Procedure

Severity Observation

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

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Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance

entry

2.16.840.1.113883.10.20.22.4.25

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Template Title

Template
Type

templateId

Administration
Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.8

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Reason for Visit Section

section

2.16.840.1.113883.10.20.22.2.12

Review of Systems Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.18

Social History Section

section

2.16.840.1.113883.10.20.22.2.17

entry

2.16.840.1.113883.10.20.15.3.8

Estimated Date of Delivery

entry

2.16.840.1.113883.10.20.15.3.1

Smoking Status Observation

entry

2.16.840.1.113883.10.22.4.78

Social History Observation

entry

2.16.840.1.113883.10.20.22.4.38

section

2.16.840.1.113883.10.20.22.2.4

entry

2.16.840.1.113883.10.20.22.4.26

entry

2.16.840.1.113883.10.20.22.4.27

Severity Observation

Pregnancy Observation

Vital Signs Section (entries optional)
Vital Signs Organizer
Vital Sign Observation

4.5 History and Physical (H&P) Note
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.3(open)]
A History and Physical (H&P) Note is a medical report that documents the
current and past conditions of the patient. It contains essential information that
helps determine an individual's health status.
The first portion of the report is a current collection of organized information
unique to an individual, typically supplied by the patient or their caregiver,
about the current medical problem or the reason for the patient encounter. This
information is followed by a description of any past or ongoing medical issues,
including current medications and allergies. Information is also obtained about
the patient's lifestyle, habits, and diseases among family members.
The next portion of the report contains information obtained by physically
examining the patient and gathering diagnostic information in the form of
laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the
intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well
as before operative procedures. An initial evaluation in an ambulatory setting is
often documented in the form of an H&P Note.

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4.5.1 H&P Note Header Constraints
The H&P Note must conform to the US Realm Clinical Document Header. The
following sections include additional header constraints for conformant H&P
Notes.
1. SHALL contain exactly one [1..1] templateId(CONF:9968) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10045).

4.5.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of a H&P Note as well as the templateId
for the US Realm Clinical Document Header template.
1. SHALL contain exactly one [1..1] templateId (CONF:8283) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.3" History and Physical
Note (CONF:10046).
Figure 56: H&P ClinicalDocument/templateId example





4.5.1.2 ClinicalDocument/code
At publication time for this guide, H&P Note limits the
ClinicalDocument/code to those codes shown in the H&P LOINC Document
Type Codes table. Valid codes are those whose scale is DOC and whose type of
service is some variation of History and Physical.
The H&P Note recommends use of a single document type code, 34117-2
"History & Physical", with further specification provided by author or
performer, setting, or specialty. Some codes in the H&P LOINC Document Type
Codes table are pre-coordinated with the practice setting or the training or
professional level of the author. Use of these codes is not recommended, as this
duplicates information potentially present with the header. When precoordinated 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.
2. SHALL contain exactly one [1..1] code (CONF:17185).
a. This code SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet HPDocumentType
2.16.840.1.113883.1.11.20.22 DYNAMIC (CONF:17186).

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Table 31: H&P LOINC Document Type Codes
Value Set: HPDocumentType 2.16.840.1.113883.1.11.20.22 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC Code

Type of Service
‘Component’

Setting
‘System’

Specialty/Training/
Professional Level
‘Method_Type’

Preferred Code
34117-2

History & Physical

Additional Codes
11492-6

History & Physical

Hospital

28626-0

History & Physical

Physician

34774-0

History & Physical

General surgery

34115-6

History & Physical

Hospital

Medical Student

34116-4

History & Physical

Nursing home

Physician

34095-0

Comprehensive History &
Physical

34096-8

Comprehensive History &
Physical

51849-8

Admission History & Physical

47039-3

Admission History & Physical

34763-3

Admission History & Physical

34094-3

Admission History & Physical

34138-8

Targeted History & Physical

Nursing home

Inpatient
General medicine
Hospital

Cardiology

Figure 57: H&P ClinicalDocument/code example


Figure 58: H&P use of translation to include local equivalents for document type




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4.5.1.3 Participant
The participant element in the H&P header follows the General Header
Constraints for participants. H&P Note does not specify any use for
functionCode for participants. Local policies will determine how this element
should be used in implementations.

4.5.1.4 InFulfillmentOf
inFulfillmentOf elements describe the prior orders that are fulfilled (in whole
or part) by the service events described in this document. For example, the prior
order might be a referral and the H&P Note may be in partial fulfillment of that
referral.
2. MAY contain zero or more [0..*] inFulfillmentOf (CONF:8336).
a. An inFulfillmentOf element records the prior orders that are fulfilled
(in whole or part) by the service events described in this document.
For example, the prior order might be a referral and this H&P Note
may be in partial fulfillment of that referral. (CONF:8337).

4.5.1.5 ComponentOf
The H&P Note is always associated with an encounter.
The effectiveTime represents the time interval or point in time in which the
encounter took place.
The encounterParticipant elements represent only those participants in the
encounter, not necessarily the entire episode of care.
The responsibleParty element represents only the party responsible for the
encounter, not necessarily the entire episode of care.
3. SHALL contain exactly one [1..1] componentOf (CONF:8338).
a. This componentOf SHALL contain exactly one [1..1]
encompassingEncounter (CONF:8339).
i. This encompassingEncounter SHALL contain exactly one [1..1]
id (CONF:8340).
ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:8341).
1. This effectiveTime SHALL contain exactly one [1..1] US
Realm Date and Time (DT.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.3) (CONF:10135).
iii. This encompassingEncounter MAY contain zero or one [0..1]
location (CONF:8344).
iv. This encompassingEncounter MAY contain zero or one [0..1]
responsibleParty (CONF:8345).
1. The responsibleParty element records only the party
responsible for the encounter, not necessarily the
entire episode of care. (CONF:8347).
2. The responsibleParty element, if present, SHALL
contain an assignedEntity element, which SHALL
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contain an assignedPerson element, a
representedOrganization element, or both.
(CONF:8348).
v. This encompassingEncounter MAY contain zero or more [0..*]
encounterParticipant (CONF:8342).
1. The encounterParticipant element, if present, records
only participants in the encounter, not necessarily in
the entire episode of care. (CONF:8346).
2. An encounterParticipant element, if present, SHALL
contain an assignedEntity element, which SHALL
contain an assignedPerson element, a
representedOrganization element, or both.
(CONF:8343).
Figure 59: H&P componentOf example











4.5.2 H&P Note Body Constraints
The H&P Note supports both narrative sections and sections requiring code
clinical statements. The required and optional sections are listed in the
Document Types and Required/Optional Sections table. The table below the
constraints shows all templates including entries within each section.
1. SHALL contain exactly one [1..1] component (CONF:8349).
a. A History and Physical document can have either a structuredBody
or a nonXMLBody. (CONF:8350).
i.

A History and Physical document 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
2.16.840.1.113883.10.20.22.1.3), coded entries are optional.
(CONF:8352).

b. If structuredBody, the component/structuredBody SHALL conform to
the section constraints below (CONF:9597).
i.

This section SHALL contain exactly one [1..1] Allergies
Section (entries optional)

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(templateId:2.16.840.1.113883.10.20.22.2.6)
(CONF:9602).
ii. SHALL include an Assessment and Plan Section, or an
Assessment Section and a Plan Section. (CONF:9986).
iii. SHALL NOT include an Assessment/Plan Section when an
Assessment Section and a Plan of Care Section are present.
(CONF:10056)
iv. MAY contain zero or one [0..1] Assessment Section
(templateId:2.16.840.1.113883.10.20.22.2.8)
(CONF:9605).
v. MAY contain zero or one [0..1] Plan of Care Section
(templateId:2.16.840.1.113883.10.20.22.2.10)
(CONF:9607).
vi. MAY contain zero or one [0..1] Assessment and Plan
Section (templateId:2.16.840.1.113883.10.20.22.2.9)
(CONF:9987).
vii. SHALL include a Chief Complaint and Reason for Visit Section,
Chief Complaint Section, or a Reason for Visit Section.
(CONF:9642).
viii. SHALL NOT include a Chief Complaint and Reason for Visit
Section with either a Chief Complaint Section or a Reason for
Visit Section. (CONF:10057)
ix. MAY contain zero or one [0..1] Chief Complaint Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
(CONF:9611).
x. MAY contain zero or one [0..1] Chief Complaint and Reason
for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.13)
(CONF:9613).
xi. SHALL contain exactly one [1..1] Family History Section
(templateId:2.16.840.1.113883.10.20.22.2.15)
(CONF:9615).
xii. SHALL contain exactly one [1..1] General Status Section
(templateId:2.16.840.1.113883.10.20.2.5)
(CONF:9617).
xiii. SHALL contain exactly one [1..1] History of Past Illness
Section
(templateId:2.16.840.1.113883.10.20.22.2.20)
(CONF:9619).
xiv. SHALL contain exactly one [1..1] Medications Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.1)
(CONF:9623).
xv. SHALL contain exactly one [1..1] Physical Exam Section
(templateId:2.16.840.1.113883.10.20.2.10)
(CONF:9625).

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xvi. SHALL contain exactly one [1..1] Reason for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.12)
(CONF:9627).
xvii. SHALL contain exactly one [1..1] Results Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.3)
(CONF:9629).
xviii. SHALL contain exactly one [1..1] Review of Systems
Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18)
(CONF:9631).
xix. SHALL contain exactly one [1..1] Social History Section
(templateId:2.16.840.1.113883.10.20.22.2.17)
(CONF:9633).
xx. SHALL contain exactly one [1..1] Vital Signs Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.4)
(CONF:9635).
xxi. SHOULD contain exactly one [1..1] History of Present
Illness Section (templateId:
1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:9621).
xxii. MAY contain zero or one [0..1] Immunizations Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.2)
(CONF:9637).
xxiii. MAY contain zero or one [0..1] Instructions Section
(templateId:2.16.840.1.113883.10.20.22.2.45)
(CONF:16807).
xxiv. MAY contain zero or one [0..1] Problem Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.5)
(CONF:9639).
xxv. MAY contain zero or one [0..1] Procedures Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.7)
(CONF:9641).
The following table shows relationships among the templates in the body of an
H&P Note.
Table 32: Template Containment for an H&P Note
Template Title

Template
Type

templateId

History and Physical

document

2.16.840.1.113883.10.20.22.1.3

section

2.16.840.1.113883.10.20.22.2.6

entry

2.16.840.1.113883.10.20.22.4.30

entry

2.16.840.1.113883.10.20.22.4.7

entry

2.16.840.1.113883.10.20.22.4.28

Allergies Section (entries optional)
Allergy Problem Act
Allergy - Intolerance Observation
Allergy Status Observation

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Template Title

Template
Type

templateId

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

entry

2.16.840.1.113883.10.20.22.4.54

Immunization Medication

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Template Title

Template
Type

templateId

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.9

Information

Severity Observation
Severity Observation
Assessment and Plan Section

entry

2.16.840.1.113883.10.20.22.4.39

Assessment Section

Plan of Care Activity Act

section

2.16.840.1.113883.10.20.22.2.8

Chief Complaint and Reason for Visit
Section

section

2.16.840.1.113883.10.20.22.2.13

Chief Complaint Section

section

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

Family History Section

section

2.16.840.1.113883.10.20.22.2.15

entry

2.16.840.1.113883.10.20.22.4.45

Family History Organizer
Family History Observation

entry

2.16.840.1.113883.10.20.22.4.46

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Family History Death Observation

entry

2.16.840.1.113883.10.20.22.4.47

General Status Section

section

2.16.840.1.113883.10.20.2.5

History of Past Illness Section

section

2.16.840.1.113883.10.20.22.2.20

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

Problem Observation

entry

2.16.840.1.113883.10.20.22.4.6

History of Present Illness Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.4

Immunizations Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.2

entry

2.16.840.1.113883.10.20.22.4.52

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Immunization Refusal Reason

entry

2.16.840.1.113883.10.20.22.4.53

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Immunization Activity

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Template Title

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.23

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

Medication Information
Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

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Template Title

Template
Type

templateId

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.1

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

Severity Observation
Medications Section (entries optional)
Medication Activity

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

Severity Observation

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Template Title

Template
Type

templateId

Physical Exam Section

section

2.16.840.1.113883.10.20.2.10

Plan of Care Section

section

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

entry

2.16.840.1.113883.10.20.22.4.43

section

2.16.840.1.113883.10.20.22.2.5

entry

2.16.840.1.113883.10.20.22.4.3

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

section

2.16.840.1.113883.10.20.22.2.7

entry

2.16.840.1.113883.10.20.22.4.12

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Problem Section (entries optional)
Problem Concern Act (Condition)
Problem Observation

Procedures Section (entries optional)
Procedure Activity Act

Procedure Activity Procedure

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Template Title

Template
Type

templateId

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.13

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

Severity Observation
Service Delivery Location
Procedure Activity Observation

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Severity Observation

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Template Title

Template
Type

templateId

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.8

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

Severity Observation

entry

2.16.840.1.113883.10.20.22.4.32

Reason for Visit Section

section

2.16.840.1.113883.10.20.22.2.12

Results Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.3

entry

2.16.840.1.113883.10.20.22.4.1

entry

2.16.840.1.113883.10.20.22.4.2

Review of Systems Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.18

Social History Section

section

2.16.840.1.113883.10.20.22.2.17

entry

2.16.840.1.113883.10.20.15.3.8

Result Organizer
Result Observation

Pregnancy Observation
Estimated Date of Delivery

entry

2.16.840.1.113883.10.20.15.3.1

Smoking Status Observation

entry

2.16.840.1.113883.10.22.4.78

Social History Observation

entry

2.16.840.1.113883.10.20.22.4.38

section

2.16.840.1.113883.10.20.22.2.4

entry

2.16.840.1.113883.10.20.22.4.26

entry

2.16.840.1.113883.10.20.22.4.27

Vital Signs Section (entries optional)
Vital Signs Organizer
Vital Sign Observation

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4.6 Operative Note
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.7(open)]
The Operative Note is a frequently used type of procedure note with specific
requirements set forth by regulatory agencies.
The Operative Note is created immediately following a surgical procedure and
records the pre- and post-surgical diagnosis, pertinent events of the procedure,
as well as the condition of the patient following the procedure. The report should
be sufficiently detailed to support the diagnoses, justify the treatment, document
the course of the procedure, and provide continuity of care.24

4.6.1 Operative Note Header Constraints
The Operative Note must conform to the US Realm Clinical Document Header.
The following sections include additional header constraints for conformant
Operative Notes.
1. SHALL contain exactly one [1..1] templateId (CONF:9914) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10047).

4.6.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of an Operative Note as well as the
templateId for the US Realm Clinical Document Header template.
The following asserts conformance to an Operative Note.
2. SHALL contain exactly one [1..1] templateId (CONF:8483) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.7" (CONF:10048).
Figure 60: Operative note ClinicalDocument/templateId example





4.6.1.2 ClinicalDocument/code
The Surgical Operation Note LOINC Document Codes table shows the LOINC
codes suitable for Discharge Summary, as of publication of this implementation
guide. This is a dynamic value set meaning that these codes may be added to or
deprecated by LOINC.
24

http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?Stan
dardsFAQId=215&StandardsFAQChapterId=13
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The Operative Note recommends use of a single document type code, 11504-8
"Surgical Operation Note", with further specification provided by author or
performer, setting, or specialty. Some of the LOINC codes in the Surgical
Operation Note LOINC Document Codes table are pre-coordinated with the
practice setting or the training or professional level of the author. Use of precoordinated codes is not recommended because of potential conflict with other
information in the header. When these 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.
3. SHALL contain exactly one [1..1] code (CONF:17187).
a. This code SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet SurgicalOperationNoteDocumentTypeCode
2.16.840.1.113883.11.20.1.1 DYNAMIC (CONF:17188).
Table 33: Surgical Operation Note LOINC Document Codes
Value Set: SurgicalOperationNoteDocumentTypeCode 2.16.840.1.113883.11.20.1.1
DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC
Code

Type of Service
‘Component’

Setting
‘System’

Specialty/Training/Professional
Level ‘Method_Type’

{Setting}

{Provider}

Preferred Code
11504-8

Surgical operation
note

Additional Codes
34137-0

Surgical operation
note

Outpatient

{Provider}

28583-3

Surgical operation
note

{Setting}

Dentistry

28624-5

Surgical operation
note

{Setting}

Podiatry

28573-4

Surgical operation
note

{Setting}

Physician

34877-1

Surgical operation
note

{Setting}

Urology

34874-8

Surgical operation
note

{Setting}

Surgery

34870-6

Surgical operation
note

{Setting}

Plastic surgery

34868-0

Surgical operation
note

{Setting}

Orthopedics

34818-5

Surgical operation
note

{Setting}

Otorhinolaryngology

The following code should not be used; it is a duplicate
34871-4

Surgical operation
note

{Setting}

Podiatry

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Figure 61: Operative note ClinicalDocument/code example


4.6.1.3 DocumentationOf
A serviceEvent represents the main act, such as a colonoscopy or an
appendectomy, being documented. A serviceEvent can further specialize the
act inherent in the ClinicalDocument/code, such as where the
ClinicalDocument/code is simply "Surgical Operation Note" and the procedure
is "Appendectomy." serviceEvent is required in the Operative Note and it must
be equivalent to or further specialize the value inherent in the
ClinicalDocument/code; it shall not conflict with the value inherent in the
ClinicalDocument/code, as such a conflict would create ambiguity.
serviceEvent/effectiveTime can be used to indicate the time the actual
event (as opposed to the encounter surrounding the event) took place.
If the date and the duration of the procedure is known,
serviceEvent/effectiveTime/low is used with a width element that
describes the duration; no high element is used. However, if only the date is
known, the date is placed in both the low and high elements.
4. SHALL contain at least one [1..*] documentationOf (CONF:8486).
a. Such documentationOf SHALL contain exactly one [1..1]
serviceEvent (CONF:8493).
i. The value of Clinical Document
/documentationOf/serviceEvent/code SHALL be from ICD9
CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT4 (CodeSystem 2.16.840.1.113883.6.12), or values
descending from 71388002 (Procedure) from the SNOMED
CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet
Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC.
(CONF:8487).
ii. This serviceEvent SHALL contain exactly one [1..1]
effectiveTime (CONF:8494).
1. This effectiveTime SHALL contain exactly one [1..1] US
Realm Date and Time (DT.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.3)
(CONF:10136).
2. The serviceEvent/effectiveTime SHALL be present with
effectiveTime/low (CONF:8488).
3. If a width is not present, the
serviceEvent/effectiveTime SHALL include
effectiveTime/high. (CONF:10058)
4. When only the date and the length of the procedure
are known a width element SHALL be present and the

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serviceEvent/effectiveTime/high SHALL not be
present. (CONF:10060).
The performer represents clinicians who actually and principally carry out the
serviceEvent. Typically, these are clinicians who have surgical privileges in
their institutions such as Surgeons, Obstetrician/Gynecologists, and Family
Practice Physicians. The performer may also be Nonphysician Providers (NPP)
who have surgical privileges. There may be more than one primary performer in
the case of complicated surgeries. There are occasionally co-surgeons. Usually
they will be billing separately and will each dictate their own notes. An example
may be spinal surgery , where a general surgeon and an orthopedic surgeon
both are present and billing off the same Current Procedural Terminology (CPT)
codes. Typically two Operative Notes are generated; however, each will list the
other as a co-surgeon.
iii. This serviceEvent SHALL contain exactly one [1..1] performer
(CONF:8489) such that it
1. SHALL contain exactly one [1..1] @typeCode="PPRF"
Primary performer (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8495).
2. SHALL contain exactly one [1..1] assignedEntity
(CONF:10917).
a. This assignedEntity SHALL contain exactly one
[1..1] code with @xsi:type="CE" (CONF:8490).
i.

This code SHOULD contain exactly one
[1..1] @code, which SHOULD be selected
from ValueSet Provider Type
2.16.840.1.113883.3.88.12.3221.4
DYNAMIC (CONF:8491).

b. Any assistants SHALL be identified and SHALL be identified as
secondary performers (SPRF). (CONF:8512).

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Table 34: Provider Type Value Set (excerpt)
Value Set: Provider Type 2.16.840.1.113883.3.88.12.3221.4 DYNAMIC
Code System(s):

NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101

Description:

The Provider type vocabulary classifies providers according to the type of
license or accreditation they hold or the service they provide.

http://www.nucc.org/index.php?option=com_content&task=view
&id=14&Itemid=40
Code

Code System

Print Name

207L00000X

NUCC Health Care Provider
Taxonomy

Anesthesiology

207X00000X

NUCC Health Care Provider
Taxonomy

Orthopedic Surgery

207VG0400X

NUCC Health Care Provider
Taxonomy

Gynecology

…
Table 35: Procedure Codes from SNOMED CT
Value Set: Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC
Code System(s):

SNOMED CT 2.16.840.1.113883.6.96

Description:

SNOMED CT Procedure codes. Any code descending from 71388002
(Procedure) inclusive.
https://uts.nlm.nih.gov/snomedctBrowser.html (requires sign-up)

Code

Code System

Print Name

408816000

SNOMED CT

Artificial rupture of membranes

20050329

SNOMED CT

Laparoscopic Appendectomy

62013009

SNOMED CT

Ambulating patient

…

Figure 62: Operative note serviceEvent example






...


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Figure 63: Operative note performer example





1013 Healthcare Drive
Ann Arbor
MI
99999
US




Dr.
Carl
Cutter





4.6.2 Operative Note Body Constraints
The Operative Note supports both narrative sections and sections requiring code
clinical statements. The required and optional sections are listed in the
Document Types and Required/Optional Sections table. The table below the
constraints shows all templates including entries within each section.
1. SHALL contain exactly one [1..1] component (CONF:9585).
a. An Operative Note can have either a structuredBody or a
nonXMLBody (CONF:9586).
i.

An Operative 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 2.16.840.1.113883.10.20.22.1.7),
coded entries are optional. (CONF:9587).

b. If structuredBody, the component/structuredBody SHALL conform to
the section constraints below (CONF:9596).
i.

contain exactly one [1..1] Anesthesia Section
(2.16.840.1.113883.10.20.22.2.25) (CONF:9883).
SHALL

ii. SHALL contain exactly one [1..1] Complications Section
(2.16.840.1.113883.10.20.22.2.37) (CONF:9885).
iii. SHALL contain exactly one [1..1] Postoperative Diagnosis
Section (2.16.840.1.113883.10.20.22.2.35)
(CONF:9913).

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iv. SHALL contain exactly one [1..1] Preoperative Diagnosis
Section (2.16.840.1.113883.10.20.22.2.34)
(CONF:9888).
v. SHALL contain exactly one [1..1] Procedure Estimated
Blood Loss Section
(2.16.840.1.113883.10.20.18.2.9) (CONF:9890).
vi. SHALL contain exactly one [1..1] Procedure Findings
Section (2.16.840.1.113883.10.20.22.2.28)
(CONF:9892).
vii. SHALL contain exactly one [1..1] Procedure Specimens
Taken Section (2.16.840.1.113883.10.20.22.2.31)
(CONF:9894).
viii. SHALL contain exactly one [1..1] Procedure Description
Section (2.16.840.1.113883.10.20.22.2.27)
(CONF:9896).
ix. MAY contain zero or one [0..1] Procedure Implants Section
(2.16.840.1.113883.10.20.22.2.40) (CONF:9898).
x. MAY contain zero or one [0..1] Operative Note Fluids
Section (2.16.840.1.113883.10.20.7.12) (CONF:9900).
xi. MAY contain zero or one [0..1] Operative Note Surgical
Procedure Section (2.16.840.1.113883.10.20.7.14)
(CONF:9902).
xii. MAY contain zero or one [0..1] Plan of Care Section
(2.16.840.1.113883.10.20.22.2.10) (CONF:9904).
xiii. MAY contain zero or one [0..1] Planned Procedure Section
(2.16.840.1.113883.10.20.22.2.30) (CONF:9906).
xiv. MAY contain zero or one [0..1] Procedure Disposition
Section (2.16.840.1.113883.10.20.18.2.12)
(CONF:9908).
xv. MAY contain zero or one [0..1] Procedure Indications
Section (2.16.840.1.113883.10.20.22.2.29)
(CONF:9910).
xvi. MAY contain zero or one [0..1] Surgical Drains Section
(2.16.840.1.113883.10.20.7.13) (CONF:9912).

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The following table shows relationships among the templates in the body of an
Operative Note.
Table 36: Template Containment for an Operative Note
Template Title

Template
Type

templateId

Operative Note

document

2.16.840.1.113883.10.20.22.1.7

section

2.16.840.1.113883.10.20.22.2.25

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Anesthesia Section
Medication Activity

Procedure Activity Procedure

Severity Observation
Procedure Activity Procedure

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Template Title

Template
Type

templateId

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.8

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

section

2.16.840.1.113883.10.20.22.2.37

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

Operative Note Fluids Section

section

2.16.840.1.113883.10.20.7.12

Operative Note Surgical Procedure Section

section

2.16.840.1.113883.10.20.7.14

Plan of Care Section

Severity Observation

Complications Section
Problem Observation

section

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

entry

2.16.840.1.113883.10.20.22.4.43

section

2.16.840.1.113883.10.20.22.2.30

entry

2.16.840.1.113883.10.20.22.4.41

Postoperative Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.35

Preoperative Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.34

Preoperative Diagnosis

entry

2.16.840.1.113883.10.20.22.4.65

Problem Observation

entry

2.16.840.1.113883.10.20.22.4.4

Planned Procedure Section
Plan of Care Activity Procedure

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Template Title

Template
Type

templateId

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

Procedure Description Section

section

2.16.840.1.113883.10.20.22.2.27

Procedure Disposition Section

section

2.16.840.1.113883.10.20.18.2.12

Procedure Estimated Blood Loss Section

section

2.16.840.1.113883.10.20.18.2.9

Procedure Findings Section

section

2.16.840.1.113883.10.20.22.2.28

Problem Observation

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

Procedure Implants Section

section

2.16.840.1.113883.10.20.22.2.40

Procedure Indications Section

section

2.16.840.1.113883.10.20.22.2.29

entry

2.16.840.1.113883.10.20.22.4.19

Procedure Specimens Taken Section

section

2.16.840.1.113883.10.20.22.2.31

Surgical Drains Section

section

2.16.840.1.113883.10.20.7.13

Indication

4.7 Procedure Note
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.6(open)]
Procedure Note is a broad term that encompasses many specific types of nonoperative procedures including interventional cardiology, interventional
radiology, gastrointestinal endoscopy, osteopathic manipulation, and many
other specialty fields. Procedure Notes are documents that are differentiated
from Operative Notes in that the procedures documented do not involve incision
or excision as the primary act.
The Procedure Note is created immediately following a non-operative procedure
and records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient’s
tolerance of the procedure. The document should be sufficiently detailed to
justify the procedure, describe the course of the procedure, and provide
continuity of care.

4.7.1 Procedure Note Header Constraints
The Procedure Note must conform to the US Realm Clinical Document Header.
The following sections include additional header constraints for conformant
Procedure Notes
1. SHALL contain exactly one [1..1] templateId/ (CONF:9969) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10049).

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4.7.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of a Procedure Note as well as the
templateId for the US Realm Clinical Document Header template.
2. SHALL contain exactly one [1..1] templateId (CONF:8496) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.6" (CONF:10050).
Figure 64: Procedure note ClinicalDocument/templateId category I example





4.7.1.2 ClinicalDocument/code
The Procedure Note limits document type codes to those codes listed in the
LOINC Codes for Procedure Note Documents. The tables lists all codes having
the scale DOC (document) and a ‘component’ referring to a non-operative
procedure, whether or not the text string "Procedure" is present.
The Procedure Note recommends use of a single document type code, 28570-0
"Procedure Note", with further specification provided by author or performer,
setting, or specialty. Some of the LOINC codes in the LOINC Codes for Procedure
Note Documents table are pre-coordinated with the practice setting or the
training or professional level of the author. Use of pre-coordinated codes is not
recommended because of potential conflict with other information in the header.
When these 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.
3. SHALL contain exactly one [1..1] code (CONF:17182).
a. This code SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet ProcedureNoteDocumentTypeCodes
2.16.840.1.113883.11.20.6.1 DYNAMIC (CONF:17183).

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Table 37: Procedure Note LOINC Document Type Codes
Value Set: ProcedureNoteDocumentTypeCodes 2.16.840.1.113883.11.20.6.1 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC
Code

Type of Service
‘Component’

Setting
‘System’

Specialty/Training/Professional Level
‘Method_Type’

{Setting}

{Provider}

Preferred Code
28570-0

Procedure note

Additional Codes
11505-5

Procedure note

{Setting}

Physician

18744-3

Study report

Respiratory
system

Bronchoscopy

18745-0

Study report

Heart

Cardiac catheterization

18746-8

Study report

Lower GI
tract

Colonoscopy

18751-8

Study report

Upper GI
tract

Endoscopy

18753-4

Study report

Lower GI
tract

Flexible sigmoidoscopy

18836-7

Procedure

Cardiac
stress study

*

28577-5

Procedure note

{Setting}

Dentistry

28625-2

Procedure note

{Setting}

Podiatry

29757-2

Study report

Cvx/Vag

Colposcopy

33721-2

Bone marrow biopsy
report

Bone mar

34121-4

Interventional
procedure note

{Setting}

34896-1

Interventional
procedure note

{Setting}

Cardiology

34899-5

Interventional
procedure note

{Setting}

Gastroenterology

47048-4

Diagnostic
interventional study
report

{Setting}

Interventional radiology

48807-2

Bone marrow
aspiration report

Bone mar

Figure 65: Procedure note ClinicalDocument/code example


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4.7.1.3 ComponentOf
4. SHOULD contain zero or one [0..1] componentOf/encompassingEncounter
(CONF:8499).
a. This componentOf/encompassingEncounter SHALL contain exactly
one [1..1] code (CONF:8501).
b. This componentOf/encompassingEncounter SHALL contain at least
one [1..*] location/healthCareFacility/id (CONF:8500).
c. This componentOf/encompassingEncounter MAY contain zero or one
[0..1] encounterParticipant (CONF:8502) such that it
i. SHALL contain exactly one [1..1] @typeCode="REF" Referrer
(CodeSystem: HL7ParticipationType
2.16.840.1.113883.5.90) (CONF:8503).

4.7.1.4 Generic Participant: Primary Care Provider
The participant element in the Procedure Note header follows the General
Header Constraints for participants. The Participant Scenarios table shows a
number of scenarios and the values for various participants.
5. MAY contain zero or more [0..*] participant (CONF:8504) such that it
a. SHALL contain exactly one [1..1] @typeCode="IND" Individual
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8505).
b. SHALL contain exactly one [1..1] functionCode="PCP" Primary Care
Physician (CodeSystem: participationFunction
2.16.840.1.113883.5.88) (CONF:8506).
c. SHALL contain exactly one [1..1]
associatedEntity/@classCode="PROV" Provider (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:8507).
i. This associatedEntity/@classCode SHALL contain exactly one
[1..1] associatedPerson (CONF:8508).

4.7.1.5 Participant Scenarios
Table 38: Participant Scenario
Scenario

Author

Custodian

Data
Enterer

Encompassing
Encounter/
Encounter
Participant

Legal
Authenticator

Participant

Service
Event/
Performer

Colonoscopy Participant Scenario: A surgeon refers a patient to an endoscopist. A colonoscopy is
performed at an outpatient surgery center. The endoscopist inputs information into an EHR. The
outpatient surgery center EHR generates a Procedure Note to send to the Hospital EHR.
Endoscopic
CDA
Procedure
Note

Endoscopist

Outpatient
surgery
center

None

Surgeon
[REF
(referrer)]

Endoscopist

None

Endoscopis
t

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Scenario

Author

Custodian

Data
Enterer

Encompassing
Encounter/
Encounter
Participant

Legal
Authenticator

Participant

Service
Event/
Performer

Office Removal of Wart Participation Scenario: A wart is removed during an office visit. The PCP
dictates the procedure into the local transcription system. The transcription system generates a CDA
Procedure Note to the EHR.
CDA
Procedure
Note

PCP

PCP
office

Transcriptionist

None

PCP

None

PCP

Dental Procedure Participation Scenario: Dentist extracts a tooth after the patient has a cleaning by
the hygenist. He enters the information into his Dental EHR.
Procedure
input to
EHR

Dentist

Dentist
office

Varies

None

Dentist

None

Dentist
Hygenist

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedure (Interventional Radiology)
Participant Scenario: At a university hospital, a TIPS procedure is performed by the interventional
radiology fellow, with the help of an interventional radiology nurse, under the supervision of an
attending interventional radiologist. The radiology technician enters the data into the EMR. The patient
was referred to the university hospital by his oncologist. The patient is insured by Cigna.
Procedure
Note is
input in
EHR

Interventional
radiology
fellow

Good
Health
Hospita
l

Interventional
radiology
technician

REF
(referrer)
Oncologist

Attending
interventional
radiologist

Cigna

Interventional
radiology
fellow
Nurse
Attending
interventional
radiologist

Lumbar Puncture (spinal tap) Procedure Participant Scenario: At a university hospital, a lumbar
puncture is performed by a medical student, with the help of an intern, under the supervisory authority
of an attending neurologist. The student performs the procedure and dictates the note. The note is
signed by the intern and attending. The patient has a family doctor that is not participating in the
procedure, did not refer the patient, and does not have privileges at the providing organization but is
recorded in the note.
Procedure
Note is
dictated
by the
medical
student

Medical
student

Good
Health
Hospita
l

Transcriptionist

None

Neurology
attending
(Intern is
authenticator)

Family
doctor

Medical
student
Intern

4.7.1.6 ServiceEvent
A serviceEvent is required in the Procedure Note to represent the main act,
such as a colonoscopy or a cardiac stress study, being documented. It must be
equivalent to or further specialize the value inherent in the
ClinicalDocument/@code (such as where the ClinicalDocument/@code is
simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not

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conflict with the value inherent in the ClinicalDocument/@code, as such a
conflict would create ambiguity. A serviceEvent/effectiveTime element
indicates the time the actual event (as opposed to the encounter surrounding
the event) took place.
serviceEvent/effectiveTime may be represented two different ways in the
Procedure Note. For accuracy to the second, the best method is
effectiveTime/low together with effectiveTime/high. If a more general
time, such as minutes or hours, is acceptable OR if the duration is unknown, an
effectiveTime/low with a width element may be used. If the duration is
unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for
the width element.
6. SHALL contain at least one [1..*] documentationOf (CONF:8510).
a. Such documentationOf SHALL contain exactly one [1..1]
serviceEvent (CONF:10061).
i.

The value of Clinical Document
/documentationOf/serviceEvent/code SHALL be from ICD9 CM
Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4
(codeSystem 2.16.840.1.113883.6.12), or values descending
from 71388002 (Procedure) from the SNOMED CT
(codeSystem 2.16.840.1.113883.6.96) ValueSet Procedure
2.16.840.1.113883.3.88.12.80.28 DYNAMIC. (CONF:8511).

ii. This serviceEvent SHALL contain exactly one [1..1]
effectiveTime (CONF:10062).
1. This effectiveTime SHALL contain exactly one [1..1] US
Realm Date and Time (DT.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.3) (CONF:10063)
2. The serviceEvent/effectiveTime SHALL be present with
effectiveTime/low (CONF:8513).
3. If a width is not present, the
serviceEvent/effectiveTime SHALL include
effectiveTime/high. (CONF:8514)
4. When only the date and the length of the procedure
are known a width element SHALL be present and the
serviceEvent/effectiveTime/high SHALL not be present.
(CONF:8515).
The performer participant represents clinicians who actually and principally
carry out the serviceEvent. Typically, these are clinicians who have the
appropriate privileges in their institutions such as gastroenterologists,
interventional radiologists, and family practice physicians. Performers may also
be non-physician providers (NPPs) who have other significant roles in the
procedure such as a radiology technician, dental assistant, or nurse.
iii. SHALL contain exactly one [1..1] performer (CONF:8520) such
that it
1. SHALL contain exactly one [1..1] @typeCode="PPRF"
Primary Performer (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8521).
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2. SHALL contain exactly one [1..1] assignedEntity
(CONF:14911).
a. This assignedEntity SHOULD contain zero or one
[0..1] code (CONF:14912).
i.

The code, if present, SHOULD contain
zero or one [0..1] @code, which SHALL be
selected from ValueSet Healthcare
Provider Taxonomy (NUCC - HIPAA)
2.16.840.1.114222.4.11.1066
DYNAMIC (CONF:14913).

iv. Any assistants SHALL be identified and SHALL be identified as
secondary performers (SPRF). (CONF:8524).
Table 39: Healthcare Provider Taxonomy Value Set
Value Set: Healthcare Provider Taxonomy (NUCC - HIPAA) 2.16.840.1.114222.4.11.1066
DYNAMIC
Code System(s):
Code

NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101
Code System

Print Name

122300000X

NUCC Health Care Provider Taxonomy

Dentist

124Q00000X

NUCC Health Care Provider Taxonomy

Dental Hygienist

126800000X

NUCC Health Care Provider Taxonomy

Dental Assistant/Tech

133V00000X

NUCC Health Care Provider Taxonomy

Dietitian, Registered

146L00000X

NUCC Health Care Provider Taxonomy

EMT/Paramedic

163W00000X

NUCC Health Care Provider Taxonomy

Registered Nurse

163WI0500X

NUCC Health Care Provider Taxonomy

IVT Team Staff

163WI0600X

NUCC Health Care Provider Taxonomy

Infection Control Professional

163WX0106X

NUCC Health Care Provider Taxonomy

Occupational Health
Professional

164W00000X

NUCC Health Care Provider Taxonomy

Licensed Practical Nurse

167G00000X

NUCC Health Care Provider Taxonomy

Psychiatric Technician

183500000X

NUCC Health Care Provider Taxonomy

Pharmacist

207PE0004X

NUCC Health Care Provider Taxonomy

Other First Responder

227800000X

NUCC Health Care Provider Taxonomy

Respiratory Therapist/Tech

227900000X

NUCC Health Care Provider Taxonomy

Other Student

246QM0706X

NUCC Health Care Provider Taxonomy

Medical Technologist

246RP1900X

NUCC Health Care Provider Taxonomy

Phlebotomist/IV Team

247100000X

NUCC Health Care Provider Taxonomy

Radiologic Technologist

261QD0000X

NUCC Health Care Provider Taxonomy

Other Dental Worker

261QP2000X

NUCC Health Care Provider Taxonomy

Physical Therapist

261QR1100X

NUCC Health Care Provider Taxonomy

Researcher

332B00000X

NUCC Health Care Provider Taxonomy

Central Supply

363A00000X

NUCC Health Care Provider Taxonomy

Physician Assistant

363L00000X

NUCC Health Care Provider Taxonomy

Nurse Practitioner

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Value Set: Healthcare Provider Taxonomy (NUCC - HIPAA) 2.16.840.1.114222.4.11.1066
DYNAMIC
Code System(s):
Code

NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101
Code System

Print Name

364SC1501X

NUCC Health Care Provider Taxonomy

Public Health Worker

367500000X

NUCC Health Care Provider Taxonomy

Nurse Anesthetist

367A00000X

NUCC Health Care Provider Taxonomy

Nurse Midwife

3747A0650X

NUCC Health Care Provider Taxonomy

Attendant/orderly

376K00000X

NUCC Health Care Provider Taxonomy

Nursing Assistant

Figure 66: Procedure note serviceEvent example






...


Figure 67: Procedure note serviceEvent example with null value in width element






...


Page 176
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July 2012

Figure 68: Procedure note performer example





1001 Hospital Lane
Ann Arbor
MI
99999
US




Dr.
Tony
Tum




4.7.2 Procedure Note Body Constraints
The Procedure Note supports both narrative sections and sections requiring code
clinical statements. The required and optional sections are listed in the
Document Types and Required/Optional Sections table. The table below the
constraints shows all templates including entries within each section.
1. SHALL contain exactly one [1..1] component (CONF:9588).
a. A Procedure Note can have either a structuredBody or a
nonXMLBody (CONF:9589).
i.

A Procedure 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 2.16.840.1.113883.10.20.22.1.6),
coded entries are optional. (CONF:9590).

b. If structuredBody, the component/structuredBody SHALL conform to
the section constraints below (CONF:9595).
i.

Each section SHALL have a title and the title SHALL NOT
be empty (CONF:9937).

ii. SHALL include an Assessment and Plan Section, or an
Assessment Section and a Plan Section. (CONF:9643).
iii. SHALL NOT include an Assessment/Plan Section when an
Assessment Section and a Plan of Care Section are present.
(CONF:10064)

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iv. MAY contain zero or one [0..1] Assessment Section
(templateId:2.16.840.1.113883.10.20.22.2.8)
(CONF:9645).
v. MAY contain zero or one [0..1] Plan of Care Section
(templateId:2.16.840.1.113883.10.20.22.2.10)
(CONF:9647).
vi. MAY contain zero or one [0..1] Assessment and Plan
Section (templateId:2.16.840.1.113883.10.20.22.2.9)
(CONF:9649).
vii. SHALL contain exactly one [1..1] Complications Section
(templateId:2.16.840.1.113883.10.20.22.2.37)
(CONF:9802).
viii. SHALL contain exactly one [1..1] Postprocedure Diagnosis
Section
(templateId:2.16.840.1.113883.10.20.22.2.36)
(CONF:9850).
ix. SHALL contain exactly one [1..1] Procedure Description
Section
(templateId:2.16.840.1.113883.10.20.22.2.27)
(CONF:9805).
x. SHALL contain exactly one [1..1] Procedure Indications
Section
(templateId:2.16.840.1.113883.10.20.22.2.29)
(CONF:9807).
xi. MAY contain zero or one [0..1] Allergies Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.6)
(CONF:9809).
xii. MAY contain zero or one [0..1] Anesthesia Section
(templateId:2.16.840.1.113883.10.20.22.2.25)
(CONF:9811).
xiii. SHALL NOT include a Chief Complaint and Reason for Visit
Section with either a Chief Complaint Section or a Reason for
Visit Section. (CONF:10065)
xiv. MAY contain zero or one [0..1] Chief Complaint Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
(CONF:9813).
xv. MAY contain zero or one [0..1] Chief Complaint and Reason
for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.13)
(CONF:9815).
xvi. MAY contain zero or one [0..1] Family History Section
(templateId:2.16.840.1.113883.10.20.22.2.15)
(CONF:9817).
xvii. MAY contain zero or one [0..1] History of Past Illness
Section

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(templateId:2.16.840.1.113883.10.20.22.2.20)
(CONF:9819).
xviii. MAY contain zero or one [0..1] History of Present
Illness Section (templateId:
1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:9821).
xix. MAY contain zero or one [0..1] Medical (General) History
Section
(templateId:2.16.840.1.113883.10.20.22.2.39)
(CONF:9823).
xx. MAY contain zero or one [0..1] Medications Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.1)
(CONF:9825).
xxi. MAY contain zero or one [0..1] Medications Administered
Section
(templateId:2.16.840.1.113883.10.20.22.2.38)
(CONF:9827).
xxii. MAY contain zero or one [0..1] Physical Exam Section
(templateId:2.16.840.1.113883.10.20.2.10)
(CONF:9829).
xxiii. MAY contain zero or one [0..1] Planned Procedure
Section
(templateId:2.16.840.1.113883.10.20.22.2.30)
(CONF:9831).
xxiv. MAY contain zero or one [0..1] Procedure Disposition
Section
(templateId:2.16.840.1.113883.10.20.18.2.12)
(CONF:9833).
xxv. MAY contain zero or one [0..1] Procedure Estimated Blood
Loss Section
(templateId:2.16.840.1.113883.10.20.18.2.9)
(CONF:9835).
xxvi. MAY contain zero or one [0..1] Procedure Findings
Section
(templateId:2.16.840.1.113883.10.20.22.2.28)
(CONF:9837).
xxvii. MAY contain zero or one [0..1] Procedure Implants
Section
(templateId:2.16.840.1.113883.10.20.22.2.40)
(CONF:9839).
xxviii. MAY contain zero or one [0..1] Procedure Specimens
Taken Section
(templateId:2.16.840.1.113883.10.20.22.2.31)
(CONF:9841).
xxix. MAY contain zero or one [0..1] Procedures Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.7)
(CONF:9843).
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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xxx. MAY contain zero or one [0..1] Reason for Visit Section
(templateId:2.16.840.1.113883.10.20.22.2.12)
(CONF:9845).
xxxi. MAY contain zero or one [0..1] Review of Systems
Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18)
(CONF:9847).
xxxii. MAY contain zero or one [0..1] Social History Section
(templateId:2.16.840.1.113883.10.20.22.2.17)
(CONF:9849).
The following table shows relationships among the templates in the body of a
Procedure Note.
Table 40: Template Containment for a Procedure Note
Template Title

Template
Type

templateId

Procedure Note

document

2.16.840.1.113883.10.20.22.1.6

section

2.16.840.1.113883.10.20.22.2.6

entry

2.16.840.1.113883.10.20.22.4.30

Allergies Section (entries optional)
Allergy Problem Act
Allergy - Intolerance Observation

entry

2.16.840.1.113883.10.20.22.4.7

Allergy Status Observation

entry

2.16.840.1.113883.10.20.22.4.28

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

entry

2.16.840.1.113883.10.20.22.4.19

Indication

Page 180
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July 2012

Template Title

Template
Type

templateId

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.25

Severity Observation
Severity Observation
Anesthesia Section
Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

entry

2.16.840.1.113883.10.20.22.4.54

Immunization Medication Information

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Template Title

Template
Type

templateId

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

Procedure Activity Procedure

Severity Observation
Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.8

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

section

2.16.840.1.113883.10.20.22.2.9

entry

2.16.840.1.113883.10.20.22.4.39

section

2.16.840.1.113883.10.20.22.2.8

Severity Observation

Assessment and Plan Section
Plan of Care Activity Act
Assessment Section

Page 182
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July 2012

Template Title

Template
Type

templateId

Chief Complaint and Reason for Visit
Section

section

2.16.840.1.113883.10.20.22.2.13

Chief Complaint Section

section

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

Complications Section

section

2.16.840.1.113883.10.20.22.2.37

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

section

2.16.840.1.113883.10.20.22.2.15

entry

2.16.840.1.113883.10.20.22.4.45

entry

2.16.840.1.113883.10.20.22.4.46

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Family History Death Observation

entry

2.16.840.1.113883.10.20.22.4.47

section

2.16.840.1.113883.10.20.22.2.20

Problem Observation

Family History Section
Family History Organizer
Family History Observation

History of Past Illness Section
Problem Observation

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

History of Present Illness Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.4

Medical (General) History Section

section

2.16.840.1.113883.10.20.22.2.39

Medications Administered Section

section

2.16.840.1.113883.10.20.22.2.38

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Template Title

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.1

Procedure Activity Procedure

Severity Observation
Medications Section (entries optional)
Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

Physical Exam Section

section

2.16.840.1.113883.10.20.2.10

Plan of Care Section

section

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Procedure Activity Procedure

Severity Observation

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July 2012

Template Title

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.43

section

2.16.840.1.113883.10.20.22.2.30

entry

2.16.840.1.113883.10.20.22.4.41

section

2.16.840.1.113883.10.20.22.2.36

Postprocedure Diagnosis

entry

2.16.840.1.113883.10.20.22.4.51

Problem Observation

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

Procedure Description Section

section

2.16.840.1.113883.10.20.22.2.27

Procedure Disposition Section

section

2.16.840.1.113883.10.20.18.2.12

Procedure Estimated Blood Loss Section

section

2.16.840.1.113883.10.20.18.2.9

Procedure Findings Section

section

2.16.840.1.113883.10.20.22.2.28

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

Procedure Implants Section

section

2.16.840.1.113883.10.20.22.2.40

Procedure Indications Section

section

2.16.840.1.113883.10.20.22.2.29

entry

2.16.840.1.113883.10.20.22.4.19

Procedure Specimens Taken Section

section

2.16.840.1.113883.10.20.22.2.31

Procedures Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.7

entry

2.16.840.1.113883.10.20.22.4.12

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

entry

2.16.840.1.113883.10.20.22.4.54

Plan of Care Activity Supply
Planned Procedure Section
Plan of Care Activity Procedure
Postprocedure Diagnosis Section

Problem Observation

Indication

Procedure Activity Act

Immunization Medication Information

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Template Title

Template
Type

templateId

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.13

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

Procedure Activity Procedure

Severity Observation
Service Delivery Location
Procedure Activity Observation

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

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July 2012

Template Title

Template
Type

templateId

entry

2.16.840.1.113883.10.20.22.4.8

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.8

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Reason for Visit Section

section

2.16.840.1.113883.10.20.22.2.12

Review of Systems Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.18

Social History Section

section

2.16.840.1.113883.10.20.22.2.17

entry

2.16.840.1.113883.10.20.15.3.8

Estimated Date of Delivery

entry

2.16.840.1.113883.10.20.15.3.1

Smoking Status Observation

entry

2.16.840.1.113883.10.22.4.78

Social History Observation

entry

2.16.840.1.113883.10.20.22.4.38

Severity Observation

Severity Observation

Pregnancy Observation

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4.8 Progress Note
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.9(open)]
A Progress Note documents a patient’s clinical status during a hospitalization or
outpatient visit; thus, it is associated with an encounter.
Taber’s25 medical dictionary defines a Progress Note as “An ongoing record of a
patient's illness and treatment. Physicians, nurses, consultants, and therapists
record their notes concerning the progress or lack of progress made by the
patient between the time of the previous note and the most recent note.”
Mosby’s26 medical dictionary defines a Progress Note as “Notes made by a nurse,
physician, social worker, physical therapist, and other health care professionals
that describe the patient's condition and the treatment given or planned.”
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be
a Progress Report for Medicare. Medicare B Section 1833(e) defines the
requirements of a Medicare Progress Report.

4.8.1 Progress Note Header Constraints
The Progress Note must conform to the US Realm Clinical Document Header.
The following sections include additional header constraints for conformant
Progress Notes.
1. SHALL contain exactly one [1..1] templateId/ (CONF:9483) such that it
a. SHALL contain exactly one [1..1]
templateId/@root="2.16.840.1.113883.10.20.22.1.1"
(CONF:10051).

4.8.1.1 ClinicalDocument/templateId
Conformant documents must carry the document-level templateId asserting
conformance with specific constraints of a Progress Note as well as the
templateId for the US Realm Clinical Document Header template.
The following asserts conformance to a Progress Note.
2. SHALL contain exactly one [1..1] templateId (CONF:7588) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.9" (CONF:10052).
Figure 69: Progress note ClinicalDocument/templateId example





Taber's Cyclopedic Medical Dictionary, 21st Edition, F.A. Davis Company.
http://www.tabers.com
26 Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.
25

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July 2012

4.8.1.2 ClinicalDocument/code
The Progress Note limits document type codes to those codes listed in the
Progress Note LOINC Document Codes, as of publication of this implementation
guide. This is a dynamic value set meaning that these codes may be added to or
deprecated by LOINC. The table lists all codes that have the scale DOC
(document) and a ‘component’ referring to “subsequent evaluation notes”.
The Progress Note recommends use of a single document type code, 11506-3
"Subsequent evaluation note", with further specification provided by author
or performer, setting, or specialty. Some of the LOINC codes in the Progress Note
LOINC Document Codes table are pre-coordinated with the practice setting or
the training or professional level of the author. Use of pre-coordinated codes is
not recommended because of potential conflict with other information in the
header. When these 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. Note: The LOINC display name
"Subsequent evaluation note" is equivalent to Progress Note.
3. SHALL contain exactly one [1..1] code (CONF:17189).
a. This code SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet ProgressNoteDocumentTypeCode
2.16.840.1.113883.11.20.8.1 DYNAMIC (CONF:17190).

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© 2012 Health Level Seven, Inc. All rights reserved.

Table 41: Progress Note LOINC Document Codes
Value Set: ProgressNoteDocumentTypeCode 2.16.840.1.113883.11.20.8.1 DYNAMIC
Code System: LOINC 2.16.840.1.113883.6.1
LOINC
Code

Type of Service
‘Component’

Setting ‘System’

Specialty/Training/
Professional Level
‘Method_Type’

{Setting}

{Provider}

Preferred Code
11506-3

Subsequent evaluation note

Additional Codes
18733-6

Subsequent evaluation note

{Setting}

Attending physician

18762-5

Subsequent evaluation note

{Setting}

Chiropractor

28569-2

Subsequent evaluation note

{Setting}

Consulting physician

28617-9

Subsequent evaluation note

{Setting}

Dentistry

34900-1

Subsequent evaluation note

{Setting}

General medicine

34904-3

Subsequent evaluation note

{Setting}

Mental health

18764-1

Subsequent evaluation note

{Setting}

Nurse practitioner

28623-7

Subsequent evaluation note

{Setting}

Nursing

11507-1

Subsequent evaluation note

{Setting}

Occupational therapy

11508-9

Subsequent evaluation note

{Setting}

Physical therapy

11509-7

Subsequent evaluation note

{Setting}

Podiatry

28627-8

Subsequent evaluation note

{Setting}

Psychiatry

11510-5

Subsequent evaluation note

{Setting}

Psychology

28656-7

Subsequent evaluation note

{Setting}

Social service

11512-1

Subsequent evaluation note

{Setting}

Speech therapy

34126-3

Subsequent evaluation note

Critical care unit

{Provider}

15507-7

Subsequent evaluation note

Emergency …

{Provider}

34129-7

Subsequent evaluation note

Home health

{Provider}

34125-5

Subsequent evaluation note

Home health care

Case manager

34130-5

Subsequent evaluation note

Hospital

{Provider}

34131-3

Subsequent evaluation note

Outpatient

{Provider}

34124-8

Subsequent evaluation note

Outpatient

Cardiology

34127-1

Subsequent evaluation note

Outpatient

Dental hygienist

34128-9

Subsequent evaluation note

Outpatient

Dentistry

34901-9

Subsequent evaluation note

Outpatient

General medicine

34132-1

Subsequent evaluation note

Outpatient

Pharmacy

Figure 70: Progress note ClinicalDocument/code example



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July 2012

4.8.1.3 DocumentationOf
A documentationOf can contain a serviceEvent to further specialize the act
inherent in the ClinicalDocument/code.
In a Progress Note, a serviceEvent can represent the event of writing the
Progress Note. The serviceEvent/effectiveTime is the time period the note
documents.
4. SHOULD contain zero or one [0..1] documentationOf (CONF:7603).
a. SHALL contain exactly one [1..1] serviceEvent/@classCode="PCPR"
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7604).
i.

contain exactly one [1..1] templateId (CONF:9480)
such that it
SHALL

1. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.21.3.1"
(CONF:10068).
ii. SHOULD contain exactly one [1..1] effectiveTime
(CONF:9481).
1. The serviceEvent/effectiveTime SHALL contain exactly
one [1..1] US Realm Date and Time
(DT.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.3) (CONF:10137)
2. The serviceEvent/effectiveTime element SHOULD be
present with effectiveTime/low element (CONF:9482).
3. If a width element is not present, the serviceEvent
SHALL include effectiveTime/high (CONF:10066).
Figure 71: Progress note serviceEvent example







...



4.8.1.4 ComponentOf
The Progress Note is always associated with an encounter by the
componentOf/encompassingEncounter element in the header.
The effectiveTime element for an encompassingEncounter represents the
time or time interval in which the encounter took place. A single encounter may
contain multiple Progress Notes; hence the effectiveTime elements for a
Progress Note (recorded in serviceEvent) and for an encounter (recorded in
encompassingEncounter) represent different time intervals.

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All visits take place at a specific location. When available, the location ID is
included in the encompassingEncounter/location/healthCareFacility/id
element.
5. SHALL contain exactly one [1..1] componentOf (CONF:7595).
a. This componentOf SHALL contain exactly one [1..1]
encompassingEncounter (CONF:7596).
i. This encompassingEncounter SHALL contain at least [1..*] id
(CONF:7597).
ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:7598).
1. This effectiveTime SHALL contain exactly one [1..1] US
Realm Date and Time (DT.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.3)
(CONF:10138).
2. This effectiveTime SHALL contain exactly one [1..1] low
(CONF:7599).
iii. This encompassingEncounter SHALL contain exactly one [1..1]
location/healthCareFacility/id (CONF:7611).
Figure 72: Progress note componentOf example















4.8.2 Progress Note Body Constraints
The Progress Note supports both narrative sections and sections requiring code
clinical statements. The sections are listed in the table below and in the
Document Types and Required/Optional Sections table. The table below the
constraints shows all templates including entries within each section.
1. SHALL contain exactly one [1..1] component (CONF:9591).
a. A Progress Note can have either a structuredBody or a nonXMLBody
(CONF:9592).
i.

A 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

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July 2012

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 (CONF:9593).
b. If structuredBody, the component/structuredBody SHALL conform to
the section constraints below (CONF:9594).
i.

include an Assessment and Plan Section, or an
Assessment Section and a Plan Section. (CONF:8704).
SHALL

ii. SHALL NOT include an Assessment/Plan Section when an
Assessment Section and a Plan of Care Section are present.
(CONF:10069)
iii. MAY contain zero or one [0..1] Assessment Section
(templateId:2.16.840.1.113883.10.20.22.2.8)
(CONF:8776).
iv. MAY contain zero or one [0..1] Plan of Care Section
(templateId:2.16.840.1.113883.10.20.22.2.10)
(CONF:8775).
contain zero or one [0..1] Assessment and Plan
Section (templateId:2.16.840.1.113883.10.20.22.2.9)
(CONF:8774).
MAY

v. MAY contain zero or one [0..1] Allergies Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.6)
(CONF:8773).
vi. MAY contain zero or one [0..1] Chief Complaint Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
(CONF:8772).
vii. MAY contain zero or one [0..1] Instructions Section
(templateId:2.16.840.1.113883.10.20.22.2.45)
(CONF:16806).
viii. MAY contain zero or one [0..1] Interventions Section
(templateId:2.16.840.1.113883.10.20.21.2.3)
(CONF:8778).
ix. MAY contain zero or one [0..1] Medications Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.1)
(CONF:8771).
x. MAY contain zero or one [0..1] Objective Section
(templateId:2.16.840.1.113883.10.20.21.2.1)
(CONF:8770).
xi. MAY contain zero or one [0..1] Physical Exam Section
(templateId:2.16.840.1.113883.10.20.2.10)
(CONF:8780).
xii. MAY contain zero or one [0..1] Problem Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.5)
(CONF:8786).

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xiii. MAY contain zero or one [0..1] Results Section (entries
optional)
(templateId:2.16.840.1.113883.10.20.22.2.3)
(CONF:8782).
xiv. MAY contain zero or one [0..1] Review of Systems Section
(templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18)
(CONF:8788).
xv. MAY contain zero or one [0..1] Subjective Section
(templateId:2.16.840.1.113883.10.20.21.2.2)
(CONF:8790).
xvi. MAY contain zero or one [0..1] Vital Signs Section
(entries optional)
(templateId:2.16.840.1.113883.10.20.22.2.4)
(CONF:8784).
The following table shows relationships among the templates in the body of a
Progress Note.
Table 42: Template Containment for a Progress Note
Template Title

Template
Type

templateId

Progress Note

document

2.16.840.1.113883.10.20.22.1.9

section

2.16.840.1.113883.10.20.22.2.6

entry

2.16.840.1.113883.10.20.22.4.30

entry

2.16.840.1.113883.10.20.22.4.7

Allergy Status Observation

entry

2.16.840.1.113883.10.20.22.4.28

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Allergies Section (entries optional)
Allergy Problem Act
Allergy - Intolerance Observation

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Template Title

Template
Type

templateId

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

entry

2.16.840.1.113883.10.20.22.4.8

section

2.16.840.1.113883.10.20.22.2.9

entry

2.16.840.1.113883.10.20.22.4.39

Assessment Section

section

2.16.840.1.113883.10.20.22.2.8

Chief Complaint Section

section

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

Instructions Section

section

2.16.840.1.113883.10.20.21.2.45

entry

2.16.840.1.113883.10.20.22.4.20

Interventions Section

section

2.16.840.1.113883.10.20.21.2.3

Medications Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.1

entry

2.16.840.1.113883.10.20.22.4.16

entry

2.16.840.1.113883.10.20.22.4.24

Severity Observation
Severity Observation
Assessment and Plan Section
Plan of Care Activity Act

Instructions

Medication Activity
Drug Vehicle

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Template Title

Template
Type

templateId

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication
Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

entry

2.16.840.1.113883.10.20.22.4.14

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

entry

2.16.840.1.113883.10.20.22.4.8

Objective Section

section

2.16.840.1.113883.10.20.21.2.1

Physical Exam Section

section

2.16.840.1.113883.10.20.2.10

Plan of Care Section

section

2.16.840.1.113883.10.20.22.2.10

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

entry

2.16.840.1.113883.10.20.22.4.43

section

2.16.840.1.113883.10.20.22.2.5

entry

2.16.840.1.113883.10.20.22.4.3

Procedure Activity Procedure

Severity Observation

Problem Section (entries optional)
Problem Concern Act (Condition)
Problem Observation

entry

2.16.840.1.113883.10.20.22.4.4

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Health Status Observation

entry

2.16.840.1.113883.10.20.22.4.5

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

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Template Title

Template
Type

templateId

section

2.16.840.1.113883.10.20.22.2.3

entry

2.16.840.1.113883.10.20.22.4.1

entry

2.16.840.1.113883.10.20.22.4.2

Review of Systems Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.18

Subjective Section

section

2.16.840.1.113883.10.20.21.2.2

Vital Signs Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.4

entry

2.16.840.1.113883.10.20.22.4.26

entry

2.16.840.1.113883.10.20.22.4.27

Results Section (entries optional)
Result Organizer
Result Observation

Vital Signs Organizer
Vital Sign Observation

4.9

Unstructured Document
[ClinicalDocument: templateId 2.16.840.1.113883.10.20.21.1.10(open)]
An unstructured document is a document which is used when the patient
record is captured in an unstructured format that is encapsulated within an
image file or as unstructured text in an electronic file such as a word processing
or Portable Document Format (PDF) document.
There is a need to raise the level of interoperability for these documents to
provide full access to the longitudinal patient record across a continuum of care.
Until this gap is addressed, image and multi-media files will continue to be a
portion of the patient record that remains difficult to access and share with all
participants in a patient’s care. The Unstructured Document type addresses this
gap by providing consistent guidance on the use of CDA for such documents.
An Unstructured Document (UD) document type can (1) include unstructured
content, such as a graphic, directly in a text element with a mediaType
attribute, or (2) reference a single document file, such as a word-processing
document, using a text/reference element.
For guidance on how to handle multiple files, on the selection of media types for
this IG, and on the identification of external files, see the subsections which
follow the constraints below.
IHE’s XDS-SD (Cross-Transaction Specifications and Content Specifications,
Scanned Documents Module) profile addresses a similar, more restricted use
case, specifically for scanned documents or documents electronically created
from existing text sources, and limits content to PDF-A or text. This
Unstructured Documents implementation guide is applicable not only for
scanned documents in non-PDF formats, but also for clinical documents
produced through word processing applications, etc.
For conformance with both specifications, please review the appendix on XDSSD and US Realm Clinical Document Header Comparison and ensure that your

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documents at a minimum conform to all the SHALL constraints from either
specification27.

4.9.1 Unstructured Document Header Constraints
An Unstructured Document must conform to the US Realm Clinical Document
Header. The following sections include additional header constraints for
conformant Unstructured Documents.
1. SHALL contain exactly one [1..1] templateId (CONF:9970) such that it
a. SHALL contain exactly one [1..1]
templateId/@root="2.16.840.1.113883.10.20.22.1.1"
(CONF:10053).

4.9.1.1 ClinicalDocument/templateId
Conformant Unstructured Documents must carry the document-level
templateId asserting conformance with this guide.
2. SHALL contain exactly one [1..1] templateId (CONF:7710) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.10" (CONF:10054).

4.9.1.2 RecordTarget
The recordTarget element records the patient or patients whose health
information is recorded in the Unstructured Documents instance. The following
constraint is an addition to those in the US Realm Clinical Document Header.
3. SHALL contain exactly one [1..1] recordTarget/patientRole/id
(CONF:7643).

4.9.1.3 Author
The author represents the person who created the original document.
If the referenced document is a scan, the person who did the scan must be
recorded in dataEnterer.
The following constraints are in addition to those in the US Realm Clinical
Document Header.
4. SHALL contain exactly one [1..1] author/assignedAuthor (CONF:7640).
a. This author/assignedAuthor SHALL contain exactly one [1..1] addr
(CONF:7641).
b. This author/assignedAuthor SHALL contain exactly one [1..1] telecom
(CONF:7642).

Note that the Consolidation Project is providing a number of change requests to IHE. One of
those recommendations should be the elimination of these discrepancies so that the IHE profile is
a proper subset of this guide.
27

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4.9.1.4 Custodian
The following constraints are in addition to those in the US Ream Header.
5. SHALL contain exactly one [1..1]
custodian/assignedCustodian/representedCustodianOrganization
(CONF:7645).
a. This
custodian/assignedCustodian/representedCustodianOrganization
SHALL contain exactly one [1..1] id (CONF:7648).
b. This
custodian/assignedCustodian/representedCustodianOrganization
SHALL contain exactly one [1..1] name (CONF:7649).
c. This
custodian/assignedCustodian/representedCustodianOrganization
SHALL contain exactly one [1..1] telecom (CONF:7650).
d. This
custodian/assignedCustodian/representedCustodianOrganization
SHALL contain exactly one [1..1] addr (CONF:7651).

4.9.2 Unstructured Document Body Constraints
An Unstructured Document must include a nonXMLBody component with a
single text element. The text element can reference an external file using a
reference element, or include unstructured content directly with a mediaType
attribute.
The nonXMLBody/text element also has a "compression" attribute that can be
used to indicate that the unstructured content was compressed before being
Base64Encoded. At a minimum, a compression value of "DF" for the deflate
compression algorithm (RFC 1951 [http://www.ietf.org/rfc/rfc1951.txt]) must
be supported although it is not required that content be compressed.
6. SHALL contain exactly one [1..1] component/nonXMLBody (CONF:7620).
a. This component/nonXMLBody SHALL contain exactly one [1..1] text
(CONF:7622).
i. The text element SHALL either contain a reference element
with a value attribute, or have a representation attribute
with the value of B64, a mediaType attribute, and contain
the media content. (CONF:7623).
1. The value of @mediaType, if present, SHALL be drawn
from the value set 2.16.840.1.113883.11.20.7.1
SupportedFileFormats STATIC 20100512.
(CONF:7624).

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Table 43: Supported File Formats Value Set (Unstructured Documents)
Value Set: SupportedFileFormats 2.16.840.1.113883.11.20.7.1 STATIC 20100512
Word Processing/Narrative Formats

Code

MSWord

application/msword*

PDF

application/pdf

Plain Text

text/plain

RTF Text

text/rtf

HTML

text/html

Graphic Formats

Code

GIF Image

image/gif

TIF Image

image/tiff

JPEG Image

image/jpeg

PNG Image

image/png

* The developers explicitly excluded newer versions of MSWord because they are wellformed, structured XML documents, which are not appropriate in an Unstructured
Document. MSWord versions after 2007 have media type:
application/vnd.openxmlformats-officedocument.wordprocessingml.document.
Figure 73: nonXMLBody example with embedded content


e1xydGY...



Figure 74: nonXMLBody example with referenced content








Figure 75: nonXMLBody example with compressed content


dhUhkasd437hbjfQS7…



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4.9.2.1 Multiple Files and File Packaging
If multiple files, such as several scanned files, constitute a single document,
options include: use a CDA document type that has a structuredBody, use a
multi-page/graphic file type such as PDF, or stitch the separate images into a
single image.
For guidance on how to package a CDA Unstructured Document together with
an unstructured document it references, see the MIME Multipart/Related
Messages appendix.

4.9.2.2 Media Types Supported
The Unstructured Document model does not support all possible file formats
and it excludes structured formats such as generic XML. The media types
supported are commonly used within a healthcare setting as part of the patient
record.
The CDA Data Types specification 28 provides an extensible value set of MIME
(Multipurpose Internet Mail Extensions) media types that are supported by base
CDA. Exclusions from and extensions to that list are discussed below.
Media type exclusions. This guide restricts usage of media types listed in the
CDA Data Types specification. In the absence of a use case for a video format as
part of the patient record, video formats are not included. However, an
unstructured document can link to a video or other file format; for example, a
Microsoft Word file can contain a link to a video.
Media type extensions. Although the CDA Data Types specification indicates
that ‘application/msword’ should not be used, that format is very common in
use cases that apply to Unstructured Documents, and this guide allows it. The
usage applies only to documents in binary format; it is not appropriate for rich
text format (RTF) which has a separate MIME type, or the .docx format, which is
not currently recommended for use in an Unstructured Document.
Local policy. Some content formats—in particular, tagged-image file format
(TIFF)—entail further complexity. While this guide allows TIFF because it is in
common use, its variants introduce profound interoperability issues: local
implementations would establish policy to ensure appropriate interoperability.
Microsoft Word binary formats entail similar issues.

4.9.2.3 Identification of Referenced Files
The example code in this section and in the sample file use simple filenames
with relative paths because they are easy to read as examples. However, simple
filenames and relative paths can cause problems when files are moved among
systems.
The hazard to be avoided can be illustrated as follows: Suppose an
Unstructured Document that references a file "ekg.pdf" is transmitted to a
receiver who places that Unstructured Document in a directory that already
contains an Unstructured Document for another patient, which also references
28

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a file "ekg.pdf". Now the patient header information for the transmitted
document is associated with the ekg.pdf of the previously-existing document.
Thus, the use of relative paths and simple filenames can pose a danger to
patient safety.
The alternative of providing an absolute URL (Uniform Resource Locator) will
fail if the URL is inaccessible; even within a single organization, machine
identifiers may be mapped differently at different locations.
Therefore this guide, while it cannot specify business practices, recommends
the use of unique names for referenced files.
One approach to generating a unique name is to construct it from the globallyunique document id (root and extension) concatenated to a locally unique
reference for the external file. The following figure illustrates this technique
used with a CDA document that has an id root 2.16.840.1.113883.19 and
extension 999021.
Figure 76: Unique file reference example


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5

SECTION-LEVEL TEMPLATES
This section contains the section-level templates referenced by one or more of
the document types of this consolidated guide. These templates describe the
purpose of each section and the section-level constraints.
Section-level templates are always included in a document.
Each section-level template contains the following:
Template metadata (e.g., templateId, etc.)
Description and explanatory narrative
LOINC section code
Section title
Requirements for a text element
Entry-level template names and Ids for referenced templates (required
and optional)
Narrative Text
The text element within the section stores the narrative to be rendered, as
described in the CDA R2 specification 29, and is referred to as the CDA narrative
block.
The content model of the CDA narrative block schema is hand crafted to meet
requirements of human readability and rendering. The schema is registered as a
MIME type (text/x-hl7-text+xml), which is the fixed media type for the text
element.
As noted in the CDA R2 specification, the document originator is responsible for
ensuring that the narrative block contains the complete, human readable,
attested content of the section. Structured entries support computer processing
and computation and are not a replacement for the attestable, human-readable
content of the CDA narrative block. The special case of structured entries with
an entry relationship of "DRIV" (is derived from) indicates to the receiving
application that the source of the narrative block is the structured entries, and
that the contents of the two are clinically equivalent.
As for all CDA documents—even when a report consisting entirely of structured
entries is transformed into CDA—the encoding application must ensure that the
authenticated content (narrative plus multimedia) is a faithful and complete
rendering of the clinical content of the structured source data. As a general
guideline, a generated narrative block should include the same human readable
content that would be available to users viewing that content in the originating
system. Although content formatting in the narrative block need not be identical
to that in the originating system, the narrative block should use elements from
the CDA narrative block schema to provide sufficient formatting to support

29

HL7 Clinical Document Architecture, Release 2.0.

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human readability when rendered according to the rules defined in Section
Narrative Block (§ 4.3.5 ) of the CDA R2 specification.
By definition, a receiving application cannot assume that all clinical content in a
section (i.e., in the narrative block and multimedia) is contained in the
structured entries unless the entries in the section have an entry relationship of
"DRIV".
Additional specification information for the CDA narrative block can be found in
the CDA R2 specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and
6.
Required and Optional Sections
The table on Sections and Required/Optional Document Types summarizes the
use and reuse of section-level templates across the document types. Note that
the constraints for the entry templates themselves are contained in the entrylevel templates section of this guide. The templates required for the Final Rules
on Stage 1 Meaningful Use are noted by an “R” in the last column of the table.

Consultation Note

Diagnostic Imaging Report

Discharge Summary

H&P Note

Operative Note

Procedure Note

Progress Note

Unstructured Document

O

–

–

–

–

–

–

–

*

–

–

O

–

–

–

–

–

*

2.16.840.1.113883.10.20.22.2.6.1
2.16.840.1.113883.10.20.22.2.6

R

O

–

R

R

–

O

O

*

59774-0

(no coded entries required)
2.16.840.1.113883.10.20.22.2.25

–

–

–

–

–

R

O

–

*

Assessment
**

51848-0

(no coded entries required)
2.16.840.1.113883.10.20.22.2.8

–

R

–

–

R

–

R

–

*

Assessment
and Plan**

51847-2

(no coded entries required)
2.16.840.1.113883.10.20.22.2.9

–

R

–

–

R

–

R

R

*

Chief
Complaint***

10154-3

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

–

O

–

O

R

–

O

O

Chief
Complaint
and Reason
for Visit***

46239-0

(no coded entries required)
2.16.840.1.113883.10.20.22.2.13

–

R

–

O

R

–

O

–

Section
Name

LOINC

Advance
Directives

42348-3

Addendum

55107-7

Allergies

48765-2

Anesthesia

templateId
Coded Entries Required
Coded Entries Optional
(no coded entries required)
2.16.840.1.113883.10.20.22.2.21

Page 204
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July 2012

*

Stage 1 Meaningful Use

CCD

Table 44: Sections and Required/Optional Document Types with Structured Body

R

Consultation Note

Diagnostic Imaging Report

Discharge Summary

H&P Note

Operative Note

Procedure Note

Progress Note

Unstructured Document

–

O

–

–

–

–

–

*

–

–

O

–

–

R

R

–

*

55110-1

–

–

O

–

–

–

–

–

*

Current
Imaging
Procedure
Descriptions

55111-9

–

–

O

–

–

–

–

–

*

DICOM
Object
Catalog

121181
(DCM)

2.16.840.1.113883.10.20.6.1.1

–

–

R

–

–

–

–

–

–

Discharge
Diet

42344-2

(no coded entries required)
1.3.6.1.4.1.19376.1.5.3.1.3.33

–

–

–

O

–

–

–

–

*

Document
Summary

55112-7

–

–

O

–

–

–

–

–

*

Encounters

46240-8

(no coded entries required)
2.16.840.1.113883.10.20.22.2.22

O

–

–

–

–

–

–

–

*

Family
History

10157-6

—
2.16.840.1.113883.10.20.22.2.15

O

O

–

O

R

–

O

–

*

Findings
(Radiology
Study Observation)

18782-3

(no coded entries required)
2.16.840.1.113883.10.20.6.1.2

–

–

R

–

–

–

–

–

*

Functional
Status

47420-5

(no coded entries required)
2.16.840.1.113883.10.20.22.2.14

O

–

–

O

–

–

–

–

*

General
Status

10210-3

(no coded entries required)
2.16.840.1.113883.10.20.2.5

–

O

–

–

R

–

–

–

History of
Past Illness
(Past Medical
History)

11348-0

(no coded entries required)
2.16.840.1.113883.10.20.22.2.20

–

O

–

O

O

–

O

–

*

History of
Present
Illness

10164-2

(no coded entries required)
1.3.6.1.4.1.19376.1.5.3.1.3.4

–

R

–

O

O

–

O

–

*

LOINC

Clinical
Presentation

55108-5

Complications

55109-3

Conclusions

templateId
Coded Entries Required
Coded Entries Optional

(no coded entries required)
2.16.840.1.113883.10.20.22.2.37

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 205
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

Stage 1 Meaningful Use

CCD
–

Section
Name

Consultation Note

Diagnostic Imaging Report

Discharge Summary

H&P Note

Operative Note

Procedure Note

Progress Note

Unstructured Document

46241-6

(no coded entries required)
2.16.840.1.113883.10.20.22.2.43

–

–

–

O

–

–

–

–

–

Hospital
Consultation

18841-7

(no coded entries required)
2.16.840.1.113883.10.20.22.2.42

–

–

–

O

–

–

–

–

–

Hospital
Course

8648-8

(no coded entries required)
1.3.6.1.4.1.19376.1.5.3.1.3.5

–

–

–

R

–

–

–

–

*

Hospital
Discharge
Diagnosis

11535-2

(no coded entries required)
2.16.840.1.113883.10.20.22.2.24

–

–

–

R

–

–

–

–

*

Hospital
Discharge
Instructions

8653-8

(no coded entries required)
2.16.840.1.113883.10.20.22.2.41

–

–

–

O

–

–

–

–

–

Hospital
Discharge
Medications

10183-2

2.16.840.1.113883.10.20.22.2.11.1
2.16.840.1.113883.10.20.22.2.11

–

–

–

R

–

–

–

–

*

Hospital
Discharge
Physical

10184-0

(no coded entries required)
1.3.6.1.4.1.19376.1.5.3.1.3.26

–

–

–

O

–

–

–

–

*

Hospital
Discharge
Studies
Summary

11493-4

(no coded entries required)
2.16.840.1.113883.10.20.22.2.16

–

–

–

O

–

–

–

–

*

Immunizations

11369-6

2.16.840.1.113883.10.20.22.2.2.1
2.16.840.1.113883.10.20.22.2.2

O

O

–

O

O

–

–

–

*

Instructions

69730-0

(no coded entries required)
2.16.840.1.113883.10.20.22.2.45

–

–

–

–

O

–

–

O

*

Interventions

62387-6

(no coded entries required)
2.16.840.1.113883.10.20.21.2.3

–

–

–

–

–

–

–

O

*

Key Images

55113-5

–

–

O

–

–

–

–

–

*

Medical
Equipment

46264-8

(no coded entries required)
2.16.840.1.113883.10.20.22.2.23

O

–

–

–

–

–

–

–

*

Medical
(General)
History

11329-0

2.16.840.1.113883.10.20.22.2.39

–

–

O

–

–

–

O

–

*

LOINC

templateId
Coded Entries Required
Coded Entries Optional

Page 206
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© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Stage 1 Meaningful Use

CCD

Hospital
Admission
Diagnosis

Section
Name

CCD

Consultation Note

Diagnostic Imaging Report

Discharge Summary

H&P Note

Operative Note

Procedure Note

Progress Note

Unstructured Document

Stage 1 Meaningful Use

Medications

10160-0

2.16.840.1.113883.10.20.22.2.1.1
2.16.840.1.113883.10.20.22.2.1

R

O

–

–

R

–

O

O

*

R

Medications
Administered

29549-3

(no coded entries required)
2.16.840.1.113883.10.20.22.2.38

–

–

–

–

–

–

O

–

*

Objective

61149-1

(no coded entries required)
2.16.840.1.113883.10.20.21.2.1

–

–

–

–

–

–

–

O

*

Operative
Note Fluids

10216-0

(no coded entries required)
2.16.840.1.113883.10.20.7.12

–

–

–

–

–

O

–

–

*

Operative
Note Surgical
Procedure

10223-6

(no coded entries required)
2.16.840.1.113883.10.20.7.14

–

–

–

–

–

O

–

–

*

Payers

48768-6

(no coded entries required)
2.16.840.1.113883.10.20.22.2.18

O

–

–

–

–

–

–

–

*

Physical
Exam

29545-1

(no coded entries required)
2.16.840.1.113883.10.20.2.10

–

R

–

–

R

–

O

O

*

Plan of
Care**

18776-5

(no coded entries required)
2.16.840.1.113883.10.20.22.2.10

O

R

–

R

R

O

R

–

*

Planned
Procedure

59772-4

(no coded entries required)
2.16.840.1.113883.10.20.22.2.30

–

–

–

–

–

O

O

–

*

Postoperative
Diagnosis

10218-6

(no coded entries required)
2.16.840.1.113883.10.20.22.2.35

–

–

–

–

–

R

–

–

*

Postprocedure
Diagnosis

59769-0

(no coded entries required)
2.16.840.1.113883.10.20.22.2.36

–

–

–

–

–

–

R

–

*

Preoperative
Diagnosis

10219-4

(no coded entries required)
2.16.840.1.113883.10.20.22.2.34

–

–

–

–

–

R

–

–

*

Prior Imaging
Procedure
Descriptions

55114-3

(no coded entries required)

–

–

O

–

–

–

–

–

*

Problem

11450-4

2.16.840.1.113883.10.20.22.2.5.1
2.16.840.1.113883.10.20.22.2.5

R

O

–

O

O

–

–

O

*

Procedure
Description

29554-3

(no coded entries required)
2.16.840.1.113883.10.20.22.2.27

–

–

–

–

–

R

R

–

*

Procedure
Disposition

59775-7

(no coded entries required)
2.16.840.1.113883.10.20.18.2.12

–

–

–

–

–

O

R

–

*

Section
Name

LOINC

templateId
Coded Entries Required
Coded Entries Optional

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 207
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

R

Consultation Note

Diagnostic Imaging Report

Discharge Summary

H&P Note

Operative Note

Procedure Note

Progress Note

Unstructured Document

59770-8

(no coded entries required)
2.16.840.1.113883.10.20.18.2.9

–

–

–

–

–

R

O

–

*

Procedure
Findings

59776-5

(no coded entries required)
2.16.840.1.113883.10.20.22.2.28

–

–

–

–

–

R

O

–

*

Procedure
Implants

59771-6

(no coded entries required)
2.16.840.1.113883.10.20.22.2.40

–

–

–

–

–

–

O

Procedure
Indications

59768-2

(no coded entries required)
2.16.840.1.113883.10.20.22.2.29

–

–

–

–

–

O

R

–

*

Procedure
Specimens
Taken

59773-2

(no coded entries required)
2.16.840.1.113883.10.20.22.2.31

–

–

–

–

–

R

O

–

*

Procedures
List of
Surgeries
(History of
Procedures)

47519-4

2.16.840.1.113883.10.20.22.2.7.1
2.16.840.1.113883.10.20.22.2.7

O

O

–

O

O

–

O

–

*

Radiology
Comparison
Study –
Observation

18834-2

–

–

O

–

–

–

–

–

*

Radiology –
Impression

19005-8

–

–

O

–

–

–

–

–

*

Radiology
Study –
Recommenda
tions

18783-1

–

–

O

–

–

–

–

–

*

Radiology
Reason for
Study

18785-6

–

–

O

–

–

–

–

–

*

Reason for
Referral****

42349-1

(no coded entries required)
1.3.6.1.4.1.19376.1.5.3.1.3.1

–

R

–

–

–

–

–

–

*

Reason for
Visit***

29299-5

2.16.840.1.113883.10.20.22.2.12

–

R

–

O

R

–

O

–

–

Requested
Imaging
Studies
Information

55115-0

–

–

O

–

–

–

–

–

*

30

LOINC

templateId
Coded Entries Required
Coded Entries Optional

Stage 1 Meaningful Use

CCD

Procedure
Estimated
Blood Loss

Section
Name

*

R
30

Required only for inpatient settings

Page 208
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July 2012

Section
Name

LOINC

CCD

Consultation Note

Diagnostic Imaging Report

Discharge Summary

H&P Note

Operative Note

Procedure Note

Progress Note

Unstructured Document

Stage 1 Meaningful Use

Results

30954-2

2.16.840.1.113883.10.20.22.2.3.1
2.16.840.1.113883.10.20.22.2.3

R

O

–

–

R

–

–

O

*

R

Review of
Systems

10187-3

(no coded entries required)
1.3.6.1.4.1.19376.1.5.3.1.3.18

–

O

–

O

R

–

O

O

*

Social
History

29762-2

(no coded entries required)
2.16.840.1.113883.10.20.22.2.17

O

O

–

O

R

–

O

–

*

Subjective

61150-9

(no coded entries required)
2.16.840.1.113883.10.20.21.2.2

–

–

–

–

–

–

–

O

*

Surgical
Drains

11537-8

(no coded entries required)
2.16.840.1.113883.10.20.7.13

–

–

–

–

–

O

–

–

*

Vital Signs

8716-3

2.16.840.1.113883.10.20.22.2.4.1
2.16.840.1.113883.10.20.22.2.4

O

O

–

O

R

–

–

O

*

templateId
Coded Entries Required
Coded Entries Optional

– not required or optional; these sections can be included if appropriate for the
document type
* content could be present and is unstructured
** wherever referenced, intent is that either “Assessment and Plan” is present or both
“Assessment” and “Plan of Care”. Only these combinations should be used
*** wherever referenced, intent is that either “Chief Complaint/Reason for Visit” is
present or “Chief Complaint”, and/or “Reason for Visit”. Only these combinations
should be used
****in Consultation Note, either “Reason for Referral”, “Reason for Visit”, or “Chief
Complaint/Reason for Visit” must be present

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 209
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

5.1

Advance Directives Section 42348-3
Table 45: Advance Directives Section Contexts
Used By:

Contains Entries:

Coded entries optional:
Continuity of Care Document (CCD) (optional)

Advance Directive Observation

Coded entries required:
---

Figure 77: Advance directives section UML diagram

This section contains data defining the patient’s advance directives and any
reference to supporting documentation. The most recent and up-to-date
directives are required, if known, and should be listed in as much detail as
possible. This section contains data such as the existence of living wills,
healthcare proxies, and CPR and resuscitation status. If referenced documents
are available, they can be included in the CCD exchange package.
NOTE: The descriptions in this section differentiate between “advance directives”
and “advance directive documents”. The former are the directions whereas the
latter are legal documents containing those directions. Thus, an advance
directive might be “no cardiopulmonary resuscitation”, and this directive might
be stated in a legal advance directive document.
Advance Directives Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.21(open)]
The following constraints apply to an Advance Directive section in which entries
are not required.
1. SHALL contain exactly one [1..1] templateId (CONF:7928) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.21" (CONF:10376).
2. SHALL contain exactly one [1..1] code (CONF:15340).
a. This code SHALL contain exactly one [1..1] @code="42348-3" Advance
Directives (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15342).
3. SHALL contain exactly one [1..1] title (CONF:7930).
4. SHALL contain exactly one [1..1] text (CONF:7931).
5. MAY contain zero or more [0..*] entry (CONF:7957) such that it
a. SHALL contain exactly one [1..1] Advance Directive Observation
(2.16.840.1.113883.10.20.22.4.48) (CONF:8800).
Page 210
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July 2012

Advance Directives Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.21.1(open)]
The following constraints apply to an Advance Directive section in which entries
are required.
1. Conforms to Advance Directives Section (entries optional)
template (2.16.840.1.113883.10.20.22.2.21).
2. SHALL contain exactly one [1..1] templateId (CONF:8643) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.21.1" (CONF:10377).
3. SHALL contain exactly one [1..1] code (CONF:15343).
a. This code SHALL contain exactly one [1..1] @code="42348-3" Advance
Directives (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15344).
4. SHALL contain exactly one [1..1] title (CONF:8645).
5. SHALL contain exactly one [1..1] text (CONF:8646).
6. SHALL contain at least one [1..*] entry (CONF:8647) such that it
a. SHALL contain exactly one [1..1] Advance Directive Observation
(2.16.840.1.113883.10.20.22.4.48) (CONF:8801).
Figure 78: Advance directives section example






...




...




HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 211
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

5.2

Allergies Section 48765-2
Table 46: Allergies Section Contexts
Used By:

Contains Entries:

Coded entries optional:
Progress Note (optional)
Consultation Note (optional)
Discharge Summary (required)
History and Physical (required)
Procedure Note (optional)

Allergy Problem Act

Coded entries required:
Continuity of Care Document (CCD) (required)

Figure 79: Allergies section UML diagram

This section lists and describes any medication allergies, adverse reactions,
idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and
metabolic variations or adverse reactions/allergies to other substances (such as
latex, iodine, tape adhesives) used to assure the safety of health care delivery. At
a minimum, it should list currently active and any relevant historical allergies
and adverse reactions.
Allergies Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.6(open)]
The following constraints apply to an Allergies section in which entries are not
required.
1. SHALL contain exactly one [1..1] templateId (CONF:7800) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.6" (CONF:10378).
2. SHALL contain exactly one [1..1] code (CONF:15345).
Page 212
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© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

a. This code SHALL contain exactly one [1..1] @code="48765-2"
Allergies, adverse reactions, alerts (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15346).
3. SHALL contain exactly one [1..1] title (CONF:7802).
4. SHALL contain exactly one [1..1] text (CONF:7803).
5. SHOULD contain zero or more [0..*] entry (CONF:7804) such that it
a. SHALL contain exactly one [1..1] Allergy Problem Act
(2.16.840.1.113883.10.20.22.4.30) (CONF:7805)
Allergies Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.6.1(open)]
The following constraints apply to an Allergies section in which entries are
required.
1. Conforms to Allergies Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.6).
2. SHALL contain exactly one [1..1] templateId (CONF:7527) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.6.1" (CONF:10379).
3. SHALL contain exactly one [1..1] code (CONF:15349).
a. This code SHALL contain exactly one [1..1] @code="48765-2"
Allergies, adverse reactions, alerts (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15350).
4. SHALL contain exactly one [1..1] title (CONF:7534).
5. SHALL contain exactly one [1..1] text (CONF:7530).
6. SHALL contain at least one [1..*] entry (CONF:7531) such that it
a. SHALL contain exactly one [1..1] Allergy Problem Act
(2.16.840.1.113883.10.20.22.4.30) (CONF:7532).
Figure 80: Allergies section example





...





...




HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
Page 213
July 2012
© 2012 Health Level Seven, Inc. All rights reserved.

5.3 Anesthesia Section 59774-0
[section: templateId 2.16.840.1.113883.10.20.22.2.25(open)]
Table 47: Anesthesia Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)
Operative Note (required)

Medication Activity
Procedure Activity Procedure

The Anesthesia section briefly records the type of anesthesia (e.g., general or
local) and may state the actual agent used. This may or may not be a subsection
of the Procedure Description section. The full details of anesthesia are usually
found in a separate Anesthesia Note.
1. SHALL contain exactly one [1..1] templateId (CONF:8066) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.25" (CONF:10380).
2. SHALL contain exactly one [1..1] code (CONF:15351).
a. This code SHALL contain exactly one [1..1] @code="59774-0"
Anesthesia (CONF:15352).
3. SHALL contain exactly one [1..1] title (CONF:8068).
4. SHALL contain exactly one [1..1] text (CONF:8069).
5. MAY contain zero or more [0..*] entry (CONF:8092) such that it
a. SHALL contain exactly one [1..1] Procedure Activity Procedure
(2.16.840.1.113883.10.20.22.4.14) (CONF:8093).
6. MAY contain zero or more [0..*] entry (CONF:8094) such that it
a. SHALL contain exactly one [1..1] Medication Activity
(2.16.840.1.113883.10.20.22.4.16) (CONF:8095).

Page 214
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© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Figure 81: Anesthesia section example





 Conscious sedation with propofol 200 mg IV 




...






...




5.4 Assessment and Plan Section 51847-2
[section: templateId 2.16.840.1.113883.10.20.22.2.9(open)]
Table 48: Assessment and Plan Section Contexts
Used By:

Contains Entries:

Progress Note (optional)
Consultation Note (optional)
Procedure Note (optional)
History and Physical (optional)

Plan of Care Activity Act

The Assessment and Plan sections may be combined or separated to meet local
policy requirements.
The Assessment and Plan section represents both the clinician’s conclusions
and working assumptions that will guide treatment of the patient (see
Assessment Section above) and pending orders, interventions, encounters,
services, and procedures for the patient (see Plan of Care Section below).
1. SHALL contain exactly one [1..1] templateId (CONF:7705) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.9" (CONF:10381).
2. SHALL contain exactly one [1..1] code (CONF:15353).

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a. This code SHALL contain exactly one [1..1] @code="51847-2"
Assessment and Plan (CONF:15354).
3. SHALL contain exactly one [1..1] text (CONF:7707).
4. MAY contain zero or more [0..*] entry (CONF:7708) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity Act
(2.16.840.1.113883.10.20.22.4.39) (CONF:8798).
Figure 82: Assessment and plan section example





...





...




5.5 Assessment Section 51848-0
[section: templateId 2.16.840.1.113883.10.20.22.2.8(open)]
Table 49: Assessment Section Contexts
Used By:

Contains Entries:

Progress Note (optional)
Consultation Note (optional)
History and Physical (optional)
Procedure Note (optional)

The Assessment section (also referred to as “impression” or “diagnoses” outside
of the context of CDA) represents the clinician's conclusions and working
assumptions that will guide treatment of the patient. The assessment may be a
list of specific disease entities or a narrative block.
1. SHALL contain exactly one [1..1] templateId (CONF:7711) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.8" (CONF:10382).
2. SHALL contain exactly one [1..1] code (CONF:14757).
a. This code SHALL contain exactly one [1..1] @code="51848-0"
Assessments (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:14758).
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3. SHALL contain exactly one [1..1] title (CONF:16774).
4. SHALL contain exactly one [1..1] text (CONF:7713).
Figure 83: Assessment section example





...



5.6

Chief Complaint and Reason for Visit Section 46239-0
[section: templateId 2.16.840.1.113883.10.20.22.2.13(open)]
Table 50: Chief Complaint and Reason for Visit Section Contexts
Used By:

Contains Entries:

Consultation Note (optional)
Discharge Summary (optional)
History and Physical (optional)
Procedure Note (optional)

This section records the patient's chief complaint (the patient’s own description)
and/or the reason for the patient's visit (the provider’s description of the reason
for visit). Local policy determines whether the information is divided into two
sections or recorded in one section serving both purposes.
1. SHALL contain exactly one [1..1] templateId (CONF:7840) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.13" (CONF:10383).
2. SHALL contain exactly one [1..1] code (CONF:15449).
a. This code SHALL contain exactly one [1..1] @code="46239-0" Chief
Complaint and Reason for Visit (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15450).
3. SHALL contain exactly one [1..1] title (CONF:7842).
4. SHALL contain exactly one [1..1] text (CONF:7843).

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Figure 84: Chief complaint and reason for visit section example




Back Pain


5.7

Chief Complaint Section 10154-3
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1(open)]
Table 51: Chief Complaint Section Contexts
Used By:

Contains Entries:

Progress Note (optional)
Consultation Note (optional)
Discharge Summary (optional)
History and Physical (optional)
Procedure Note (optional)

This section records the patient's chief complaint (the patient’s own description).
1. SHALL contain exactly one [1..1] templateId (CONF:7832) such that it
a. SHALL contain exactly one [1..1]
@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1" (CONF:10453).
2. SHALL contain exactly one [1..1] code (CONF:15451).
a. This code SHALL contain exactly one [1..1] @code="10154-3" Chief
Complaint (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15452).
3. SHALL contain exactly one [1..1] title (CONF:7834).
4. SHALL contain exactly one [1..1] text (CONF:7835).
Figure 85: Chief complaint section example




Back Pain


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5.8

Complications Section 55109-3
[section: templateId 2.16.840.1.113883.10.20.22.2.37(open)]
Table 52: Complications Section Contexts
Used By:

Contains Entries:

Procedure Note (required)
Operative Note (required)

Problem Observation

The Complications section records problems that occurred during the procedure
or other activity. The complications may have been known risks or
unanticipated problems.
1. SHALL contain exactly one [1..1] templateId (CONF:8174) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.37" (CONF:10384).
2. SHALL contain exactly one [1..1] code (CONF:15453).
a. This code SHALL contain exactly one [1..1] @code="55109-3"
Complications (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15454).
3. SHALL contain exactly one [1..1] title (CONF:8176).
4. SHALL contain exactly one [1..1] text (CONF:8177).
5. There SHALL be a statement providing details of the complication(s) or it
SHALL explicitly state there were no complications. (CONF:8797).
6. MAY contain zero or more [0..*] entry (CONF:8795) such that it
a. SHALL contain exactly one [1..1] Problem Observation
(2.16.840.1.113883.10.20.22.4.4) (CONF:8796).
Figure 86: Complications section example




Asthmatic symptoms while under general anesthesia.




...




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5.9

DICOM Object Catalog Section - DCM 121181
[section: templateId 2.16.840.1.113883.10.20.6.1.1(open)]
Table 53: DICOM Object Catalog Section - DCM 121181 Contexts
Used By:

Contains Entries:

Diagnostic Imaging Report

Study Act

DICOM Object Catalog lists all referenced objects and their parent Series and
Studies, plus other DICOM attributes required for retrieving the objects.
DICOM Object Catalog sections are not intended for viewing and contain empty
section text.
9. SHALL contain exactly one [1..1] templateId (CONF:8525) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.1.1" (CONF:10454).
10. A DICOM Object Catalog SHALL be present if the document contains
references to DICOM Images. If present, it SHALL be the first section in the
document (CONF:8527).
11. SHALL contain exactly one [1..1] code (CONF:15456).
a. This code SHALL contain exactly one [1..1] @code="121181" Dicom
Object Catalog (CodeSystem: DCM 1.2.840.10008.2.16.4)
(CONF:15457).
12. SHALL contain at least one [1..*] entry (CONF:8530).
a. Such entries SHALL contain exactly one [1..1] Study Act
(templateId:2.16.840.1.113883.10.20.6.2.6) (CONF:15458).

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Figure 87: DICOM object catalog section example














...






...





...








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5.10 Discharge Diet Section 42344-2
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.33(open)]
Table 54: Discharge Diet Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)

This section records a narrative description of the expectations for diet and
nutrition, including nutrition prescription, proposals, goals, and order requests
for monitoring, tracking, or improving the nutritional status of the patient, used
in a discharge from a facility such as an emergency department, hospital, or
nursing home.
1. SHALL contain exactly one [1..1] templateId (CONF:7975) such that it
a. SHALL contain exactly one [1..1]
@root="1.3.6.1.4.1.19376.1.5.3.1.3.33" (CONF:10455).
2. SHALL contain exactly one [1..1] code (CONF:15459).
a. This code SHALL contain exactly one [1..1] @code="42344-2"
Discharge Diet (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15460).
3. SHALL contain exactly one [1..1] title (CONF:7977).
4. SHALL contain exactly one [1..1] text (CONF:7978).
Figure 88: Discharge diet section example




 Low-fat, low-salt, cardiac diet 


5.11 Encounters Section 46240-8
Table 55: Encounters Section Contexts
Used By:

Contains Entries:

Coded entries optional:
Continuity of Care Document (CCD) (optional)

Encounter Activities

Coded entries required:
---

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Figure 89: Encounters section UML diagram

This section lists and describes any healthcare encounters pertinent to the
patient’s current health status or historical health history. An Encounter is an
interaction, regardless of the setting, between a patient and a practitioner who is
vested with primary responsibility for diagnosing, evaluating, or treating the
patient’s condition. It may include visits, appointments, as well as non-face-toface interactions. It is also a contact between a patient and a practitioner who
has primary responsibility for assessing and treating the patient at a given
contact, exercising independent judgment. This section may contain all
encounters for the time period being summarized, but should include notable
encounters.
Encounters Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.22(open)]
The following constraints apply to an Encounters section in which entries are
not required.
1. SHALL contain exactly one [1..1] templateId (CONF:7940) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.22" (CONF:10386).
2. SHALL contain exactly one [1..1] code (CONF:15461).
a. This code SHALL contain exactly one [1..1] @code="46240-8"
Encounters (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15462).
3. SHALL contain exactly one [1..1] title (CONF:7942).
4. SHALL contain exactly one [1..1] text (CONF:7943).
5. SHOULD contain zero or more [0..*] entry (CONF:7951) such that it
a. SHALL contain exactly one [1..1] Encounter Activities
(2.16.840.1.113883.10.20.22.4.49) (CONF:8802).
Encounters Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.22.1(open)]
The following constraints apply to an Encounters section in which entries are
required.
1. Conforms to Encounters Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.22).
2. SHALL contain exactly one [1..1] templateId (CONF:8705) such that it

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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.22.1" (CONF:10387).
3. SHALL contain exactly one [1..1] code (CONF:15466).
a. This code SHALL contain exactly one [1..1] @code="46240-8"
Encounters (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15467).
4. SHALL contain exactly one [1..1] title (CONF:8707).
5. SHALL contain exactly one [1..1] text (CONF:8708).
6. SHALL contain at least one [1..*] entry (CONF:8709) such that it
a. SHALL contain exactly one [1..1] Encounter Activities
(2.16.840.1.113883.10.20.22.4.49) (CONF:8803).
Figure 90: Encounters section example






...





...




5.12 Family History Section 10157-6
[section: templateId 2.16.840.1.113883.10.20.22.2.15(open)]
Table 56: Family History Section Contexts
Used By:

Contains Entries:

Consultation Note (optional)
Discharge Summary (optional)
History and Physical (required)
Procedure Note (optional)
Continuity of Care Document (CCD) (optional)

Family History Organizer

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Figure 91: Family history section UML diagram

This section contains data defining the patient’s genetic relatives in terms of
possible or relevant health risk factors that have a potential impact on the
patient’s healthcare risk profile.
1. SHALL contain exactly one [1..1] templateId (CONF:7932) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.15" (CONF:10388).
2. SHALL contain exactly one [1..1] code (CONF:15469).
a. This code SHALL contain exactly one [1..1] @code="10157-6" Family
History (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15470).
3. SHALL contain exactly one [1..1] title (CONF:7934).
4. SHALL contain exactly one [1..1] text (CONF:7935).
5. MAY contain zero or more [0..*] entry (CONF:7955) such that it
a. SHALL contain exactly one [1..1] Family History Organizer
(2.16.840.1.113883.10.20.22.4.45) (CONF:8799).
Figure 92: Family history section example






...





...




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5.13 Findings Section (DIR) 18782-3
[section: templateId 2.16.840.1.113883.10.20.6.1.2(open)]
Table 57: Findings Section Contexts
Used By:

Contains Entries:

Diagnostic Imaging Report (required)

The Findings section contains the main narrative body of the report. While not
an absolute requirement for transformed DICOM SR reports, it is suggested that
Diagnostic Imaging Reports authored in CDA follow Term Info guidelines 31 for
the codes in the various observations and procedures recorded in this section.
1. SHALL contain exactly one [1..1] templateId (CONF:8531) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.1.2" (CONF:10456).
2. This section SHOULD contain only the direct observations in the report, with
topics such as Reason for Study, History, and Impression placed in separate
sections. However, in cases where the source of report content provides a
single block of text not separated into these sections, that text SHALL be
placed in the Findings section. (CONF:8532).
Figure 93: Findings section example






Finding
The cardiomediastinum is


Diameter
45mm

...



...



31

. 

http://www.hl7.org/special/committees/terminfo/index.cfm

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5.14 Functional Status Section 47420-5
[section: templateId 2.16.840.1.113883.10.20.22.2.14(open)]
Table 58: Functional Status Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)
Continuity of Care Document (CCD) (optional)

Assessment Scale Observation
Caregiver Characteristics
Cognitive Status Problem Observation
Cognitive Status Result Observation
Cognitive Status Result Organizer
Functional Status Problem Observation
Functional Status Result Observation
Functional Status Result Organizer
Non-Medicinal Supply Activity
Highest Pressure Ulcer Stage
Number of Pressure Ulcers Observation
Pressure Ulcer Observation

Figure 94: Functional status section UML diagram

*The Large UML Diagrams appendix provides a larger version of this diagram

The Functional Status section describes the patient’s physical state, status of
functioning, and environmental status at the time the document was created.
A patient’s physical state may include information regarding the patient’s
physical findings as they relate to problems, including but not limited to:
Pressure Ulcers
Amputations
Heart murmur
Ostomies
A patient’s functional status may include information regarding the patient
relative to their general functional and cognitive ability, including:
Ambulatory ability
Mental status or competency
Activities of Daily Living (ADLs), including bathing, dressing, feeding,
grooming
Home or living situation having an effect on the health status of the
patient
Ability to care for self
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Social activity, including issues with social cognition, participation with
friends and acquaintances other than family members
Occupation activity, including activities partly or directly related to
working, housework or volunteering, family and home responsibilities or
activities related to home and family
Communication ability, including issues with speech, writing or
cognition required for communication
Perception, including sight, hearing, taste, skin sensation, kinesthetic
sense, proprioception, or balance
A patient’s environmental status may include information regarding the patient’s
current exposures from their daily environment, including but not limited to:
Airborne hazards such as second-hand smoke, volatile organic
compounds, dust, or other allergens
Radiation
Safety hazards in home, such as throw rugs, poor lighting, lack of
railings/grab bars, etc.
Safety hazards at work, such as communicable diseases, excessive heat,
excessive noise, etc.
The patient's functional status may be expressed as a problem or as a result
observation. A functional or cognitive status problem observation describes a
patient’s problem, symptoms or condition. A functional or cognitive status result
observation may include observations resulting from an assessment scale,
evaluation or question and answer assessment.
Any deviation from normal function displayed by the patient and recorded in the
record should be included. Of particular interest are those limitations that
would interfere with self-care or the medical therapeutic process in any way. In
addition, a note of normal function, an improvement, or a change in functioning
status may be included.
Table 59: Functional and Cognitive Status Problem Observation Examples
Problem Observation

Problem/Condition/Symptom

Functional Status

Cognitive Status

Dysphagia

Dementia

Orthopnea

Chronic confusion

Shortness of Breath

Depressed mood

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Table 60: Functional and Cognitive Status Result Observation Examples
Result Observation

Functional Status

Cognitive Status

Frequency
Observation

Incontinency Frequency

Behavior Frequency

Assessment Scale or
Evaluation Result

Pain Scale

Brief Interview for Mental Status

Eating
Independent
Partial/Moderate
Assistance
Substantial Assistance
Dependent

Disorganized thinking
Behavior not present
Behavior continuously present
Behavior present, fluctuates

Assessment
Question/Answer

1. SHALL contain exactly one [1..1] templateId (CONF:7920) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.14" (CONF:10389).
2. SHALL contain exactly one [1..1] code (CONF:14578).
a. This code SHALL contain exactly one [1..1] @code="47420-5"
Functional Status (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:14579).
3. SHALL contain exactly one [1..1] title (CONF:7922).
4. SHALL contain exactly one [1..1] text (CONF:7923).
5. MAY contain zero or more [0..*] entry (CONF:14414) such that it
a. SHALL contain exactly one [1..1] Functional Status Result
Organizer (templateId:2.16.840.1.113883.10.20.22.4.66)
(CONF:14415).
6. MAY contain zero or more [0..*] entry (CONF:14416) such that it
a. SHALL contain exactly one [1..1] Cognitive Status Result
Organizer (templateId:2.16.840.1.113883.10.20.22.4.75)
(CONF:14417).
7. MAY contain zero or more [0..*] entry (CONF:14418) such that it
a. SHALL contain exactly one [1..1] Functional Status Result
Observation (templateId:2.16.840.1.113883.10.20.22.4.67)
(CONF:14419).
8. MAY contain zero or more [0..*] entry (CONF:14420) such that it
a. SHALL contain exactly one [1..1] Cognitive Status Result
Observation (templateId:2.16.840.1.113883.10.20.22.4.74)
(CONF:14421).
9. MAY contain zero or more [0..*] entry (CONF:14422) such that it
a. SHALL contain exactly one [1..1] Functional Status Problem
Observation (templateId:2.16.840.1.113883.10.20.22.4.68)
(CONF:14423).

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10. MAY contain zero or more [0..*] entry (CONF:14424) such that it
a. SHALL contain exactly one [1..1] Cognitive Status Problem
Observation (templateId:2.16.840.1.113883.10.20.22.4.73)
(CONF:14425).
11. MAY contain zero or more [0..*] entry (CONF:14426) such that it
a. SHALL contain exactly one [1..1] Caregiver Characteristics
(templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14427).
12. MAY contain zero or more [0..*] entry (CONF:14580) such that it
a. SHALL contain exactly one [1..1] Assessment Scale Observation
(templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14581).
13. MAY contain zero or more [0..*] entry (CONF:14582) such that it
a. SHALL contain exactly one [1..1] Non-Medicinal Supply Activity
(templateId:2.16.840.1.113883.10.20.22.4.50) (CONF:14583).
14. MAY contain zero or more [0..*] entry (CONF:16777) such that it
a. SHALL contain exactly one [1..1] Pressure Ulcer Observation
(templateId:2.16.840.1.113883.10.20.22.4.70) (CONF:16778).
15. MAY contain zero or more [0..*] entry (CONF:16779) such that it
a. SHALL contain exactly one [1..1] Number of Pressure Ulcers
Observation (templateId:2.16.840.1.113883.10.20.22.4.76)
(CONF:16780).
16. MAY contain zero or more [0..*] entry (CONF:16781) such that it
a. SHALL contain exactly one [1..1] Highest Pressure Ulcer Stage
(templateId:2.16.840.1.113883.10.20.22.4.77) (CONF:16782).
Figure 95: Functional status section example







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Functional and Cognitive Assessment
March 23 to March 25, 2012
Condition Status




Dependence on cane
1998
Active


Memory impairment
1999
Active






...




...




...




...




...




...




...




...




...

...


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5.15 General Status Section 10210-3
[section: templateId 2.16.840.1.113883.10.20.2.5(open)]
Table 61: General Status Section Contexts
Used By:

Contains Entries:

Consultation Note (optional)
History and Physical (required)

The General Status section describes general observations and readily
observable attributes of the patient, including affect and demeanor, apparent
age compared to actual age, gender, ethnicity, nutritional status based on
appearance, body build and habitus (e.g., muscular, cachectic, obese),
developmental or other deformities, gait and mobility, personal hygiene, evidence
of distress, and voice quality and speech.
1. SHALL contain exactly one [1..1] templateId (CONF:7985) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.2.5" (CONF:10457).
2. SHALL contain exactly one [1..1] code (CONF:15472).
a. This code SHALL contain exactly one [1..1] @code="10210-3" General
Status (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15473).
3. SHALL contain exactly one [1..1] title (CONF:7987).
4. SHALL contain exactly one [1..1] text (CONF:7988).
Figure 96: General status section example





Alert and in good spirits, no acute distress.




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5.16 History of Past Illness Section 11348-0
[section: templateId 2.16.840.1.113883.10.20.22.2.20(open)]
Table 62: History of Past Illness Section Contexts
Used By:

Contains Entries:

Consultation Note (optional)
Discharge Summary (optional)
History and Physical (required)
Procedure Note (optional)

Problem Observation

This section describes the history related to the patient’s past complaints,
problems, or diagnoses. It records these details up until, and possibly pertinent
to, the patient’s current complaint or reason for seeking medical care.
1. SHALL contain exactly one [1..1] templateId (CONF:7828) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.20" (CONF:10390).
2. SHALL contain exactly one [1..1] code (CONF:15474).
a. This code SHALL contain exactly one [1..1] @code="11348-0" History
of Past Illness (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15475).
3. SHALL contain exactly one [1..1] title (CONF:7830).
4. SHALL contain exactly one [1..1] text (CONF:7831).
5. MAY contain zero or more [0..*] entry (CONF:8791) such that it
a. SHALL contain exactly one [1..1] Problem Observation
(2.16.840.1.113883.10.20.22.4.4) (CONF:8792).
Figure 97: History of past illness section example






Patient has had ..... 






...




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5.17 History of Present Illness Section 10164-2
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.4(open)]
Table 63: History of Present Illness Section Contexts
Used By:

Contains Entries:

Consultation Note (required)
Discharge Summary (optional)
History and Physical (optional)
Procedure Note (optional)

The History of Present Illness section describes the history related to the reason
for the encounter. It contains the historical details leading up to and pertaining
to the patient’s current complaint or reason for seeking medical care.
1. SHALL contain exactly one [1..1] templateId (CONF:7848) such that it
a. SHALL contain exactly one [1..1] @root="
1.3.6.1.4.1.19376.1.5.3.1.3.4" (CONF:10458).
2. SHALL contain exactly one [1..1] code (CONF:15477).
a. This code SHALL contain exactly one [1..1] @code="10164-2" History
of Present Illness (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15478).
3. SHALL contain exactly one [1..1] title (CONF:7850).
4. SHALL contain exactly one [1..1] text (CONF:7851).
Figure 98: History of present illness section example





This patient was only recently discharged for a recurrent
GI bleed as described below.
He presented to the ER today c/o a dark stool yesterday
but a normal brown stool today. On exam he was hypotensive in the
80?s resolved after .... .... .... 
Lab at discharge: Glucose 112, BUN 16, creatinine 1.1,
electrolytes normal. H. pylori antibody pending. Admission
hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet
count 256,000. Urinalysis normal. Urine culture: No growth. INR
1.1, PTT 40.
He was transfused with 6 units of packed red blood cells
with .... .... ....
GI evaluation 12 September: Colonoscopy showed single red
clot in .... .... ....



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5.18 Hospital Admission Diagnosis Section 46241-6
[section: templateId 2.16.840.1.113883.10.20.22.2.43(open)]
Table 64: Hospital Admission Diagnosis Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)

Hospital Admission Diagnosis

The Hospital Admitting Diagnosis section contains a narrative description of the
primary reason for admission to a hospital facility. The section includes an
optional entry to record patient conditions.
1. SHALL contain exactly one [1..1] templateId (CONF:9930) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.43" (CONF:10391).
2. SHALL contain exactly one [1..1] code (CONF:15479).
a. This code SHALL contain exactly one [1..1] @code="46241-6" Hospital
Admission Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15480).
3. SHALL contain exactly one [1..1] title (CONF:9932).
4. SHALL contain exactly one [1..1] text (CONF:9933).
5. SHOULD contain zero or one [0..1] entry (CONF:9934).
a. SHALL contain exactly one [1..1] Hospital Admission Diagnosis
(2.16.840.1.113883.10.20.22.4.34) (CONF:9935).
Figure 99: Hospital admission diagnosis section example




Appendicitis




...



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5.19 Hospital Admission Medications Section 42346-7 (entries
optional)
[section: templateId 2.16.840.1.113883.10.20.22.2.44 (open)]
Table 65: Hospital Admission Medications Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)

Admission Medication

The Hospital Admission Medications section defines the relevant medications
administered prior to admission to the facility. The currently active medications
must be listed.
1. SHALL contain exactly one [1..1] templateId (CONF:10098) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.44" (CONF:10392).
2. SHALL contain exactly one [1..1] code (CONF:15482).
a. This code SHALL contain exactly one [1..1] @code="42346-7"
Medications on Admission (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15483).
3. SHALL contain exactly one [1..1] title (CONF:10100).
4. SHALL contain exactly one [1..1] text (CONF:10101).
5. SHOULD contain zero or more [0..*] entry (CONF:10102) such that it
a. SHALL contain exactly one [1..1] Admission Medication
(2.16.840.1.113883.10.20.22.4.36) (CONF:10110).
Figure 100: Hospital admission medications section example





...





...


...


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5.20 Hospital Consultations Section 18841-7
[section: templateId 2.16.840.1.113883.10.20.22.2.42(open)]
Table 66: Hospital Consultations Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)

The Hospital Consultations section records consultations that occurred during
the admission.
1. SHALL contain exactly one [1..1] templateId (CONF:9915) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.42" (CONF:10393).
2. SHALL contain exactly one [1..1] code (CONF:15485).
a. This code SHALL contain exactly one [1..1] @code="18841-7" Hospital
Consultations Section (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15486).
3. SHALL contain exactly one [1..1] title (CONF:9917).
4. SHALL contain exactly one [1..1] text (CONF:9918).
Figure 101: Hospital consultations section example






Gastroenterology
Cardiology
Dietitian




5.21 Hospital Course Section 8648-8
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.5(open)]
Table 67: Hospital Course Section Contexts
Used By:

Contains Entries:

Discharge Summary (required)

The Hospital Course section describes the sequence of events from admission to
discharge in a hospital facility.

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1. SHALL contain exactly one [1..1] templateId (CONF:7852) such that it
a. SHALL contain exactly one [1..1]
@root="1.3.6.1.4.1.19376.1.5.3.1.3.5" (CONF:10459)
2. SHALL contain exactly one [1..1] code (CONF:15487).
a. This code SHALL contain exactly one [1..1] @code="8648-8" Hospital
Course (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15488).
3. SHALL contain exactly one [1..1] title (CONF:7854)
4. SHALL contain exactly one [1..1] text (CONF:7855)
Figure 102: Hospital course section example




 The patient was admitted and started on Lovenox and
nitroglycerin paste. The patient had ... 


5.22 Hospital Discharge Diagnosis Section 11535-2
[section: templateId 2.16.840.1.113883.10.20.22.2.24(open)]
Table 68: Hospital Discharge Diagnosis Section Contexts
Used By:

Contains Entries:

Discharge Summary (required)

Hospital Discharge Diagnosis

The Hospital Discharge Diagnosis section describes the relevant problems or
diagnoses at the time of discharge that occurred during the hospitalization or
that need to be followed after hospitalization. This section includes an optional
entry to record patient conditions.
1. SHALL contain exactly one [1..1] templateId (CONF:7979) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.24" (CONF:10394).
2. SHALL contain exactly one [1..1] code (CONF:15355).
a. This code SHALL contain exactly one [1..1] @code="11535-2" Hospital
Discharge Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15356).
3. SHALL contain exactly one [1..1] title (CONF:7981).
4. SHALL contain exactly one [1..1] text (CONF:7982).
5. SHOULD contain zero or one [0..1] entry (CONF:7983).

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a. This entry, if present, SHALL contain exactly one [1..1] Hospital
Discharge Diagnosis
(templateId:2.16.840.1.113883.10.20.22.4.33) (CONF:7984).
Figure 103: Hospital discharge diagnosis section example






Diverticula of intestine




...




5.23 Hospital Discharge Instructions Section 8653-8
[section: templateId 2.16.840.1.113883.10.20.22.2.41(open)]
Table 69: Hospital Discharge Instructions Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)

The Hospital Discharge Instructions section records instructions at discharge.
1. SHALL contain exactly one [1..1] templateId (CONF:9919) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.41" (CONF:10395).
2. SHALL contain exactly one [1..1] code (CONF:15357).
a. This code SHALL contain exactly one [1..1] @code="8653-8" Hospital
Discharge Instructions (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15358).
3. SHALL contain exactly one [1..1] title (CONF:9921).
4. SHALL contain exactly one [1..1] text (CONF:9922).

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Figure 104: Hospital discharge instructions section example






Take all of your prescription medication as directed.
Make an appointment with your doctor to be seen two weeks
from the
date of your procedure.
You may feel slightly bloated after the procedure because of
air
that was introduced during the examination.
Call your physician if you notice:

Bleeding or black stools.

Abdominal pain.

Fever or chills.

Nausea or vomiting.

Any unusual pain or problem.

Pain or redness at the site where the intravenous needle was
placed.


Do not drink alcohol for 24 hours. Alcohol amplifies the
effect of
the sedatives given.
Do not drive or operate machinery for 24 hours.




5.24 Hospital Discharge Medications Section 10183-2
Table 70: Hospital Discharge Medications Section Contexts
Used By:

Contains Entries:

Coded entries optional:
Discharge Summary (required)

Discharge Medication

Coded entries required:
---

The Hospital Discharge Medications section defines the medications that the
patient is intended to take (or stop) after discharge. The currently active
medications must be listed. The section may also include a patient’s prescription
history and indicate the source of the medication list, for example, from a
pharmacy system versus from the patient.

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Hospital Discharge Medications Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.11(open)]
The following constraints apply to a Hospital Discharge Medications section in
which entries are not required.
1. SHALL contain exactly one [1..1] templateId (CONF:7816) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.11" (CONF:10396).
2. SHALL contain exactly one [1..1] code (CONF:15359).
a. This code SHALL contain exactly one [1..1] @code="10183-2" Hospital
Discharge Medications (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15360).
3. SHALL contain exactly one [1..1] title (CONF:7818).
4. SHALL contain exactly one [1..1] text (CONF:7819).
5. SHOULD contain zero or more [0..*] entry (CONF:7820) such that it
a. SHALL contain exactly one [1..1] Discharge Medication
(2.16.840.1.113883.10.20.22.4.35) (CONF:7883).
Hospital Discharge Medications Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.11.1(open)]
The following constraints apply to a Hospital Discharge Medications section in
which entries are required.
1. Conforms to Hospital Discharge Medications Section (entries
optional) template (2.16.840.1.113883.10.20.22.2.11).
2. SHALL contain exactly one [1..1] templateId (CONF:7822) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.11.1" (CONF:10397).
3. SHALL contain exactly one [1..1] code (CONF:15361).
a. This code SHALL contain exactly one [1..1] @code="10183-2" Hospital
Discharge Medications (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15362).
4. SHALL contain exactly one [1..1] title (CONF:7824).
5. SHALL contain exactly one [1..1] text (CONF:7825).
6. SHALL contain at least one [1..*] entry (CONF:7826) such that it
a. SHALL contain exactly one [1..1] Discharge Medication
(2.16.840.1.113883.10.20.22.4.35) (CONF:7827).

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Figure 105: Hospital discharge medications section example





...





...


...


5.25 Hospital Discharge Physical Section 10184-0
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.26(open)]
Table 71: Hospital Discharge Physical Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)

The Hospital Discharge Physical section records a narrative description of the
patient’s physical findings.
1. SHALL contain exactly one [1..1] templateId (CONF:7971) such that it
a. SHALL contain exactly one [1..1]
@root="1.3.6.1.4.1.19376.1.5.3.1.3.26" (CONF:10460)
2. SHALL contain exactly one [1..1] code (CONF:15363).
a. This code SHALL contain exactly one [1..1] @code="10184-0" Hospital
Discharge Physical (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15364).
3. SHALL contain exactly one [1..1] title (CONF:7973).
4. SHALL contain exactly one [1..1] text (CONF:7974).

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Figure 106: Hospital discharge physical section example




GENERAL: Well-developed, slightly obese man. 

NECK: Supple, with no jugular venous distension. 

HEART: Intermittent tachycardia without murmurs or
gallops.

PULMONARY: Decreased breath sounds, but no clear-cut rales
or
wheezes. 

EXTREMITIES: Free of edema.


5.26 Hospital Discharge Studies Summary Section 11493-4
[section: templateId 2.16.840.1.113883.10.20.22.2.16(open)]
Table 72: Hospital Discharge Studies Summary Section Contexts
Used By:

Contains Entries:

Discharge Summary (optional)

This section records the results of observations generated by laboratories,
imaging procedures, and other procedures. The scope includes hematology,
chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound,
CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and
procedure observations. This section often includes notable results such as
abnormal values or relevant trends, and could record all results for the period of
time being documented.
Laboratory results are typically generated by laboratories providing analytic
services in areas such as chemistry, hematology, serology, histology, cytology,
anatomic pathology, microbiology, and/or virology. These observations are based
on analysis of specimens obtained from the patient and submitted to the
laboratory.
Imaging results are typically generated by a clinician reviewing the output of an
imaging procedure, such as where a cardiologist reports the left ventricular
ejection fraction based on the review of an echocardiogram.
Procedure results are typically generated by a clinician wanting to provide more
granular information about component observations made during the
performance of a procedure, such as when a gastroenterologist reports the size
of a polyp observed during a colonoscopy.
Note that there are discrepancies between CCD and the lab domain model, such
as the effectiveTime in specimen collection.
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1. SHALL contain exactly one [1..1] templateId (CONF:7910) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.16" (CONF:10398).
2. SHALL contain exactly one [1..1] code (CONF:15365).
a. This code SHALL contain exactly one [1..1] @code="11493-4" Hospital
Discharge Studies Summary (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15366).
3. SHALL contain exactly one [1..1] title (CONF:7912).
4. SHALL contain exactly one [1..1] text (CONF:7913).
Figure 107: Hospital discharge studies summary section example





...



5.27 Immunizations Section 11369-6
Table 73: Immunizations Section Contexts
Used By:

Contains Entries:

Coded entries optional:
Consultation Note (optional)
Discharge Summary (optional)
Continuity of Care Document (CCD) (optional)
History and Physical (optional)

Immunization Activity

Coded entries required:
---

Figure 108: Immunization section* UML diagram

*The Large UML Diagrams appendix provides a larger version of this diagram

The Immunizations section defines a patient's current immunization status and
pertinent immunization history. The primary use case for the Immunization

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section is to enable communication of a patient's immunization status. The
section should include current immunization status, and may contain the entire
immunization history that is relevant to the period of time being summarized.
Immunizations Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.2(open)]
The following constraints apply to an Immunization section in which entries are
not required.
1. SHALL contain exactly one [1..1] templateId (CONF:7965) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.2" (CONF:10399).
2. SHALL contain exactly one [1..1] code (CONF:15367).
a. This code SHALL contain exactly one [1..1] @code="11369-6"
Immunizations (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15368).
3. SHALL contain exactly one [1..1] title (CONF:7967).
4. SHALL contain exactly one [1..1] text (CONF:7968).
5. SHOULD contain zero or more [0..*] entry (CONF:7969) such that it
a. SHALL contain exactly one [1..1] Immunization Activity
(2.16.840.1.113883.10.20.22.4.52) (CONF:7970).
Immunizations Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.2.1(open)]
The following constraints apply to an Immunization section in which entries are
required.
1. Conforms to Immunizations Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.2)
2. SHALL contain exactly one [1..1] templateId (CONF:9015) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.2.1" (CONF:10400)
3. SHALL contain exactly one [1..1] code (CONF:15369).
a. This code SHALL contain exactly one [1..1] @code="11369-6"
Immunizations (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15370).
4. SHALL contain exactly one [1..1] title (CONF:9017)
5. SHALL contain exactly one [1..1] text (CONF:9018)
6. SHALL contain at least one [1..*] entry (CONF:9019) such that it
a. SHALL contain exactly one [1..1] Immunization Activity
(2.16.840.1.113883.10.20.22.4.52) (CONF:9020)

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Figure 109: Immunization section example









Vaccine
Date
Status





Influenza virus vaccine, IM
Nov 1999
Completed



Influenza virus vaccine, IM
Dec 1998
Completed




Pneumococcal polysaccharide vaccine, IM
Dec 1998
Completed



Tetanus and diphtheria toxoids, IM
1997
Refused





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...


...


5.28 Instructions Section 69730-0
[section: templateId 2.16.840.1.113883.10.20.22.2.45 (open)]
Table 74: Interventions Section Contexts
Used By:

Contains Entries:

History and Physical (optional)
Progress Note (optional)

Instructions

The Instructions section records instructions given to a patient. List patient
decision aids here.
1. SHALL contain exactly one [1..1] templateId (CONF:10112) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.45" (CONF:10402).
2. SHALL contain exactly one [1..1] code (CONF:15375).
a. This code SHALL contain exactly one [1..1] @code="69730-0"
Instructions (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15376).
3. SHALL contain exactly one [1..1] title (CONF:10114).
4. SHALL contain exactly one [1..1] text (CONF:10115).
5. SHOULD contain zero or more [0..*] entry (CONF:10116).
a. SHALL contain exactly one [1..1] Instructions
(2.16.840.1.113883.10.20.22.4.20) (CONF:10117).

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Figure 110: Instructions section example





Patient may have low grade fever, mild joint pain and injection area
tenderness





...




5.29 Interventions Section 62387-6
[section: templateId 2.16.840.1.113883.10.20.21.2.3(open)]
Table 75: Interventions Section Contexts
Used By:

Contains Entries:

Progress Note (optional)

The Interventions section contains information about the specific interventions
provided during the healthcare visit. Depending on the type of intervention(s)
provided (procedural, education, application of assistive equipment, etc.), the
details will vary but may include specification of frequency, intensity, and
duration.
1. SHALL contain exactly one [1..1] templateId (CONF:8680) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.21.2.3" (CONF:10461).
2. SHALL contain exactly one [1..1] code (CONF:15377).
a. This code SHALL contain exactly one [1..1] @code="62387-6"
Interventions Provided (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15378).
3. SHALL contain exactly one [1..1] title (CONF:8682).
4. SHALL contain exactly one [1..1] text (CONF:8683).

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Figure 111: Interventions section example






Therapeutic exercise intervention: knee
extension, 3 sets, 10 repetitions, 10-lb weight. 
Therapeutic exercise intervention: arm curl, 3 sets, 10
repetitions, 15-lb weight 




5.30 Medical Equipment Section 46264-8
[section: templateId 2.16.840.1.113883.10.20.22.2.23(open)]
Table 76: Medical Equipment Section Contexts
Used By:

Contains Entries:

Continuity of Care Document (CCD) (optional)

Non-Medicinal Supply Activity

Figure 112: Medical equipment section UML diagram

The Medical Equipment section defines a patient’s implanted and external
medical devices and equipment that their health status depends on, as well as
any pertinent equipment or device history. This section is also used to itemize
any pertinent current or historical durable medical equipment (DME) used to
help maintain the patient’s health status. All pertinent equipment relevant to
the diagnosis, care, and treatment of a patient should be included.
1. SHALL contain exactly one [1..1] templateId (CONF:7944) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.23" (CONF:10404).
2. SHALL contain exactly one [1..1] code (CONF:15381).

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a. This code SHALL contain exactly one [1..1] @code="46264-8" Medical
Equipment (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15382).
3. SHALL contain exactly one [1..1] title (CONF:7946).
4. SHALL contain exactly one [1..1] text (CONF:7947).
5. SHOULD contain zero or more [0..*] entry (CONF:7948) such that it
a. SHALL contain exactly one [1..1] Non-Medicinal Supply Activity
(2.16.840.1.113883.10.20.22.4.50) (CONF:8755).
Figure 113: Medical equipment section example






...





...




5.31 Medical (General) History Section 11329-0
[section: templateId 2.16.840.1.113883.10.20.22.2.39(open)]
Table 77: Medical (General) History Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)

The Medical History section describes all aspects of the medical history of the
patient even if not pertinent to the current procedure, and may include chief
complaint, past medical history, social history, family history, surgical or
procedure history, medication history, and other history information. The
history may be limited to information pertinent to the current procedure or may
be more comprehensive. The history may be reported as a collection of random
clinical statements or it may be reported categorically. Categorical report
formats may be divided into multiple subsections including Past Medical
History, Social History.
1. SHALL contain exactly one [1..1] templateId (CONF:8160) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.39" (CONF:10403).

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2. SHALL contain exactly one [1..1] code (CONF:15379).
a. This code SHALL contain exactly one [1..1] @code="11329-0" Medical
(General) History (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15380).
3. SHALL contain exactly one [1..1] title (CONF:8162).
4. SHALL contain exactly one [1..1] text (CONF:8163).
Figure 114: Medical (general) history section example






Patient has had recent issue with acne that does not seem to
be related to any particular cause.
Previous concerns of oral cancer was actually irritated gums
as a result of mild food allergy.
Patient had recent weight gain due to sedentary lifestyle and
new job.




5.32 Medications Administered Section 29549-3
[section: templateId 2.16.840.1.113883.10.20.22.2.38(open)]
Table 78: Medications Administered Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)

Medication Activity

The Medications Administered section defines medications and fluids
administered during the procedure, encounter, or other activity excluding
anesthetic medications. This guide recommends anesthesia medications be
documented as described in the section on Anesthesia.
1. SHALL contain exactly one [1..1] templateId (CONF:8152) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.38" (CONF:10405).
2. SHALL contain exactly one [1..1] code (CONF:15383).
a. This code SHALL contain exactly one [1..1] @code="29549-3"
Medications Administered (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15384).
3. SHALL contain exactly one [1..1] title (CONF:8154).
4. SHALL contain exactly one [1..1] text (CONF:8155).

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5. MAY contain zero or more [0..*] entry (CONF:8156).
a. SHALL contain exactly one [1..1] Medication Activity
(2.16.840.1.113883.10.20.22.4.16) (CONF:8157).
Figure 115: Medications administered section example




Secretin 100 IU administered IV




...



5.33 Medications Section 10160-0
Table 79: Medications Section Contexts
Used By:

Contains Entries:

Coded entries optional:

Medication Activity

Progress Note (optional)
Consultation Note (optional)
History and Physical (required)
Procedure Note (optional)
Coded entries required:
Continuity of Care Document (CCD) (required)

Figure 116: Medications section UML diagram

*The Large UML Diagrams appendix provides a larger version of this diagram

The Medications section defines a patient's current medications and pertinent
medication history. At a minimum, the currently active medications are to be
listed, with an entire medication history as an option. The section may also
include a patient's prescription and dispense history.

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This section requires that there be either an entry indicating the subject is not
known to be on any medications, or that there be entries summarizing the
subject's medications.
Medications Section With Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.1(open)]
The following constraints apply to a Medications section in which entries are not
required.
1. SHALL contain exactly one [1..1] templateId (CONF:7791) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.1" (CONF:10432).
2. SHALL contain exactly one [1..1] @code="10160-0" History of medication use
(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7792).
3. SHALL contain exactly one [1..1] title="Medications" (CONF:7793).
4. SHALL contain exactly one [1..1] text (CONF:7794).
5. SHOULD contain zero or more [0..*] entry (CONF:7795) such that it
a. SHALL contain exactly one [1..1] Medication Activity
(2.16.840.1.113883.10.20.22.4.16) (CONF:7796).
b.

If medication use is unknown, the appropriate nullFlavor MAY be
present (see unknown information in Section 1) (CONF:10076).

Medications Section With Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.1.1(open)]
The following constraints apply to a Medications section in which entries are
required.
1. Conforms to Medications Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.1).
2. SHALL contain exactly one [1..1] templateId (CONF:7568) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.1.1" (CONF:10433).
3. SHALL contain exactly one [1..1] @code="10160-0" History of medication use
(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7569).
4. SHALL contain exactly one [1..1] title="Medications" (CONF:7570).
5. SHALL contain exactly one [1..1] text (CONF:7571).
6. SHALL contain at least one [1..*] entry (CONF:7572) such that it
a. SHALL contain exactly one [1..1] Medication Activity
(2.16.840.1.113883.10.20.22.4.16) (CONF:7573).
b.

If medication use is unknown, the appropriate nullFlavor MAY be
present (see unknown information in Section 1) (CONF:10077).

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Figure 117: Medications section entries example





...





...




5.34 Objective Section 61149-1
[section: templateId 2.16.840.1.113883.10.20.21.2.1(open)]
Table 80: Objective Section Contexts
Used By:

Contains Entries:

Progress Note (optional)

The Objective section contains data about the patient gathered through tests,
measures, or observations that produce a quantified or categorized result. It
includes important and relevant positive and negative test results, physical
findings, review of systems, and other measurements and observations.
1. SHALL contain exactly one [1..1] templateId (CONF:7869) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.21.2.1" (CONF:10462).
2. SHALL contain exactly one [1..1] code (CONF:15389).
a. This code SHALL contain exactly one [1..1] @code="61149-1"
Objective (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15390).
3. SHALL contain exactly one [1..1] title (CONF:7871).
4. SHALL contain exactly one [1..1] text (CONF:7872).

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Figure 118: Objective section example






Chest: clear to ausc. No rales, normal breath sounds
Heart: RR, PMI in normal location and no heave or evidence
of
cardiomegaly,normal heart sounds, no murm or gallop




5.35 Operative Note Fluid Section 10216-0
[section: templateId 2.16.840.1.113883.10.20.7.12(open)]
Table 81: Operative Note Fluids Section Contexts
Used By:

Contains Entries:

Operative Note (optional)

The Operative Note Fluids section may be used to record fluids administered
during the surgical procedure.
1. SHALL contain exactly one [1..1] templateId (CONF:8030) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.7.12" (CONF:10463).
2. SHALL contain exactly one [1..1] code (CONF:15391).
a. This code SHALL contain exactly one [1..1] @code="10216-0"
Operative Note Fluids (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15392).
3. SHALL contain exactly one [1..1] title (CONF:8032).
4. SHALL contain exactly one [1..1] text (CONF:8033).
5. If the Operative Note Fluids section is present, there SHALL be a statement
providing details of the fluids administered or SHALL explicitly state there
were no fluids administered (CONF:8052).

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Figure 119: Operative Note fluid section example




250 ML Ringers Lactate


5.36 Operative Note Surgical Procedure Section 10223-6
[section: templateId 2.16.840.1.113883.10.20.7.14(open)]
Table 82: Operative Note Surgical Procedure Section Contexts
Used By:

Contains Entries:

Operative Note (optional)

The Operative Note Surgical Procedure section can be used to restate the
procedures performed if appropriate for an enterprise workflow. The
procedure(s) performed associated with the Operative Note are formally modeled
in the header using serviceEvent.
1. SHALL contain exactly one [1..1] templateId (CONF:8034) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.7.14" (CONF:10464).
2. SHALL contain exactly one [1..1] code (CONF:15393).
a. This code SHALL contain exactly one [1..1] @code="10223-6"
Operative Note Surgical Procedure (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15394).
3. SHALL contain exactly one [1..1] title (CONF:8036).
4. SHALL contain exactly one [1..1] text (CONF:8037).
5. If the surgical procedure section is present there SHALL be text indicating the
procedure performed (CONF:8054).
Figure 120: Operative Note surgical procedure section example




Laparoscopic Appendectomy


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5.37 Payers Section 48768-6
[section: templateId 2.16.840.1.113883.10.20.22.2.18(open)]
Table 83: Payers Section Contexts
Used By:

Contains Entries:

Continuity of Care Document (CCD) (optional)

Coverage Activity

Figure 121: Payers section UML diagram

The Payers section contains data on the patient’s payers, whether a ‘third party’
insurance, self-pay, other payer or guarantor, or some combination of payers,
and is used to define which entity is the responsible fiduciary for the financial
aspects of a patient’s care.
Each unique instance of a payer and all the pertinent data needed to contact,
bill to, and collect from that payer should be included. Authorization information
that can be used to define pertinent referral, authorization tracking number,
procedure, therapy, intervention, device, or similar authorizations for the patient
or provider, or both should be included. At a minimum, the patient’s pertinent
current payment sources should be listed.
The sources of payment are represented as a Coverage Activity, which identifies
all of the insurance policies or government or other programs that cover some or
all of the patient's healthcare expenses. The policies or programs are sequenced
by preference. The Coverage Activity has a sequence number that represents the
preference order. Each policy or program identifies the covered party with
respect to the payer, so that the identifiers can be recorded.
1. SHALL contain exactly one [1..1] templateId (CONF:7924) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.18" (CONF:10434).
2. SHALL contain exactly one [1..1] code (CONF:15395).
a. This code SHALL contain exactly one [1..1] @code="48768-6" Payers
(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15396).
3. SHALL contain exactly one [1..1] title (CONF:7926).
4. SHALL contain exactly one [1..1] text (CONF:7927).
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5. SHOULD contain zero or more [0..*] entry (CONF:7959) such that it
a. SHALL contain exactly one [1..1] Coverage Activity
(2.16.840.1.113883.10.20.22.4.60) (CONF:8905).
Figure 122: Payers section example









Payer name
Policy type / Coverage type
Policy ID
Covered party ID
Policy Holder




Good Health Insurance
Extended healthcare / Family
Contract Number
1138345
Patient's Mother








...




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5.38 Physical Exam Section 29545-1
[section: templateId 2.16.840.1.113883.10.20.2.10 (open)]
Table 84: Physical Exam Section Contexts
Used By:

Contains Entries:

Progress Note (optional)
Consultation Note (optional)
History and Physical (required)
Procedure Note (optional)

Highest Pressure Ulcer Stage
Number of Pressure Ulcers Observation
Pressure Ulcer Observation

The Physical Exam section includes direct observations made by the clinician.
The examination may include the use of simple instruments and may also
describe simple maneuvers performed directly on the patient’s body. This
section includes only observations made by the examining clinician using
inspection, palpation, auscultation, and percussion; it does not include
laboratory or imaging findings. The exam may be limited to pertinent body
systems based on the patient’s chief complaint or it may include a
comprehensive examination. The examination may be reported as a collection of
random clinical statements or it may be reported categorically.
The Physical Exam section may contain multiple nested subsections: Vital
Signs, General Status, and those listed in the Additional Physical Examination
Subsections appendix.
1. SHALL contain exactly one [1..1] templateId (CONF:7806) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.2.10" (CONF:10465).
2. SHALL contain exactly one [1..1] code (CONF:15397).
a. This code SHALL contain exactly one [1..1] @code="29545-1" Physical
Findings (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15398).
3. SHALL contain exactly one [1..1] title (CONF:7808).
4. SHALL contain exactly one [1..1] text (CONF:7809).
5. MAY contain zero or more [0..*] entry (CONF:17094) such that it
a. SHALL contain exactly one [1..1] Pressure Ulcer Observation
(templateId:2.16.840.1.113883.10.20.22.4.70) (CONF:17095).
6. MAY contain zero or more [0..*] entry (CONF:17096) such that it
a. SHALL contain exactly one [1..1] Number of Pressure Ulcers
Observation (templateId:2.16.840.1.113883.10.20.22.4.76)
(CONF:17097).
7. MAY contain zero or more [0..*] entry (CONF:17098) such that it
a. SHALL contain exactly one [1..1] Highest Pressure Ulcer Stage
(templateId:2.16.840.1.113883.10.20.22.4.77) (CONF:17099).

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Figure 123: Physical exam section example





All normal to examination.



5.39 Plan of Care Section 18776-5
[section: templateId 2.16.840.1.113883.10.20.22.2.10(open)]
Table 85: Plan of Care Section Contexts
Used By:

Contains Entries:

Progress Note (optional)
Consultation Note (optional)
Discharge Summary (required)
History and Physical (optional)
Procedure Note (optional)
Operative Note (optional)
Continuity of Care Document (CCD) (optional)

Instructions
Plan of Care
Plan of Care
Plan of Care
Plan of Care
Plan of Care
Plan of Care

Activity
Activity
Activity
Activity
Activity
Activity

Act
Encounter
Observation
Procedure
Substance Administration
Supply

Figure 124: Plan of care section UML diagram

*The Large UML Diagrams appendix provides a larger version of this diagram

The Plan of Care section contains data that defines pending orders,
interventions, encounters, services, and procedures for the patient. It is limited
to prospective, unfulfilled, or incomplete orders and requests only, which are
indicated by the @moodCode of the entries within this section. All active,
incomplete, or pending orders, appointments, referrals, procedures, services, or
any other pending event of clinical significance to the current care of the patient
should be listed unless constrained due to privacy issues. The plan may also
contain information about ongoing care of the patient and information regarding
goals and clinical reminders. Clinical reminders are placed here to provide
prompts for disease prevention and management, patient safety, and health-care
quality improvements, including widely accepted performance measures. The
plan may also indicate that patient education will be provided.
1. SHALL contain exactly one [1..1] templateId (CONF:7723) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.10" (CONF:10435).
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2. SHALL contain exactly one [1..1] code (CONF:14749).
a. This code SHALL contain exactly one [1..1] @code="18776-5" Plan of
Care (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:14750).
3. SHALL contain exactly one [1..1] title (CONF:16986).
4. SHALL contain exactly one [1..1] text (CONF:7725).
5. MAY contain zero or more [0..*] entry (CONF:7726) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity Act
(2.16.840.1.113883.10.20.22.4.39) (CONF:8804).
6. MAY contain zero or more [0..*] entry (CONF:8805) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity
Encounter (2.16.840.1.113883.10.20.22.4.40) (CONF:8806).
7. MAY contain zero or more [0..*] entry (CONF:8807) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity
Observation (2.16.840.1.113883.10.20.22.4.44) (CONF:8808).
8. MAY contain zero or more [0..*] entry (CONF:8809) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity
Procedure (2.16.840.1.113883.10.20.22.4.41) (CONF:8810).
9. MAY contain zero or more [0..*] entry (CONF:8811) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity
Substance Administration
(2.16.840.1.113883.10.20.22.4.42) (CONF:8812).
10. MAY contain zero or more [0..*] entry (CONF:8813) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity Supply
(templateId:2.16.840.1.113883.10.20.22.4.43) (CONF:14756).
11. MAY contain zero or more [0..*] entry (CONF:14695) such that it
a. SHALL contain exactly one [1..1] Instructions
(templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:16751).
Figure 125: Plan of care section example






...





...






...






...






...




5.40 Planned Procedure Section 59772-4
[section: templateId 2.16.840.1.113883.10.20.22.2.30(open)]
Table 86: Planned Procedure Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)
Operative Note (optional)

Plan of Care Activity Procedure

The Planned Procedure section records the procedure(s) that a clinician thought
would need to be done based on the preoperative assessment. It may be
important to record the procedure(s) that were originally planned for, consented
to, and perhaps pre-approved by the payor, particularly if different from the
actual procedure(s) and procedure details, to provide evidence to various

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stakeholders that the providers are aware of the discrepancy and the
justification can be found in the procedure details.
1. SHALL contain exactly one [1..1] templateId (CONF:8082) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.30" (CONF:10436).
2. SHALL contain exactly one [1..1] code (CONF:15399).
a. This code SHALL contain exactly one [1..1] @code="59772-4" Planned
Procedure (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15400).
3. SHALL contain exactly one [1..1] title (CONF:8084).
4. SHALL contain exactly one [1..1] text (CONF:8085).
5. MAY contain zero or more [0..*] entry (CONF:8744) such that it
a. SHALL contain exactly one [1..1] Plan of Care Activity
Procedure (2.16.840.1.113883.10.20.22.4.41) (CONF:8766).
Figure 126: Planned procedure section example






...





...




5.41 Postoperative Diagnosis Section 10218-6
[section: templateId 2.16.840.1.113883.10.20.22.2.35(open)]
Table 87: Postoperative Diagnosis Section Contexts
Used By:

Contains Entries:

Operative Note (required)

The Postoperative Diagnosis section records the diagnosis or diagnoses
discovered or confirmed during the surgery. Often it is the same as the
preoperative diagnosis.
1. SHALL contain exactly one [1..1] templateId (CONF:8101) such that it

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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.35" (CONF:10437).
2. SHALL contain exactly one [1..1] code (CONF:15401).
a. This code SHALL contain exactly one [1..1] @code="10218-6"
Postoperative Diagnosis (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15402).
3. SHALL contain exactly one [1..1] title (CONF:8103).
4. SHALL contain exactly one [1..1] text (CONF:8104).
Figure 127: Postoperative diagnosis section example




Appendicitis with periappendiceal abscess


5.42 Postprocedure Diagnosis Section 59769-0
[section: templateId 2.16.840.1.113883.10.20.22.2.36(open)]
Table 88: Postprocedure Diagnosis Section Contexts
Used By:

Contains Entries:

Procedure Note (required)

Postprocedure Diagnosis

The Postprocedure Diagnosis section records the diagnosis or diagnoses
discovered or confirmed during the procedure. Often it is the same as the preprocedure diagnosis or indication.
1. SHALL contain exactly one [1..1] templateId (CONF:8167) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.36" (CONF:10438).
2. SHALL contain exactly one [1..1] code (CONF:15403).
a. This code SHALL contain exactly one [1..1] @code="59769-0"
Postprocedure Diagnosis (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15404).
3. SHALL contain exactly one [1..1] title (CONF:8170).
4. SHALL contain exactly one [1..1] text (CONF:8171).
5. SHOULD contain zero or one [0..1] entry (CONF:8762) such that it
a. SHALL contain exactly one [1..1] Postprocedure Diagnosis
(2.16.840.1.113883.10.20.22.4.51) (CONF:8764).

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Figure 128: Postprocedure diagnosis section example





...





...




5.43 Preoperative Diagnosis Section 10219-4
[section: templateId 2.16.840.1.113883.10.20.22.2.34(open)]
Table 89: Preoperative Diagnosis Section Contexts
Used By:

Contains Entries:

Operative Note (required)

Preoperative Diagnosis

The Preoperative Diagnosis section records the surgical diagnosis or diagnoses
assigned to the patient before the surgical procedure and is the reason for the
surgery. The preoperative diagnosis is, in the opinion of the surgeon, the
diagnosis that will be confirmed during surgery.
1. SHALL contain exactly one [1..1] templateId (CONF:8097) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.34" (CONF:10439).
2. SHALL contain exactly one [1..1] code (CONF:15405).
a. This code SHALL contain exactly one [1..1] @code="10219-4"
Preoperative Diagnosis (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15406).
3. SHALL contain exactly one [1..1] title (CONF:8099).
4. SHALL contain exactly one [1..1] text (CONF:8100).
5. SHOULD contain zero or one [0..1] entry (CONF:10096) such that it
a. SHALL contain exactly one [1..1] Preoperative Diagnosis
(2.16.840.1.113883.10.20.22.4.65) (CONF:10097).

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Figure 129: Preoperative diagnosis section example




Appendicitis




...




5.44 Problem Section 11450-4
Table 90: Problem Section Contexts
Used By:

Contains Entries:

Entries optional:
Progress Note (optional)
Consultation Note (optional)
Discharge Summary (optional)
History and Physical (optional)

Problem Concern Act (Condition)

Entries required:
Continuity of Care Document (CCD) (required)

Figure 130: Problem section UML diagram

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This section lists and describes all relevant clinical problems at the time the
document is generated. At a minimum, all pertinent current and historical
problems should be listed.
Problem Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.5(open)]
The following constraints apply to a Problem section in which entries are not
required.
1. SHALL contain exactly one [1..1] templateId (CONF:7877) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.5" (CONF:10440).
2. SHALL contain exactly one [1..1] code (CONF:15407).
a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem
List (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15408).
3. SHALL contain exactly one [1..1] title (CONF:7879).
4. SHALL contain exactly one [1..1] text (CONF:7880).
5. SHOULD contain zero or more [0..*] entry (CONF:7881).
a. SHALL contain exactly one [1..1] Problem Concern Act
(Condition) (2.16.840.1.113883.10.20.22.4.3) (CONF:7882).
Problem Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.5.1(open)]
The following constraints apply to a Problem section in which entries are
required.
1. Conforms to Problem Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.5).
2. SHALL contain exactly one [1..1] templateId (CONF:9179) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.5.1" (CONF:10441).
3. SHALL contain exactly one [1..1] code (CONF:15409).
a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem
List (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15410).
4. SHALL contain exactly one [1..1] title (CONF:9181).
5. SHALL contain exactly one [1..1] text (CONF:9182).
6. SHALL contain at least one [1..*] entry (CONF:9183).
a. SHALL contain exactly one [1..1] Problem Concern Act
(Condition) (2.16.840.1.113883.10.20.22.4.3) (CONF:9184).

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Figure 131: Problem section example






Pneumonia: Resolved in March 1998 
...





...




Figure 132: Pressure ulcer on a problem list example







2 Stage 3 Pressure Ulcers
...


















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5.45 Procedure Description Section 29554-3
[section: templateId 2.16.840.1.113883.10.20.22.2.27(open)]
Table 91: Procedure Description Section Contexts
Used By:

Contains Entries:

Procedure Note (required)
Operative Note (required)

The Procedure Description section records the particulars of the procedure and
may include procedure site preparation, surgical site preparation, pertinent
details related to sedation/anesthesia, pertinent details related to measurements
and markings, procedure times, medications administered, estimated blood loss,
specimens removed, implants, instrumentation, sponge counts, tissue
manipulation, wound closure, sutures used, vital signs and other monitoring
data. Local practice often identifies the level and type of detail required based on
the procedure or specialty.
1. SHALL contain exactly one [1..1] templateId (CONF:8062) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.27" (CONF:10442).
2. SHALL contain exactly one [1..1] code (CONF:15411).
a. This code SHALL contain exactly one [1..1] @code="29554-3"
Procedure Description (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15412).
3. SHALL contain exactly one [1..1] title (CONF:8064).
4. SHALL contain exactly one [1..1] text (CONF:8065).
Figure 133: Procedure description section example




The patient was taken to the endoscopy suite where ...



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5.46 Procedure Disposition Section 59775-7
[section: templateId 2.16.840.1.113883.10.20.18.2.12(open)]
Table 92: Procedure Disposition Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)
Operative Note (optional)

The Procedure Disposition section records the status and condition of the
patient at the completion of the procedure or surgery. It often also states where
the patent was transferred to for the next level of care.
1. SHALL contain exactly one [1..1] templateId (CONF:8070) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.18.2.12" (CONF:10466).
2. SHALL contain exactly one [1..1] code (CONF:15413).
a. This code SHALL contain exactly one [1..1] @code="59775-7"
Procedure Disposition (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15414).
3. SHALL contain exactly one [1..1] title (CONF:8072).
4. SHALL contain exactly one [1..1] text (CONF:8073).
Figure 134: Procedure disposition section example




The patient was taken to the Endoscopy Recovery Unit in stable
condition.


5.47 Procedure Estimated Blood Loss Section 59770-8
[section: templateId 2.16.840.1.113883.10.20.18.2.9(open)]
Table 93: Procedure Estimated Blood Loss Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)
Operative Note (required)

The Estimated Blood Loss section may be a subsection of another section such
as the Procedure Description section. The Estimated Blood Loss section records
the approximate amount of blood that the patient lost during the procedure or

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surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it
may be descriptive, e.g., “minimal” or “none”.
1. SHALL contain exactly one [1..1] templateId (CONF:8074) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.18.2.9" (CONF:10467).
2. SHALL contain exactly one [1..1] code (CONF:15415).
a. This code SHALL contain exactly one [1..1] @code="59770-8"
Procedure Estimated Blood Loss (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15416).
3. SHALL contain exactly one [1..1] title (CONF:8076).
4. SHALL contain exactly one [1..1] text (CONF:8077).
5. The Estimated Blood Loss section SHALL include a statement providing an
estimate of the amount of blood lost during the procedure, even if the
estimate is text, such as "minimal" or "none" (CONF:8741).
Figure 135: Procedure estimated blood loss section example




Minimal


5.48 Procedure Findings Section 59776-5
[section: templateId 2.16.840.1.113883.10.20.22.2.28(open)]
Table 94: Procedure Findings Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)
Operative Note (required)

Problem Observation

The Procedure Findings section records clinically significant observations
confirmed or discovered during the procedure or surgery.
1. SHALL contain exactly one [1..1] templateId (CONF:8078) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.28" (CONF:10443).
2. SHALL contain exactly one [1..1] code (CONF:15417).
a. This code SHALL contain exactly one [1..1] @code="59776-5"
Procedure Findings (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15418).
3. SHALL contain exactly one [1..1] title (CONF:8080).
4. SHALL contain exactly one [1..1] text (CONF:8081).
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5. MAY contain zero or more [0..*] entry (CONF:8090) such that it
a. SHALL contain exactly one [1..1] Problem Observation
(2.16.840.1.113883.10.20.22.4.4) (CONF:8091).
Figure 136: Procedure findings section example




A 6 mm sessile polyp was found in the ascending colon and
removed by
snare, no cautery. Bleeding was controlled. Moderate
diverticulosis
and hemorrhoids were incidentally noted.




...




5.49 Procedure Implants Section 59771-6
[section: templateId 2.16.840.1.113883.10.20.22.2.40(open)]
Table 95: Procedure Implants Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)
Operative Note (optional)

The Procedure Implants section records any materials placed during the
procedure including stents, tubes, and drains.
1. SHALL contain exactly one [1..1] templateId (CONF:8178) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.40" (CONF:10444).
2. SHALL contain exactly one [1..1] code (CONF:15373).
a. This code SHALL contain exactly one [1..1] @code="59771-6"
Procedure Implants (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15374).
3. SHALL contain exactly one [1..1] title (CONF:8180).
4. SHALL contain exactly one [1..1] text (CONF:8181).
5. The Implants section SHALL include a statement providing details of the
implants placed, or assert no implants were placed (CONF:8769).
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Figure 137: Procedure implants section example




No implants were placed.


5.50 Procedure Indications Section 59768-2
[section: templateId 2.16.840.1.113883.10.20.22.2.29(open)]
Table 96: Procedure Indications Section Contexts
Used By:

Contains Entries:

Procedure Note (required)
Operative Note (optional)

Indication

The Procedure Indications section records details about the reason for the
procedure or surgery. This section may include the pre-procedure diagnosis or
diagnoses as well as one or more symptoms that contribute to the reason the
procedure is being performed.
1. SHALL contain exactly one [1..1] templateId (CONF:8058) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.29" (CONF:10445).
2. SHALL contain exactly one [1..1] code (CONF:15419).
a. This code SHALL contain exactly one [1..1] @code="59768-2"
Procedure Indications (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15420).
3. SHALL contain exactly one [1..1] title (CONF:8060).
4. SHALL contain exactly one [1..1] text (CONF:8061).
5. MAY contain zero or more [0..*] entry (CONF:8743) such that it
a. SHALL contain exactly one [1..1] Indication
(2.16.840.1.113883.10.20.22.4.19) (CONF:8765).

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Figure 138: Procedure indications section example




The procedure is performed for screening in a low risk
individual.





...




5.51 Procedure Specimens Taken Section 59773-2
[section: templateId 2.16.840.1.113883.10.20.22.2.31(open)]
Table 97: Procedure Specimens Taken Section Contexts
Used By:

Contains Entries:

Procedure Note (optional)
Operative Note (required)

The Procedure Specimens Taken section records the tissues, objects, or samples
taken from the patient during the procedure including biopsies, aspiration fluid,
or other samples sent for pathological analysis. The narrative may include a
description of the specimens.
1. SHALL contain exactly one [1..1] templateId (CONF:8086) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.31" (CONF:10446).
2. SHALL contain exactly one [1..1] code (CONF:15421).
a. This code SHALL contain exactly one [1..1] @code="59773-2"
Procedure Specimens Taken (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15422).
3. SHALL contain exactly one [1..1] title (CONF:8088).
4. SHALL contain exactly one [1..1] text (CONF:8089).
5. 5. The Procedure Specimens Taken section SHALL list all specimens removed
or SHALL explicitly state that no specimens were taken (CONF:8742).

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Figure 139: Procedure specimens taken section example




Ascending colon polyp


5.52 Procedures Section 47519-4
Table 98: Procedures Section Contexts
Used By:

Contains Entries:

Entries optional:
Consultation Note (optional)
Discharge Summary (optional)
Procedure Note (optional)
History and Physical (optional)

Procedure Activity Act
Procedure Activity Observation
Procedure Activity Procedure

Entries required:
Continuity of Care Document (CCD) (optional)

Figure 140: Procedures section UML diagram

This section defines all interventional, surgical, diagnostic, or therapeutic
procedures or treatments pertinent to the patient historically at the time the
document is generated. The section is intended to include notable procedures,
but can contain all procedures for the period of time being summarized. The
common notion of "procedure" is broader than that specified by the HL7 Version
3 Reference Information Model (RIM). Therefore this section contains procedure
templates represented with three RIM classes: Act. Observation, and Procedure.
Procedure act is for procedures the alter that physical condition of a patient
(Splenectomy). Observation act is for procedures that result in new information
about a patient but do not cause physical alteration (EEG). Act is for all other
types of procedures (dressing change).

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The length of an encounter is documented in the
documentationOf/encompassingEncounter/effectiveTime and length of
service in documentationOf/ServiceEvent/effectiveTime.
Procedures Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.7(open)]
The following constraints apply to a Procedures section in which entries are not
required.
1. SHALL contain exactly one [1..1] templateId (CONF:6270) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.7" (CONF:6271).
2. SHALL contain exactly one [1..1] code (CONF:15423).
a. This code SHALL contain exactly one [1..1] @code="47519-4" History
of Procedures (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15424).
3. SHALL contain exactly one [1..1] title (CONF:17184).
4. SHALL contain exactly one [1..1] text (CONF:6273).
5. MAY contain zero or more [0..*] entry (CONF:6274) such that it
a. SHALL contain exactly one [1..1] Procedure Activity Procedure
(templateId:2.16.840.1.113883.10.20.22.4.14) (CONF:15509).
6. MAY contain zero or one [0..1] entry (CONF:6278) such that it
a. SHALL contain exactly one [1..1] Procedure Activity Observation
(templateId:2.16.840.1.113883.10.20.22.4.13) (CONF:15510).
7. MAY contain zero or one [0..1] entry (CONF:8533) such that it
a. SHALL contain exactly one [1..1] Procedure Activity Act
(templateId:2.16.840.1.113883.10.20.22.4.12) (CONF:15511).
Procedures Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.7.1(open)]
The following constraints apply to a Procedures section in which entries are
required.
1. Conforms to Procedures Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.7)
2. SHALL contain exactly one [1..1] templateId (CONF:7891) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.7.1" (CONF:10447).
3. SHALL contain exactly one [1..1] code (CONF:15425).
a. This code SHALL contain exactly one [1..1] @code="47519-4" History
of Procedures (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15426).
4. SHALL contain exactly one [1..1] title (CONF:7893).
5. SHALL contain exactly one [1..1] text (CONF:7894).
6. MAY contain zero or more [0..*] entry (CONF:7895) such that it
a. SHALL contain exactly one [1..1] Procedure Activity Procedure
(2.16.840.1.113883.10.20.22.4.14) (CONF:7896).
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7. MAY contain zero or more [0..*] entry (CONF:8017) such that it
a. SHALL contain exactly one [1..1] Procedure Activity Observation
(2.16.840.1.113883.10.20.22.4.13) (CONF:8018).
8. MAY contain zero or more [0..*] entry (CONF:8019) such that it
a. SHALL contain exactly one [1..1] Procedure Activity Act
(2.16.840.1.113883.10.20.22.4.12) (CONF:8020).
9. There SHALL be at least one procedure, observation or act entry conformant
to Procedure Activity Procedure template, Procedure Activity Observation
template or Procedure Activity Act template in the Procedure Section
(CONF:8021).
Figure 141: Procedures section example






...





...






...






...




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5.53 Reason for Referral Section 42349-1
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.1(open)]
Table 99: Reason for Referral Section Contexts
Used By:

Contains Entries:

Consultation Note (optional)

A Reason for Referral section records the reason the patient is being referred for
a consultation by a provider. An optional Chief Complaint section may capture
the patient’s description of the reason for the consultation.
1. SHALL contain exactly one [1..1] templateId (CONF:7844) such that it
a. SHALL contain exactly one [1..1]
@root="1.3.6.1.4.1.19376.1.5.3.1.3.1" (CONF:10468).
2. SHALL contain exactly one [1..1] code (CONF:15427).
a. This code SHALL contain exactly one [1..1] @code="42349-1" Reason
for Referral (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15428).
3. SHALL contain exactly one [1..1] title (CONF:7846).
4. SHALL contain exactly one [1..1] text (CONF:7847).
Figure 142: Reason for referral section example






Lumbar spinal stenosis with radiculopathy.



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5.54 Reason for Visit Section 29299-5
[section: templateId 2.16.840.1.113883.10.20.22.2.12(open)]
Table 100: Reason for Visit Section Contexts
Used By:

Contains Entries:

Consultation Note (optional)
Discharge Summary (optional)
History and Physical (required)
Procedure Note (optional)

This section records the patient’s reason for the patient's visit (as documented
by the provider). Local policy determines whether Reason for Visit and Chief
Complaint are in separate or combined sections.
1. SHALL contain exactly one [1..1] templateId (CONF:7836) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.12" (CONF:10448).
2. SHALL contain exactly one [1..1] code (CONF:15429).
a. This code SHALL contain exactly one [1..1] @code="29299-5" Reason
for Visit (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15430).
3. SHALL contain exactly one [1..1] title (CONF:7838).
4. SHALL contain exactly one [1..1] text (CONF:7839).
Figure 143: Reason for visit section example





Dark stools.



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5.55 Results Section 30954-2
Table 101: Results Section Contexts
Used by:

Contains entries:

Coded entries optional:
History and Physical (required)
Consultation Note (optional)
Progress Note (optional)

Results Organizer

Coded entries required:
CCD (required)

Figure 144: Results section UML diagram

The Results section contains the results of observations generated by
laboratories, imaging procedures, and other procedures. The scope includes
observations such as hematology, chemistry, serology, virology, toxicology,
microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography,
nuclear medicine, pathology, and procedure observations. The section often
includes notable results such as abnormal values or relevant trends, and could
contain all results for the period of time being documented.
Laboratory results are typically generated by laboratories providing analytic
services in areas such as chemistry, hematology, serology, histology, cytology,
anatomic pathology, microbiology, and/or virology. These observations are based
on analysis of specimens obtained from the patient and submitted to the
laboratory.
Imaging results are typically generated by a clinician reviewing the output of an
imaging procedure, such as where a cardiologist reports the left ventricular
ejection fraction based on the review of a cardiac echocardiogram.
Procedure results are typically generated by a clinician to provide more granular
information about component observations made during a procedure, such as
where a gastroenterologist reports the size of a polyp observed during a
colonoscopy.

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Results Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.3(open)]
The following constraints apply to a Results section in which entries are not
required.
1. SHALL contain exactly one [1..1] templateId (CONF:7116) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.3" (CONF:9136).
2. SHALL contain exactly one [1..1] code (CONF:15431).
a. This code SHALL contain exactly one [1..1] @code="30954-2" Relevant
diagnostic tests and/or laboratory data (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15432).
3. SHALL contain exactly one [1..1] title (CONF:8891).
4. SHALL contain exactly one [1..1] text (CONF:7118).
5. SHOULD contain zero or more [0..*] entry (CONF:7119) such that it
a. SHALL contain exactly one [1..1] Result Organizer
(2.16.840.1.113883.10.20.22.4.1) (CONF:7120).
Results Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.3.1(open)]
The following constraints apply to a Results section in which entries are
required.
1. Conforms to Results Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.3)
2. SHALL contain exactly one [1..1] templateId (CONF:7108) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.3.1" (CONF:9137).
3. SHALL contain exactly one [1..1] code (CONF:15433).
a. This code SHALL contain exactly one [1..1] @code="30954-2" Relevant
diagnostic tests and/or laboratory data (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15434).
4. SHALL contain exactly one [1..1] title (CONF:8892).
5. SHALL contain exactly one [1..1] text (CONF:7111).
6. SHALL contain at least one [1..*] entry (CONF:7112) such that it
a. SHALL contain exactly one [1..1] Result Organizer
(2.16.840.1.113883.10.20.22.4.1) (CONF:7113).

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Figure 145: Results section example



codeSystemName="LOINC"
displayName="RESULTS" />


...




...




5.56 Review of Systems Section 10187-3
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.18(open)]
Table 102: Review of Systems Section Contexts
Used By:

Contains Entries:

Progress Note (optional)
Consultation Note (optional)
Discharge Summary (optional)
History and Physical (required)
Procedure Note (optional)

The Review of Systems section contains a relevant collection of symptoms and
functions systematically gathered by a clinician. It includes symptoms the
patient is currently experiencing, some of which were not elicited during the
history of present illness, as well as a potentially large number of pertinent
negatives, for example, symptoms that the patient denied experiencing.
1. SHALL contain exactly one [1..1] templateId (CONF:7812) such that it
a. SHALL contain exactly one [1..1]
@root="1.3.6.1.4.1.19376.1.5.3.1.3.18" (CONF:10469).
2. SHALL contain exactly one [1..1] code (CONF:15435).
a. This code SHALL contain exactly one [1..1] @code="10187-3" Review
of Systems (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15436).
3. SHALL contain exactly one [1..1] title (CONF:7814).
4. SHALL contain exactly one [1..1] text (CONF:7815).

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Figure 146: Review of systems section example






Patient denies recent history of fever or malaise. Positive
For weakness and shortness of breath. One episode of melena. No
recent
headaches. Positive for osteoarthritis in hips, knees and hands.




5.57 Social History Section 29762-2
[section: templateId 2.16.840.1.113883.10.20.22.2.17(open)]
Table 103: Social History Section Contexts
Used By:

Contains Entries:

Consultation Note (optional)
Discharge Summary (optional)
History and Physical (required)
Procedure Note (optional)
Continuity of Care Document (CCD) (optional)

Pregnancy Observation
Smoking Status Observation
Social History Observation
Tobacco Use

Figure 147: Social history section UML diagram

This section contains data defining the patient’s occupational, personal (e.g.
lifestyle), social, and environmental history and health risk factors, as well as
administrative data such as marital status, race, ethnicity and religious
affiliation. Social history can have significant influence on a patient’s physical,
psychological and emotional health and wellbeing so should be considered in the
development of a complete record.
1. SHALL contain exactly one [1..1] templateId (CONF:7936) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.17" (CONF:10449).

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2. SHALL contain exactly one [1..1] code (CONF:14819).
a. This code SHALL contain exactly one [1..1] @code="29762-2" Social
History (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:14820).
3. SHALL contain exactly one [1..1] title (CONF:7938).
4. SHALL contain exactly one [1..1] text (CONF:7939).
5. MAY contain zero or more [0..*] entry (CONF:7953) such that it
a. SHALL contain at least one [1..*] Social History Observation
(2.16.840.1.113883.10.20.22.4.38) (CONF:7954).
6. MAY contain zero or more [0..*] entry (CONF:9132) such that it
a. SHALL contain exactly one [1..1] Pregnancy Observation
(2.16.840.1.113883.10.20.15.3.8) (CONF:9133).
7. SHOULD contain zero or more [0..*] entry (CONF:14823) such that it
a. SHALL contain exactly one [1..1] Smoking Status Observation
(templateId:2.16.840.1.113883.10.22.4.78) (CONF:14824).
8. MAY contain zero or more [0..*] entry (CONF:16816) such that it
a. SHALL contain exactly one [1..1] Tobacco Use
(templateId:2.16.840.1.113883.10.20.22.4.85) (CONF:16817).
Figure 148: Social history section example






...





...






...




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5.58 Subjective Section 61150-9
[section: templateId 2.16.840.1.113883.10.20.21.2.2(open)]
Table 104: Subjective Section Contexts
Used By:

Contains Entries:

Progress Note (optional)

The Subjective section describes in a narrative format the patient’s current
condition and/or interval changes as reported by the patient or by the patient’s
guardian or another informant.
1. SHALL contain exactly one [1..1] templateId (CONF:7873) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.21.2.2" (CONF:10470).
2. SHALL contain exactly one [1..1] code (CONF:15437).
a. This code SHALL contain exactly one [1..1] @code="61150-9"
Subjective (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15438).
3. SHALL contain exactly one [1..1] title (CONF:7875).
4. SHALL contain exactly one [1..1] text (CONF:7876).
Figure 149: Subjective section example






I have used the peripheral nerve stimulator in my back for five
days.
While using it I found that I was able to do physical activity
without pain. However, afterwards for one day, I would feel pain
but
then it would go away. I also noticed that I didn’t have to take
the
Vicodin as much. I took 2 less Vicodin per day and 2 less
tramadol
everyday. I have not lain in my bed in a year and a half. I sleep
in
a recliner.




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5.59 Surgical Drains Section 11537-8
[section: templateId 2.16.840.1.113883.10.20.7.13(open)]
Table 105: Surgical Drains Section Contexts
Used By:

Contains Entries:

Operative Note (optional)

The Surgical Drains section may be used to record drains placed during the
surgical procedure. Optionally, surgical drain placement may be represented
with a text element in the Procedure Description Section.
1. SHALL contain exactly one [1..1] templateId (CONF:8038) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.7.13" (CONF:10473).
2. SHALL contain exactly one [1..1] code (CONF:15441).
a. This code SHALL contain exactly one [1..1] @code="11537-8" Surgical
Drains (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:15442).
3. SHALL contain exactly one [1..1] title (CONF:8040).
4. SHALL contain exactly one [1..1] text (CONF:8041).
5. If the Surgical Drains section is present, there SHALL be a statement
providing details of the drains placed or SHALL explicitly state there were no
drains placed (CONF:8056).
Figure 150: Surgical drains section example




Penrose drain placed


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5.60 Vital Signs Section 8716-3
Table 106: Vital Signs Section Contexts
Used By:

Contains Entries:

Entries optional:
Progress Note (optional)
Consultation Note (optional)
Discharge Summary (optional)
History and Physical (required)
Continuity of Care Document (CCD) (optional)

Vital Signs Organizer

Entries required:
---

Figure 151: Vital signs section UML diagram

The Vital Signs section contains relevant vital signs for the context and use case
of the document type, such as blood pressure, heart rate, respiratory rate,
height, weight, body mass index, head circumference, and pulse oximetry. The
section should include notable vital signs such as the most recent, maximum
and/or minimum, baseline, or relevant trends.
Vital signs are represented in the same way as other results, but are aggregated
into their own section to follow clinical conventions.
Vital Signs Section with Coded Entries Optional
[section: templateId 2.16.840.1.113883.10.20.22.2.4(open)]
The following constraints apply to a Vital Signs section in which entries are not
required.
1. SHALL contain exactly one [1..1] templateId (CONF:7268) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.4" (CONF:10451).
2. SHALL contain exactly one [1..1] code (CONF:15242).
a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital
Signs (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15243).
3. SHALL contain exactly one [1..1] title (CONF:9966).
4. SHALL contain exactly one [1..1] text (CONF:7270).
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5. SHOULD contain zero or more [0..*] entry (CONF:7271) such that it
a. SHALL contain exactly one [1..1] Vital Signs Organizer
(2.16.840.1.113883.10.20.22.4.26) (CONF:7272).
Vital Signs Section with Coded Entries Required
[section: templateId 2.16.840.1.113883.10.20.22.2.4.1(open)]
The following constraints apply to a Vital Signs section in which entries are
required.
1. Conforms to Vital Signs Section (entries optional) template
(2.16.840.1.113883.10.20.22.2.4)
2. SHALL contain exactly one [1..1] templateId (CONF:7273) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.4.1" (CONF:10452).
3. SHALL contain exactly one [1..1] code (CONF:15962).
a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital
Signs (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15963).
4. SHALL contain exactly one [1..1] title (CONF:9967).
5. SHALL contain exactly one [1..1] text (CONF:7275).
6. SHALL contain at least one [1..*] entry (CONF:7276) such that it
a. SHALL contain exactly one [1..1] Vital Signs Organizer
(2.16.840.1.113883.10.20.22.4.26) (CONF:7277).
Figure 152: Vital signs section example





...





...




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6

ENTRY-LEVEL TEMPLATES
This part of the guide describes the clinical statement entry templates used
within the sections of the consolidated documents. Entry templates contain
constraints that are required for conformance. Note that the clinical statement
templates are presented in alphabetical order; templates are not grouped by
possible containing templates.
Entry-level templates are always allowed in sections.
Each entry-level template description contains the following information:
Key template metadata (e.g., templateId, etc.)
Description and explanatory narrative.
Required CDA acts, participants and vocabularies.
Optional CDA acts, participants and vocabularies.
Several entry-level templates require an effectiveTime:
The effectiveTime of an observation is the time interval over which the
observation is known to be true. The low and high values should be as
precise as possible, but no more precise than known. While CDA has
multiple mechanisms to record this time interval (e.g., by low and high
values, low and width, high and width, or center point and width), we
constrain most to use only the low/high form. The low value is the
earliest point for which the condition is known to have existed. The high
value, when present, indicates the time at which the observation was no
longer known to be true. The full description of effectiveTime and time
intervals is contained in the CDA R2 normative edition 32.
Entry-level templates may also describe an id element, which is an identifier for
that entry. This id may be referenced within the document, or by the system
receiving the document. The id assigned must be globally unique.

6.1

Admission Medication
[act: templateId 2.16.840.1.113883.10.20.22.4.36 (open)]
Table 107: Admission Medication Contexts
Used By:

Contains Entries:

Hospital Admission Medications Section (entries optional) (optional)

Medication Activity

The Admission Medications entry codes medications that the patient took prior
to admission.

HL7 Clinical Document Architecture (CDA Release 2).
http://www.hl7.org/implement/standards/cda.cfm
32

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Table 108: Admission Medication Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.36']
@classCode

1..1

SHALL

7698

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

7699

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

16758

1..1

SHALL

16759

1..1

SHALL

15518

0..1

MAY

15519

1..*

SHALL

7701

1..1

SHALL

7702

1..1

SHALL

15520

@root
code
@code
entryRelationship
@typeCode

2.16.840.1.113883.10.20.2
2.4.36
2.16.840.1.113883.6.1
(LOINC) = 42346-7
2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ

substanceAdministration

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7698).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7699).
3. SHALL contain exactly one [1..1] templateId (CONF:16758) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.36" (CONF:16759).
4. SHALL contain exactly one [1..1] code (CONF:15518).
a. This code MAY contain zero or one [0..1] @code="42346-7"
Medications on Admission (CodeSystem: LOINC
2.16.840.1.113883.6.1) (CONF:15519).
5. SHALL contain at least one [1..*] entryRelationship (CONF:7701) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7702).
b. SHALL contain exactly one [1..1] Medication Activity
(templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:15520).

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Figure 153: Admission medication entry example














...





6.2

Advance Directive Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.48(open)]
Table 109: Advance Directive Observation Contexts
Used By:

Contains Entries:

Advance Directives Section (entries optional)
Advance Directives Section (entries required)

Advance Directives Observatations assert findings (e.g., “resuscitation status is
Full Code”) rather than orders, and should not be considered legal documents. A
legal document can be referenced using the reference/externalReference
construct.

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Table 110: Advance Directive Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.48']
@classCode

1..1

SHALL

8648

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8649

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

id

1..*

SHALL

II

8654

code

1..1

SHALL

CD

8651

2.16.840.1.113883.1.11.20.
2
(AdvanceDirectiveTypeCode)

statusCode

1..1

SHALL

CS

8652

2.16.840.1.113883.5.14
(ActStatus) = completed

effectiveTime

1..1

SHALL

TS or
IVL

8656

low

1..1

SHALL

TS

8657

high

1..1

SHALL

TS

8659

1..*

SHOULD

8662

@typeCode

1..1

SHALL

8663

templateId

1..1

SHALL

1..1

SHALL

0..1

SHOULD

participant
Role

1..1

SHALL

8825

participant

1..1

SHOULD

8667

@typeCode

1..1

SHALL

8668

participant
Role

1..1

SHALL

8669

1..1

SHALL

8670

addr

0..1

SHOULD

SET

8671

telecom

0..1

SHOULD

SET

8672

1..1

SHALL

1..1

SHALL

@root

Advance
Directive
Type

effective
Date

participant

@root
time

custodian
of the
Document

SET

8655
10485

SET

2.16.840.1.113883.5.90
(HL7ParticipationType) =
VRF

8664
10486

IVL

2.16.840.1.113883.10.20.2
2.4.48

2.16.840.1.113883.10.20.1.
58

8665

@classCode

2.16.840.1.113883.5.90
(HL7ParticipationType) =
CST

2.16.840.1.113883.5.110
(RoleClass) = AGNT

8824

playingEntity
name

PN

8673

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Name

XPath

Card.

Verb

1..*

SHOULD

8692

1..1

SHALL

8694

external
Document

1..1

SHALL

8693

id

1..*

SHALL

II

8695

text

0..1

MAY

ED

8696

0..1

MAY

8703

0..1

MAY

8697

reference
@typeCode

Data
Type

CONF#

Fixed Value

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
REFR

@mediaType
reference

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8648).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8649).
3. SHALL contain exactly one [1..1] templateId (CONF:8655) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.48" (CONF:10485).
4. SHALL contain at least one [1..*] id (CONF:8654).
5. SHALL contain exactly one [1..1] code, where the @code SHOULD be selected
from ValueSet AdvanceDirectiveTypeCode
2.16.840.1.113883.1.11.20.2 STATIC 2006-10-17 (CONF:8651).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:8652).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:8656).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:8657).
i.

If the starting time is unknown, the  element SHALL have
the nullFlavor attribute set to UNK (CONF:8658).

b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:8659).
i.

If the ending time is unknown, the  element SHALL have
the nullFlavor attribute set to UNK (CONF:8660).

ii. If the Advance Directive does not have a specified ending time,
the  element SHALL have the nullFlavor attribute set to
NA (CONF:8661).
8. SHOULD contain at least one [1..*] participant (CONF:8662) such that it
a. SHALL contain exactly one [1..1] @typeCode="VRF" Verifier
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8663).
b. SHALL contain exactly one [1..1] templateId (CONF:8664) such that
it
i.

contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.1.58" (CONF:10486).
SHALL

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c. SHOULD contain zero or one [0..1] time (CONF:8665).
i.

The data type of Observation/participant/time in a
verification SHALL be TS (time stamp) (CONF:8666).

d. SHALL contain exactly one [1..1] participantRole (CONF:8825).
9. SHOULD contain exactly one [1..1] participant (CONF:8667) such that it
a. SHALL contain exactly one [1..1] @typeCode="CST" Custodian
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8668).
b. SHALL contain exactly one [1..1] participantRole (CONF:8669).
i.

This participantRole SHALL contain exactly one [1..1]
@classCode="AGNT" Agent (CodeSystem: RoleClass
2.16.840.1.113883.5.110) (CONF:8670).

ii. This participantRole SHOULD contain zero or one [0..1] addr
(CONF:8671).
iii. This participantRole SHOULD contain zero or one [0..1]
telecom (CONF:8672).
iv. This participantRole SHALL contain exactly one [1..1]
playingEntity (CONF:8824).
1. This playingEntity SHALL contain exactly one [1..1]
name (CONF:8673).
a. The name of the agent who can provide a copy
of the Advance Directive SHALL be recorded in
the  element inside the 
element (CONF:8674).
10. SHOULD contain at least one [1..*] reference (CONF:8692) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:8694).
b. SHALL contain exactly one [1..1] externalDocument (CONF:8693).
i.

This externalDocument SHALL contain at least one [1..*] id
(CONF:8695).

ii. This externalDocument MAY contain zero or one [0..1] text
(CONF:8696).
1. The text, if present, MAY contain zero or one [0..1]
@mediaType (CONF:8703).
2. The text, if present, MAY contain zero or one [0..1]
reference (CONF:8697).
a. The URL of a referenced advance directive
document MAY be present, and SHALL be
represented in
Observation/reference/ExternalDocument/text
/reference (CONF:8698).
b. If a URL is referenced, then it SHOULD have a
corresponding linkHTML element in narrative
block (CONF:8699).

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Table 111: Advance Directive Type Code Value Set
Value Set: AdvanceDirectiveTypeCode 2.16.840.1.113883.1.11.20.2 STATIC 2006-10-17
Code System(s):
Code

SNOMED CT 2.16.840.1.113883.6.96
Code System

Print Name

52765003

SNOMED CT

Intubation

61420007

SNOMED CT

Tube Feedings

71388002

SNOMED CT

Other Directive

78823007

SNOMED CT

Life Support

89666000

SNOMED CT

CPR

225204009

SNOMED CT

IV Fluid and Support

281789004

SNOMED CT

Antibiotics

304251008

SNOMED CT

Resuscitation

Figure 154: Advance directive observation example





















Dr.
Dolin
Robert





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21 North Ave.
Burlington
MA
02368
US




Dr.
Dolin
Robert















6.3

Age Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.31(open)]
Table 112: Age Observation Contexts
Used By:

Contains Entries:

Family History Observation
Problem Observation

This Age Observation represents the subject's age at onset of an event or
observation. The age of a relative in a Family History Observation at the time of
that observation could also be inferred by comparing
RelatedSubject/subject/birthTime with Observation/effectiveTime.
However, a common scenario is that a patient will know the age of a relative
when the relative had a certain condition or when the relative died, but will not
know the actual year (e.g., "grandpa died of a heart attack at the age of 50").
Often times, neither precise dates nor ages are known (e.g. "cousin died of
congenital heart disease as an infant").

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Table 113: Age Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.31']
@classCode

1..1

SHALL

7613

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

7614

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

1..1

SHALL

10487

1..1

SHALL

7615

1..1

SHALL

16776

1..1

SHALL

15965

1..1

SHALL

15966

1..1

SHALL

1..1

SHALL

@root
code
@code
statusCode
@code
value
@unit

SET

PQ

7899
2.16.840.1.113883.10.20.22.4.31
2.16.840.1.113883.6.96 (SNOMEDCT) = 445518008
2.16.840.1.113883.5.14 (ActStatus) =
completed

7617
7618

2.16.840.1.113883.11.20.9.21
(AgePQ_UCUM) = 1

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7613).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7614).
3. SHALL contain exactly one [1..1] templateId (CONF:7899) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.31" (CONF:10487).
4. SHALL contain exactly one [1..1] code (CONF:7615).
a. This code SHALL contain exactly one [1..1] @code="445518008" Age
At Onset (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96)
(CONF:16776).
5. SHALL contain exactly one [1..1] statusCode (CONF:15965).
a. This statusCode SHALL contain exactly one [1..1] @code="completed"
Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14)
(CONF:15966).
6. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7617).
a. This value SHALL contain exactly one [1..1] @unit="1", which SHALL
be selected from ValueSet AgePQ_UCUM
2.16.840.1.113883.11.20.9.21 DYNAMIC (CONF:7618).

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Table 114: AgePQ_UCUM Value Set
Value Set: AgePQ_UCUM 2.16.840.1.113883.11.20.9.21 DYNAMIC
Code System(s):

Unified Code for Units of Measure (UCUM) 2.16.840.1.113883.6.8

Description:

A valueSet of UCUM codes for representing age value units

Code

Code System

Print Name

min

UCUM

Minute

h

UCUM

Hour

d

UCUM

Day

wk

UCUM

Week

mo

UCUM

Month

a

UCUM

Year

Figure 155: Age observation example








6.4 Allergy - Intolerance Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.7(open)]
Table 115: Allergy - Intolerance Observation Contexts
Used By:

Contains Entries:

Allergy Problem Act (required)

Allergy Status Observation
Reaction Observation
Severity Observation

This clinical statement represents that an allergy or adverse reaction exists or
does not exist. The agent that is the cause of the allergy or adverse reaction is
represented as a manufactured material participant playing entity in the allergy
- intolerance observation. While the agent is often implicit in the alert
observation (e.g. "allergy to penicillin"), it should also be asserted explicitly as an
entity. The manufactured material participant is used to represent natural and
non-natural occurring substances.
NOTE: The agent responsible for an allergy or adverse reaction is not always a
manufactured material (for example, food allergies), nor is it necessarily

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consumed. The following constraints reflect limitations in the base CDA R2
specification, and should be used to represent any type of responsible agent.
Table 116: Allergy - Intolerance Observation Constraints Overview
Name

XPath

Card.

Allergy –
Intolerance
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.7']

product

Fixed Value

SHALL

7379

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

7380

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10488

id

1..*

SHALL

7382

code

1..1

SHALL

15947

1..1

SHALL

15948

2.16.840.1.113883.5.4
(ActCode) = ASSERTION

statusCode

1..1

SHALL

7386

2.16.840.1.113883.5.14
(ActStatus) = completed

effectiveTime

1..1

SHALL

TS or
IVL

7387

value

1..1

SHALL

CD

7390

@code

1..1

SHALL

9139

originalText

0..1

SHOULD

7422

reference

0..1

MAY

15949

@value

0..1

SHOULD

15950

0..1

SHOULD

7402

1..1

SHALL

7403

1..1

SHALL

7404

participant
@typeCode

productDet
ail

CONF#

1..1

@code

adverseEve
nt
Type

Data
Type

@classCode

@root

adverseEve
nt
Date

Verb

SET

7381
2.16.840.1.113883.10.20.22.4.
7

2.16.840.1.113883.3.88.12.32
21.6.2 (Allergy/Adverse Event
Type)

2.16.840.1.113883.5.90
(HL7ParticipationType) = CSM

participantRole

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Name

XPath
@classCode

Card.

Verb

1..1

Data
Type

CONF#

Fixed Value

SHALL

7405

2.16.840.1.113883.5.110
(RoleClass) = MANU

1..1

SHALL

7406

1..1

SHALL

7407

1..1

SHALL

7419

0..1

SHOULD

7424

0..1

SHOULD

7425

0..1

SHOULD

15952

0..*

MAY

0..1

MAY

7440

1..1

SHALL

7906

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ

1..1

SHALL

7446

true

1..1

SHALL

15954

0..*

SHOULD

7447

1..1

SHALL

7907

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
MFST

1..1

SHALL

7449

true

1..1

SHALL

15955

0..1

SHOULD

9961

1..1

SHALL

9962

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ

1..1

SHALL

9964

true

1..1

SHALL

15956

playingEntity
@classCode
product
Coded
productFree
Text

code

2.16.840.1.113883.5.41
(EntityClass) = MMAT

originalText
reference
@value
translation
entryRelations
hip
@typeCode

SET


7431

@inversionInd
observation
reaction

entryRelations
hip
@typeCode

@inversionInd
observation
severity

entryRelations
hip
@typeCode

@inversionInd
observation

1. Conforms to Substance or Device Allergy - Intolerance
Observation template (2.16.840.1.113883.10.20.24.3.90).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7379).

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3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7380).
4. SHALL contain exactly one [1..1] templateId (CONF:7381) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.7" (CONF:10488).
5. SHALL contain at least one [1..*] id (CONF:7382).
6. SHALL contain exactly one [1..1] code (CONF:15947).
a. This code SHALL contain exactly one [1..1] @code="ASSERTION"
Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4)
(CONF:15948).
7. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:7386).
8. SHALL contain exactly one [1..1] effectiveTime (CONF:7387).
a. If it is unknown when the allergy began, this effectiveTime SHALL
contain low/@nullFLavor="UNK" (CONF:9103).
b. If the allergy is no longer a concern, this effectiveTime MAY contain
zero or one [0..1] high (CONF:10082).
9. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:7390).
a. This value SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet Allergy/Adverse Event Type
2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC (CONF:9139).
b. This value SHOULD contain zero or one [0..1] originalText
(CONF:7422).
i.

The originalText, if present, MAY contain zero or one [0..1]
reference (CONF:15949).
1. The reference, if present, SHOULD contain zero or one
[0..1] @value (CONF:15950).
a. This reference/@value SHALL begin with a '#'
and SHALL point to its corresponding narrative
(using the approach defined in CDA Release 2,
section 4.3.5.1) (CONF:15951).

10. SHOULD contain zero or one [0..1] participant (CONF:7402) such that it
a. SHALL contain exactly one [1..1] @typeCode="CSM" Consumable
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90
STATIC) (CONF:7403).
b. SHALL contain exactly one [1..1] participantRole (CONF:7404).
i.

This participantRole SHALL contain exactly one [1..1]
@classCode="MANU" Manufactured Product (CodeSystem:
RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:7405).

ii. This participantRole SHALL contain exactly one [1..1]
playingEntity (CONF:7406).
1. This playingEntity SHALL contain exactly one [1..1]
@classCode="MMAT" Manufactured Material
(CodeSystem: EntityClass
2.16.840.1.113883.5.41 STATIC) (CONF:7407).

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2. This playingEntity SHALL contain exactly one [1..1]
code (CONF:7419).
a. This code SHOULD contain zero or one [0..1]
originalText (CONF:7424).
i.

The originalText, if present, SHOULD
contain zero or one [0..1] reference
(CONF:7425).

1.

The reference, if present, SHOULD
contain zero or one [0..1] @value
(CONF:15952).
1.

This reference/@value
begin with a '#' and SHALL
point to its corresponding
narrative (using the approach
defined in CDA Release 2,
section 4.3.5.1) (CONF:15953).
SHALL

b. This code MAY contain zero or more [0..*]
translation (CONF:7431).
c. In an allergy to a specific medication the code
SHALL be selected from the ValueSet
2.16.840.1.113883.3.88.12.80.16 Medication
Brand Name DYNAMIC or the ValueSet
2.16.840.1.113883.3.88.12.80.17 Medication
Clinical Drug DYNAMIC (CONF:7421).
d. In an allergy to a class of medications the code
SHALL be selected from the ValueSet
2.16.840.1.113883.3.88.12.80.18 Medication
Drug Class DYNAMIC (CONF:10083).
e. In an allergy to a food or other substance the
code SHALL be selected from the ValueSet
2.16.840.1.113883.3.88.12.80.20 Ingredient
Name DYNAMIC (CONF:10084).
11. MAY contain zero or one [0..1] entryRelationship (CONF:7440) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7906).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:7446).
c. SHALL contain exactly one [1..1] Allergy Status Observation
(templateId:2.16.840.1.113883.10.20.22.4.28) (CONF:15954).
12. SHOULD contain zero or more [0..*] entryRelationship (CONF:7447) such
that it
a. SHALL contain exactly one [1..1] @typeCode="MFST" Is Manifestation
of (CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7907).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:7449).
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c. SHALL contain exactly one [1..1] Reaction Observation
(templateId:2.16.840.1.113883.10.20.22.4.9) (CONF:15955).
13. SHOULD contain zero or one [0..1] entryRelationship (CONF:9961) such
that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:9962).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:9964).
c. SHALL contain exactly one [1..1] Severity Observation
(templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:15956).
Table 117: Allergy/Adverse Event Type Value Set
Value Set: Allergy/Adverse Event Type 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC
Code System(s):

SNOMED CT 2.16.840.1.113883.6.96

Description:

This describes the type of product and intolerance suffered by the patient
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=7AFDBFB5-A277DE11-9B52-0015173D1785

Code

Code System

Print Name

420134006

SNOMED CT

Propensity to adverse reactions (disorder)

SNOMED CT

Propensity to adverse reactions to substance
(disorder)

419511003

SNOMED CT

Propensity to adverse reactions to drug (disorder)

418471000

SNOMED CT

Propensity to adverse reactions to food (disorder)

419199007

SNOMED CT

Allergy to substance (disorder)

416098002

SNOMED CT

Drug allergy (disorder)

414285001

SNOMED CT

Food allergy (disorder)

59037007

SNOMED CT

Drug intolerance (disorder)

235719002

SNOMED CT

Food intolerance (disorder)

418038007

Table 118: Medication Brand Name Value Set (excerpt)
Value Set: Medication Brand Name 2.16.840.1.113883.3.88.12.80.16 DYNAMIC
Code System(s):

RxNorm 2.16.840.1.113883.6.88

Description:

Brand names
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=229BEF3E-971CDF11-B334-0015173D1785

Code

Code System

Print Name

205734

RxNorm

Amoxicillin 25 MG/ML Oral Suspension [Amoxil]

856537

RxNorm

24 HR Propranolol Hydrochloride 60 MG Extended
Release Capsule [Inderal]

104700

RxNorm

Diazepam 5 MG Oral Tablet [Valium]

…

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Table 119: Medication Clinical Drug Value Set (excerpt)
Value Set: Medication Clinical Drug 2.16.840.1.113883.3.88.12.80.17 DYNAMIC
Code System(s):

RxNorm 2.16.840.1.113883.6.88

Description:

Clinical drug names
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=239BEF3E-971CDF11-B334-0015173D1785

Code

Code System

Print Name

313850

RxNorm

Amoxicillin 40 MG/ML Oral Suspension

856448

RxNorm

Propranolol Hydrochloride 10 MG Oral Tablet

197589

RxNorm

Diazepam 10 MG Oral Tablet

…

Table 120: Medication Drug Class Value Set (excerpt)
Value Set: Medication Drug Class 2.16.840.1.113883.3.88.12.80.18 DYNAMIC
Code System(s):

NDF-RT 2.16.840.1.113883.3.26.1.5

Description:

This identifies the pharmacological drug class, such as Cephalosporins.
Shall contain a value descending from the NDF-RT concept types of
“Mechanism of Action - N0000000223”, “Physiologic Effect N0000009802” or “Chemical Structure - N0000000002”`. NUI will be used
as the concept code.
http://phinvads.cdc.gov/vads/ViewValueSet.action?id=77FDBFB5-A277DE11-9B52-0015173D1785

Code

Code System

Print Name

N0000011161

NDF-RT

Cephalosporins

N0000005909

NDF-RT

2-Propanol

N0000006629

NDF-RT

Filgrastim

…

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Table 121: Ingredient Name Value Set (excerpt)
Value Set: Ingredient Name 2.16.840.1.113883.3.88.12.80.20 DYNAMIC
Code System(s):

Unique Ingredient Identifier (UNII) 2.16.840.1.113883.4.9

Description:

Unique ingredient identifiers (UNIIs) for substances in drugs, biologics,
foods, and devices.
http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabe
ling/ucm162523.htm

Code

Code System

Print Name

OLT4M28U3Z

UNII

((3-TRIFLUOROMETHYL)PHENYL)METHYLPHOSPHONIC ACID

L0VRY82PKO

UNII

CYCLOHEXENE, 4-[(1Z)-1,5-DIMETHYL-1,4HEXADIEN-1-YL]-1-METHYL-

62H4W26906

UNII

BISNAFIDE

QE1QX6B99R

UNII

PEANUT

…

Figure 156: Allergy - intolerance observation example















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Penicillin





6.5

Allergy Problem Act
[act: templateId 2.16.840.1.113883.10.20.22.4.30(open)]
Table 122: Allergy Problem Act Contexts
Used By:

Contains Entries:

Allergies Section (entries required)
Allergies Section (entries optional)

Allergy - Intolerance Observation

This clinical statement act represents a concern relating to a patient's allergies
or adverse events. A concern is a term used when referring to patient's problems
that are related to one another. Observations of problems or other clinical
statements captured at a point in time are wrapped in a Allergy Problem Act, or
"Concern" act, which represents the ongoing process tracked over time. This
outer Allergy Problem Act (representing the "Concern") can contain nested
problem observations or other nested clinical statements relevant to the allergy
concern.

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Table 123: Allergy Problem Act Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.30']
@classCode

1..1

SHALL

7469

2.16.840.1.113883.5.6 (HL7ActClass) =
ACT

@moodCode

1..1

SHALL

7470

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

1..1

SHALL

id

1..*

SHALL

II

7472

code

1..1

SHALL

CD

7477

2.16.840.1.113883.6.1 (LOINC) = 487652

statusCode

1..1

SHALL

CS

7485

2.16.840.1.113883.11.20.9.19
(ProblemAct statusCode)

effectiveTime

1..1

SHALL

TS or
IVL

7498

1..*

SHALL

7509

1..1

SHALL

7915

@root

Entry
Relationship
@typeCode

SET

7471
10489

2.16.840.1.113883.10.20.22.4.30

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7469).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7470).
3. SHALL contain exactly one [1..1] templateId (CONF:7471) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.30" (CONF:10489).
4. SHALL contain at least one [1..*] id (CONF:7472).
5. SHALL contain exactly one [1..1] code="48765-2" Allergies, adverse
reactions, alerts (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:7477).
6. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from
ValueSet ProblemAct statusCode 2.16.840.1.113883.11.20.9.19
STATIC 2011-09-09 (CONF:7485).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:7498).
a. If statusCode="active" Active, then effectiveTime SHALL contain [1..1]
low (CONF:7504).
b. If statusCode="completed" Completed, then effectiveTime SHALL
contain [1..1] high (CONF:10085).
8. SHALL contain at least one [1..*] entryRelationship (CONF:7509) such that
it

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a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:7915).
b. SHALL contain exactly one [1..1] Allergy - Intolerance
Observation (templateId:2.16.840.1.113883.10.20.22.4.7)
(CONF:14925).

Table 124: ProblemAct statusCode Value Set
Value Set: ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09
Code System(s):

ActStatus 2.16.840.1.113883.5.14

Description:

This value set indicates the status of the problem concern act

Code

Code System

Print Name

active

ActStatus

active

suspended

ActStatus

suspended

aborted

ActStatus

aborted

completed

ActStatus

completed

Figure 157: Allergy problem act example














...





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6.6

Allergy Status Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.28(open)]
Table 125: Allergy Status Observation Contexts
Used By:

Contains Entries:

Allergy - Intolerance Observation

This template represents the status of the allergy indicating whether it is active,
no longer active, or is an historic allergy. There can be only one allergy status
observation per alert observation.
Table 126: Allergy Status Observation Constraints Overview

Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.28']
@classCode

1..1

SHALL

7318

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

7319

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

1..1

SHALL

10490

2.16.840.1.113883.10.20.22.4.28

code

1..1

SHALL

7320

2.16.840.1.113883.6.1 (LOINC) =
33999-4

statusCode

1..1

SHALL

7321

2.16.840.1.113883.5.14 (ActStatus) =
completed

value

1..1

SHALL

7322

2.16.840.1.113883.3.88.12.80.68
(HITSPProblemStatus)

@root

SET

CE

7317

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7318).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7319).
3. SHALL contain exactly one [1..1] templateId (CONF:7317) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.28" (CONF:10490).
4. SHALL contain exactly one [1..1] code="33999-4" Status (CodeSystem:
LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:7320).
5. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:7321).
6. SHALL contain exactly one [1..1] value with @xsi:type="CE", where the @code
SHALL be selected from ValueSet HITSPProblemStatus
2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:7322).

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Table 127: HITSP Problem Status Value Set
Value Set: HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC
Code System: SNOMED CT 2.16.840.1.113883.6.96
Code

Code System

Display Name

55561003

SNOMED CT

Active

73425007

SNOMED CT

Inactive*

413322009

SNOMED CT

Resolved**

* An inactive problems refers to one that is quiescent, and may appear again in future.
** A resolved problem refers to one that used to affect a patient, but does not any more.

Figure 158: Allergy status observation example








6.7

Assessment Scale Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.69 (open)]
Table 128: Assessment Scale Observation Contexts
Used By:

Contains Entries:

Functional Status Problem Observation (optional)
Functional Status Result Observation (optional)
Cognitive Status Problem Observation (optional)
Cognitive Status Result Observation (optional)
Functional Status Section (optional)

Assessment Scale Supporting Observation

An assessment scale is a collection of observations that together yield a
summary evaluation of a particular condition. Examples include the Braden
Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in
critically ill patients), Mini-Mental Status Exam (assesses cognitive function),
APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale
(assesses coma and impaired consciousness.)

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Table 129: Assessment Scale Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.69']
@classCode

1..1

SHALL

14434

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

14435

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

14436

1..1

SHALL

14437

id

1..*

SHALL

14438

code

1..1

SHALL

14439

derivationExpr

0..1

MAY

14637

statusCode

1..1

SHALL

14444

effectiveTime

1..1

SHALL

14445

value

1..1

SHALL

14450

interpretationCode

0..*

MAY

14459

0..*

MAY

14888

author

0..*

MAY

14460

entryRelationship

0..*

SHOULD

14451

@typeCode

1..1

SHALL

16741

observation

1..1

SHALL

16742

referenceRange

0..*

MAY

16799

1..1

SHALL

16800

0..1

SHOULD

16801

reference

0..1

SHOULD

16802

@value

0..1

MAY

16803

@root

translation

2.16.840.1.113883.10.20.22.4.69

2.16.840.1.113883.5.14
(ActStatus) = completed

COMP

observationRange
text

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:14434).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14435).
3. SHALL contain exactly one [1..1] templateId (CONF:14436) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.69" (CONF:14437).
4. SHALL contain at least one [1..*] id (CONF:14438).
5. SHALL contain exactly one [1..1] code (CONF:14439).
a. SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or
SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the
assessment scale (CONF:14440).

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Such derivation expression can contain a text calculation of how the
components total up to the summed score
6. MAY contain zero or one [0..1] derivationExpr (CONF:14637).
7. SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem:
ActStatus 2.16.840.1.113883.5.14) (CONF:14444).
Represents clinically effective time of the measurement, which may be when the
measurement was performed (e.g., a BP measurement), or may be when sample
was taken (and measured some time afterwards)
8. SHALL contain exactly one [1..1] effectiveTime (CONF:14445).
9. SHALL contain exactly one [1..1] value (CONF:14450).
10. MAY contain zero or more [0..*] interpretationCode (CONF:14459).
a. The interpretationCode, if present, MAY contain zero or more [0..*]
translation (CONF:14888).
11. MAY contain zero or more [0..*] author (CONF:14460).
12. SHOULD contain zero or more [0..*] entryRelationship (CONF:14451) such
that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component
(CONF:16741).
b. SHALL contain exactly one [1..1] Assessment Scale Supporting
Observation (templateId:2.16.840.1.113883.10.20.22.4.86)
(CONF:16742).
The referenceRange/observationRange/text, if present, MAY contain a
description of the scale (e.g. for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7=
moderate pain, 8 to 10 = severe pain)
13. MAY contain zero or more [0..*] referenceRange (CONF:16799).
a. The referenceRange, if present, SHALL contain exactly one [1..1]
observationRange (CONF:16800).
i.

This observationRange SHOULD contain zero or one [0..1] text
(CONF:16801).
1. The text, if present, SHOULD contain zero or one [0..1]
reference (CONF:16802).
a. The reference, if present, MAY contain zero or
one [0..1] @value (CONF:16803).
i.

This reference/@value SHALL begin with
a '#' and SHALL point to its
corresponding narrative (using the
approach defined in CDA Release 2,
section 4.3.5.1) (CONF:16804).

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Figure 159: Assessment scale observation example

...





Text description of the
calculation






















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...

6.8

Assessment Scale Supporting Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.86 (open)]
Table 130: Assessment Scale Supporting Observation Contexts
Used By:

Contains Entries:

Assessment Scale Observation (required)

An Assessment Scale Supporting observation represents the components of a
scale used in an Assessment Scale Observation. The individual parts that make
up the component may be a group of cognitive or functional status observations.
Table 131: Assessment Scale Supporting Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.86']
@classCode

1..1

SHALL

16715

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

16716

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

1..1

SHALL

16723

id

1..*

SHALL

16724

code

1..1

SHALL

@root

@code

SET

CE

16722
2.16.840.1.113883.10.20.22.4.86

16717

1..1

SHALL

16738

statusCode

1..1

SHALL

16720

value

1..*

SHALL

16754

2.16.840.1.113883.5.14 (ActStatus) =
completed

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:16715).
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2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:16716).
3. SHALL contain exactly one [1..1] templateId (CONF:16722) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.86" (CONF:16723).
4. SHALL contain at least one [1..*] id (CONF:16724).
5. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:16717).
a. This code SHALL contain exactly one [1..1] @code (CONF:16738).
i.

Such that observation/code SHALL be from LOINC
(CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT
(CodeSystem: 2.16.840.1.113883.6.96) and represents
components of the scale (CONF:14458) (CONF:16739).

6. SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem:
ActStatus 2.16.840.1.113883.5.14) (CONF:16720).
7. SHALL contain at least one [1..*] value (CONF:16754).
a. If xsi:type="CD" , MAY have a translation code to further specify the
source if the instrument has an applicable code system and valueSet
for the integer (CONF:14639) (CONF:16755).
Figure 160: Assessment scale supporting observation example










6.9

Authorization Activity
[act: templateId 2.16.840.1.113883.10.20.1.19(open)]
Table 132: Authorization Activity Contexts
Used By:

Contains Entries:

Policy Activity (optional)

An Authorization Activity represents authorizations or pre-authorizations
currently active for the patient for the particular payer.
Authorizations are represented using an act subordinate to the policy or
program that provided it. The authorization refers to the policy or program.
Authorized treatments can be grouped into an organizer class, where common
properties, such as the reason for the authorization, can be expressed.
Subordinate acts represent what was authorized.
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Table 133: Authorization Activity Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.1.19']
@classCode

1..1

SHALL

8944

2.16.840.1.113883.5.6 (HL7ActClass) =
ACT

@moodCode

1..1

SHALL

8945

2.16.840.1.113883.5.6 (HL7ActClass) =
EVN

templateId

1..1

SHALL

1..1

SHALL

1..1

SHALL

1..*

SHALL

8948

1..1

SHALL

8949

@root
id
entry
Relationship
@typeCode

SET

8946
10529

II

2.16.840.1.113883.10.20.1.19

8947

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8944).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8945).
3. SHALL contain exactly one [1..1] templateId (CONF:8946) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.1.19" (CONF:10529).
4. SHALL contain exactly one [1..1] id (CONF:8947).
5. SHALL contain at least one [1..*] entryRelationship (CONF:8948) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:8949).
b. The target of an authorization activity with
act/entryRelationship/@typeCode="SUBJ" SHALL be a clinical
statement with moodCode="PRMS" Promise (CONF:8951).
c. The target of an authorization activity MAY contain one or more
performer, to indicate the providers that have been authorized to
provide treatment (CONF:8952).

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Figure 161: Authorization activity example












6.10 Boundary Observation
[observation: templateId 2.16.840.1.113883.10.20.6.2.11(open)]
Table 134: Boundary Observation Contexts
Used By:

Contains Entries:

Referenced Frames Observation

A Boundary Observation contains a list of integer values for the referenced
frames of a DICOM multiframe image SOP instance. It identifies the frame
numbers within the referenced SOP instance to which the reference applies. The
CDA Boundary Observation numbers frames using the same convention as
DICOM, with the first frame in the referenced object being Frame 1. A Boundary
Observation must be used if a referenced DICOM SOP instance is a multiframe
image and the reference does not apply to all frames.
Table 135: Boundary Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.6.2.11']
@classCode

1..1

SHALL

9282

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

9283

2.16.840.1.113883.5.6 (HL7ActClass) =
EVN

code

1..1

SHALL

9284

1.2.840.10008.2.16.4 (DCM) = 113036

value

1..*

SHALL

CD

9285

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9282).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:9283).

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3. SHALL contain exactly one [1..1] code="113036" Frames for Display
(CodeSystem: DCM 1.2.840.10008.2.16.4) (CONF:9284).
Each number represents a frame for display.
4. SHALL contain at least one [1..*] value with @xsi:type="INT" (CONF:9285).
Figure 162: Boundary observation example






6.11 Caregiver Characteristics
[observation: templateId 2.16.840.1.113883.10.20.22.4.72 (open)]
Table 136: Caregiver Characteristics Contexts
Used By:

Contains Entries:

Functional Status Result Observation (optional)
Cognitive Status Result Observation (optional)
Functional Status Problem Observation (optional)
Cognitive Status Problem Observation (required)
Functional Status Section (optional)

This clinical statement represents a caregiver’s willingness to provide care and
the abilities of that caregiver to provide assistance to a patient in relation to a
specific need.

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Table 137: Caregiver Characteristics Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.72']
@classCode

1..1

SHALL

14219

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

14220

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

14221

1..1

SHALL

14222

id

1..*

SHALL

14223

code

1..1

SHALL

14230

statusCode

1..1

SHALL

14233

value

1..1

SHALL

14599

participant

0..*

SHALL

14227

0..1

MAY

14830

low

1..1

SHALL

14831

high

0..1

MAY

14832

1..1

SHALL

14228

1..1

SHALL

14229

@root

time

2.16.840.1.113883.10.20.22.4.72

2.16.840.1.113883.5.14 (ActStatus) =
Completed

participantRole
@classCode

IND

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:14219).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14220).
3. SHALL contain exactly one [1..1] templateId (CONF:14221) such that it
a. This templateId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.72" (CONF:14222).
4. SHALL contain at least one [1..*] id (CONF:14223).
5. SHALL contain exactly one [1..1] code (CONF:14230).
6. SHALL contain exactly one [1..1] statusCode="Completed" (CodeSystem:
ActStatus 2.16.840.1.113883.5.14) (CONF:14233).
7. SHALL contain exactly one [1..1] value (CONF:14599).
a. Where the @code SHALL be selected from LOINC (codeSystem:
2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem:
2.16.840.1.113883.6.96 (CONF:14600).
8. SHALL contain at least one [1..*] participant (CONF:14227).
a. Such participants MAY contain zero or one [0..1] time (CONF:14830).
i.

The time, if present, SHALL contain exactly one [1..1] low
(CONF:14831).

ii. The time, if present, MAY contain zero or one [0..1] high
(CONF:14832).
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b. Such participants SHALL contain exactly one [1..1] participantRole
(CONF:14228).
i.

This participantRole SHALL contain exactly one [1..1]
@classCode="IND" (CONF:14229).

Figure 163: Caregiver characteristics example with assertion

...




...
















...


Figure 164: Caregiver characteristics example without assertion












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6.12 Code Observations
[observation: templateId 2.16.840.1.113883.10.20.6.2.13(open)]
Table 138: Code Observations Contexts
Used By:

Contains Entries:
Quantity Measurement Observation
SOP Instance Observation

DICOM Template 2000 specifies that Imaging Report Elements of Value Type
Code are contained in sections. The Imaging Report Elements are inferred from
Basic Diagnostic Imaging Report Observations that consist of image references
and measurements (linear, area, volume, and numeric). Coded DICOM Imaging
Report Elements in this context are mapped to CDA-coded observations that are
section components and are related to the SOP Instance Observations
(templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement
Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT
(Support) act relationship.

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Table 139: Code Observations Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.6.2.13']
@classCode

1..1

SHALL

9304

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

9305

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

15523

1..1

SHALL

15524

code

1..1

SHALL

CD

9307

effectiveTime

0..1

SHOULD

TS or
IVL

9309

value

1..1

SHALL

9308

entryRelationship

0..*

MAY

9311

1..1

SHALL

9312

0..*

MAY

9314

1..1

SHALL

9315

@root

@typeCode
entryRelationship
@typeCode

2.16.840.1.113883.10.20.6.2.13

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SPRT
2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SPRT

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9304).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9305).
3. SHALL contain exactly one [1..1] templateId (CONF:15523).
a. This templateId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.13" (CONF:15524).
4. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:9307).
5. SHOULD contain zero or one [0..1] effectiveTime (CONF:9309).
6. SHALL contain exactly one [1..1] value (CONF:9308).
7. Code Observations SHALL be rendered into section/text in separate
paragraphs (CONF:9310).
8. MAY contain zero or more [0..*] entryRelationship (CONF:9311) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SPRT" Has Support
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9312).
b. SHALL contain exactly one [1..1] SOP Instance Observation
(2.16.840.1.113883.10.20.6.2.8) (CONF:9313).
9. MAY contain zero or more [0..*] entryRelationship (CONF:9314) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SPRT" Has Support
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9315).
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b. SHALL contain exactly one [1..1] Quantity Measurement
Observation (2.16.840.1.113883.10.20.6.2.14) (CONF:9316).
Figure 165: Code observation example








6.13 Cognitive Status Problem Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.73 (open)]
Table 140: Cognitive Status Problem Observation Contexts
Used By:

Contains Entries:

Functional Status Section (optional)

Assessment Scale Observation
Caregiver Characteristics
Non-Medicinal Supply Activity

A cognitive status problem observation is a clinical statement that describes a
patient's cognitive condition, findings, or symptoms. Examples of cognitive
problem observations are inability to recall, amnesia, dementia, and aggressive
behavior.
A cognitive problem observation is a finding or medical condition. This is
different from a cognitive result observation, which is a response to a question
that provides insight into the patient's cognitive status, judgement,
comprehension ability, or response speed.

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Table 141: Cognitive Status Problem Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.73']
@classCode

1..1

SHALL

14319

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@mood
Code

1..1

SHALL

14320

2.16.840.1.113883.5.1001
(ActMood) = EVN

@negation
Ind

0..1

MAY

14344

templateId

1..1

SHALL

14346

1..1

SHALL

14347

id

1..1

SHALL

14321

code

1..1

SHALL

14804

0..1

SHOULD

14805

0..1

SHOULD

14341

reference/
@value

0..1

SHOULD

14342

statusCode

1..1

SHALL

14323

effective
Time

0..1

SHOULD

TS or
IVL

14324

value

1..1

SHALL

CD

14349

Method
Code

0..*

MAY

14693

entry
Relationship

0..*

MAY

14331

1..1

SHALL

14588

supply

1..1

SHALL

14351

entry
Relationship

0..*

SHALL

14335

1..1

SHALL

14589

1..1

SHALL

14352

0..*

SHALL

14467

1..1

SHALL

14590

1..1

SHALL

14468

@root

@code
text

@typeCode

@typeCode

2.16.840.1.113883.10.20.22.4.73

2.16.840.1.113883.6.96 (SNOMEDCT) = 373930000

2.16.840.1.113883.5.14 (ActStatus)
= completed

2.16.840.1.113883.3.88.12.3221.7.
4 (Problem)

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = REFR

observation
entry
Relationship
@typeCode

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = COMP

observation

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1. Conforms to Problem Observation template
(2.16.840.1.113883.10.20.22.4.4).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:14319).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:14320).
Use negationInd="true" to indicate that the problem was not observed.
4. MAY contain zero or one [0..1] @negationInd (CONF:14344).
5. SHALL contain exactly one [1..1] templateId (CONF:14346) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.73" (CONF:14347).
6. SHALL contain exactly one [1..1] id (CONF:14321).
7. SHALL contain exactly one [1..1] code (CONF:14804).
a. This code SHOULD contain zero or one [0..1] @code="373930000"
Cognitive function finding (CodeSystem: SNOMED-CT
2.16.840.1.113883.6.96) (CONF:14805).
8. SHOULD contain zero or one [0..1] text (CONF:14341).
a. The text, if present, SHOULD contain zero or one [0..1]
reference/@value (CONF:14342).
i.

This reference/@value SHALL begin with a '#' and SHALL point
to its corresponding narrative (using the approach defined in
CDA Release 2, section 4.3.5.1) (CONF:14343).

9. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:14323).
10. SHOULD contain zero or one [0..1] effectiveTime (CONF:14324).
a. The onset date SHALL be recorded in the low element of the
effectiveTime element when known (CONF:14325).
b. The resolution date SHALL be recorded in the high element of the
effectiveTime element when known (CONF:14326).
c. If the problem is known to be resolved, but the date of resolution is
not known, then the high element SHALL be present, and the
nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of
a high element within a problem does indicate that the problem has
been resolved (CONF:14327).
11. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHOULD be selected from ValueSet Problem
2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:14349).
12. MAY contain zero or more [0..*] methodCode (CONF:14693).
13. MAY contain zero or more [0..*] entryRelationship (CONF:14331) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14588).
b. SHALL contain exactly one [1..1] Non-Medicinal Supply Activity
(templateId:2.16.840.1.113883.10.20.22.4.50) (CONF:14351).

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14. SHALL contain zero or more [0..*] entryRelationship (CONF:14335) such
that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14589).
b. SHALL contain exactly one [1..1] Caregiver Characteristics
(templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14352).
15. SHALL contain zero or more [0..*] entryRelationship (CONF:14467) such
that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14590).
b. SHALL contain exactly one [1..1] Assessment Scale Observation
(templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14468).
Table 142: Problem type value set
Value Set: Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01
Code System(s):
Description:

SNOMED CT 2.16.840.1.113883.6.96
This value set indicates the level of medical judgment used to determine
the existence of a problem.

Code

Code System

Print Name

404684003

SNOMED CT

Finding

409586006

SNOMED CT

Complaint

282291009

SNOMED CT

Diagnosis

64572001

SNOMED CT

Condition

248536006

SNOMED CT

Finding of functional performance and activity

418799008

SNOMED CT

Symptom

55607006

SNOMED CT

Problem

373930000

SNOMED CT

Cognitive function finding

Table 143: Problem Value Set (excerpt)
Value Set: Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC
Code System(s):

SNOMED CT 2.16.840.1.113883.6.96

Description:

Problems and diagnoses. Limited to terms descending from the Clinical
Findings (404684003) or Situation with Explicit Context (243796009)
hierarchies.

http://phinvads.cdc.gov/vads/ViewValueSet.action?id=70FDBFB
5-A277-DE11-9B52-0015173D1785
Code

Code System

Print Name

46635009

SNOMED CT

Diabetes mellitus type 1

234422006

SNOMED CT

Acute porphyria

31712002

SNOMED CT

Primary biliary cirrhosis

302002000

SNOMED CT

Difficulty moving

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Value Set: Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC
Code System(s):

SNOMED CT 2.16.840.1.113883.6.96

Description:

Problems and diagnoses. Limited to terms descending from the Clinical
Findings (404684003) or Situation with Explicit Context (243796009)
hierarchies.

http://phinvads.cdc.gov/vads/ViewValueSet.action?id=70FDBFB
5-A277-DE11-9B52-0015173D1785
Code

Code System

Print Name

15188001

SNOMED CT

Hearing loss

48167000

SNOMED CT

Amnesia

…
Figure 166:Cognitive status problem observation example






...










...






...




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6.14 Cognitive Status Result Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.74 (open)]
Table 144: Cognitive Status Result Observation Contexts
Used By:

Contains Entries:

Cognitive Status Result Organizer (required)
Functional Status Section (optional)

Assessment Scale Observation
Caregiver Characteristics
Non-Medicinal Supply Activity

This clinical statement contains details of an evaluation or assessment of a
patient’s cognitive status. The evaluation may include assessment of a patient's
mood, memory, and ability to make decisions. The statement, if present, will
include supporting caregivers, non-medical devices, and the time period for
which the evaluation and assessment were performed.
This is different from a cognitive status problem observation, which is a clinical
statement that describes a patient's cognitive condition, findings, or symptoms.
Examples of cognitive problem observations are inability to recall, amnesia,
dementia, and aggressive behavior.

Table 145: Cognitive Status Result Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.74']
@classCode

1..1

SHALL

14249

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

14250

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

1..1

SHALL

14256

id

1..*

SHALL

14257

code

1..1

SHALL

14591

0..1

SHOULD

14592

0..1

SHOULD

14258

reference/
@value

0..1

SHOULD

14259

statusCode

1..1

SHALL

14254

effectiveTime

1..1

SHALL

value

1..1

SHALL

@root

@code
text

SET

TS or
IVL

14255
2.16.840.1.113883.10.20.22.4.74

2.16.840.1.113883.6.96 (SNOMED-CT)
= 373930000

2.16.840.1.113883.5.14 (ActStatus) =
completed

14261
14263

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Name

XPath

Card.

Verb

interpretationCode

0..*

SHOULD

methodCode

0..1

MAY

SET

14265

targetSiteCode

0..1

MAY

SET

14270

author

0..1

MAY

14266

entryRelationship

0..*

MAY

14272

@typeCode

1..1

SHALL

14593

supply

1..1

SHALL

14273

0..*

MAY

14276

@typeCode

1..1

SHALL

14594

observation

1..1

SHALL

14277

0..*

MAY

14469

@typeCode

1..1

SHALL

14595

observation

1..1

SHALL

14470

referenceRange

0..*

SHOULD

14267

1..1

SHALL

14268

0..0

SHALL
NOT

14269

entryRelationship

entryRelationship

Data
Type

CONF#

Fixed Value

14264

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = COMP

observationRange
code

1. Conforms to Result Observation template
(2.16.840.1.113883.10.20.22.4.2).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:14249).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:14250).
4. SHALL contain exactly one [1..1] templateId (CONF:14255) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.74" (CONF:14256).
5. SHALL contain at least one [1..*] id (CONF:14257).
6. SHALL contain exactly one [1..1] code (CONF:14591).
a. This code SHOULD contain zero or one [0..1] @code="373930000"
Cognitive function finding (CodeSystem: SNOMED-CT
2.16.840.1.113883.6.96) (CONF:14592).
7. SHOULD contain zero or one [0..1] text (CONF:14258).
a. The text, if present, SHOULD contain zero or one [0..1]
reference/@value (CONF:14259).
i.

This reference/@value SHALL begin with a '#' and SHALL point
to its corresponding narrative (using the approach defined in
CDA Release 2, section 4.3.5.1) (CONF:14260).

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8. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:14254).
Represents clinically effective time of the measurement, which may be the time
the measurement was performed (e.g., a BP measurement), or may be the time
the sample was taken (and measured some time afterwards).
9. SHALL contain exactly one [1..1] effectiveTime (CONF:14261).
10. SHALL contain exactly one [1..1] value (CONF:14263).
a. If xsi:type=“CD”, SHOULD contain a code from SNOMED CT
(CodeSystem: 2.16.840.1.113883.6.96) (CONF:14271).
11. SHOULD contain zero or more [0..*] interpretationCode (CONF:14264).
12. MAY contain zero or one [0..1] methodCode (CONF:14265).
13. MAY contain zero or one [0..1] targetSiteCode (CONF:14270).
14. MAY contain zero or one [0..1] author (CONF:14266).
15. MAY contain zero or more [0..*] entryRelationship (CONF:14272) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14593).
b. SHALL contain exactly one [1..1] Non-Medicinal Supply Activity
(templateId:2.16.840.1.113883.10.20.22.4.50) (CONF:14273).
16. MAY contain zero or more [0..*] entryRelationship (CONF:14276) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14594).
b. SHALL contain exactly one [1..1] Caregiver Characteristics
(templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14277).
17. MAY contain zero or more [0..*] entryRelationship (CONF:14469) such that
it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14595).
b. SHALL contain exactly one [1..1] Assessment Scale Observation
(templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14470).
18. SHOULD contain zero or more [0..*] referenceRange (CONF:14267).
a. The referenceRange, if present, SHALL contain exactly one [1..1]
observationRange (CONF:14268).
i.

This observationRange SHALL NOT contain [0..0] code
(CONF:14269).

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Figure 167: Cognitive status result observation example













...






...




6.15 Cognitive Status Result Organizer
[organizer: templateId 2.16.840.1.113883.10.20.22.4.75 (open)]
Table 146: Cognitive Status Result Organizer Contexts
Used By:

Contains Entries:

Functional Status Section (optional)

Cognitive Status Result Observation

This clinical statement identifies a set of cognitive status result observations. It
contains information applicable to all of the contained cognitive status result
observations. A result organizer may be used to group questions in a Patient
Health Questionaire (PHQ).
An appropriate nullFlavor can be used when the organizer/code or
organizer/id is unknown.

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Table 147: Cognitive Status Result Organizer Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

organizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.75']
@classCode

1..1

SHALL

14369

2.16.840.1.113883.5.6 (HL7ActClass) =
CLUSTER

@moodCode

1..1

SHALL

14371

2.16.840.1.113883.5.1001 (ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

14376

id

1..*

SHALL

14377

code

1..1

SHALL

14378

0..1

SHOULD

14697

statusCode

1..1

SHALL

14372

component

1..*

SHALL

14373

1..1

SHALL

14381

@root

@code

SET

14375
2.16.840.1.113883.10.20.22.4.75

2.16.840.1.113883.5.14 (ActStatus) =
completed

observation

1. Conforms to Result Organizer template
(2.16.840.1.113883.10.20.22.4.1).
2. SHALL contain exactly one [1..1] @classCode, which SHALL be selected from
CodeSystem HL7ActClass (2.16.840.1.113883.5.6)="CLUSTER"
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:14369).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:14371).
4. SHALL contain exactly one [1..1] templateId (CONF:14375) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.75" (CONF:14376).
5. SHALL contain at least one [1..*] id (CONF:14377).
6. SHALL contain exactly one [1..1] code (CONF:14378).
a. This code SHOULD contain zero or one [0..1] @code (CONF:14697).
i.

Should be selected from ICF (codeSystem
2.16.840.1.113883.6.254) or SNOMED CT (codeSystem
2.16.840.1.113883.6.96) (CONF:14698).

7. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:14372).
8. SHALL contain at least one [1..*] component (CONF:14373) such that it
a. SHALL contain exactly one [1..1] Cognitive Status Result
Observation (templateId:2.16.840.1.113883.10.20.22.4.74)
(CONF:14381).

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Figure 168 Cognitive status result organizer example










...






...




6.16 Comment Activity
[act: templateId 2.16.840.1.113883.10.20.22.4.64(open)]
Table 148: Comment Activity Contexts
Used By:

Contains Entries:

Any document

Comments are free text data that cannot otherwise be recorded using data
elements already defined by this specification. They are not to be used to record
information that can be recorded elsewhere. For example, a free text description
of the severity of an allergic reaction would not be recorded in a comment.

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Table 149: Comment Activity Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.64']
@classCode

1..1

SHALL

9425

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

9426

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

code

1..1

SHALL

text

1..1

SHALL

1..1

SHALL

9431

9433

@root

SET

9427
10491

2.16.840.1.113883.10.20.22.4
.64

CD

9428

2.16.840.1.113883.6.1
(LOINC) = 48767-8

ED

9430

free
Text
Comment

reference/@value

author

author

0..1

MAY

time

1..1

SHALL

assignedAuthor

1..1

SHALL

id

1..1

SHALL

II

9436

addr

1..1

SHALL

SET

9437

IVL

9434
9435

1. Data elements defined elsewhere in the specification SHALL NOT be recorded
using the Comment Activity (CONF:9429).
2. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:9425).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9426).
4. SHALL contain exactly one [1..1] templateId (CONF:9427) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.64" (CONF:10491).
5. SHALL contain exactly one [1..1] code="48767-8" Annotation Comment
(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:9428).
a. This text SHALL contain exactly one [1..1] reference (CONF:15967).
i.

This reference SHALL contain exactly one [1..1] @value
(CONF:15968).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15969).

6. MAY contain zero or one [0..1] author (CONF:9433).
a. The author, if present, SHALL contain exactly one [1..1] time
(CONF:9434).

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b. The author, if present, SHALL contain exactly one [1..1]
assignedAuthor (CONF:9435).
i.

This assignedAuthor SHALL contain exactly one [1..1] id
(CONF:9436).

ii. This assignedAuthor SHALL contain exactly one [1..1] addr
(CONF:9437).
1. 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:10480).
iii. SHALL include assignedPerson/name or
representedOrganization/name (CONF:9438).
iv. An assignedPerson/name SHALL be a conformant US Realm
Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1) (CONF:9439).
Figure 169: Comment act example




The patient stated that he was looking forward to an upcoming
vacation to New York with his family. He was concerned that he may
not have enough medication for the trip. An additional prescription
was provided to cover that period of time.







21 North Ave.
Burlington
MA
02368
US




Henry
Seven






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6.17 Coverage Activity
[act: templateId 2.16.840.1.113883.10.20.22.4.60 (open)]
Table 150: Coverage Activity Contexts
Used By:

Contains Entries:

Payers Section (optional)

Policy Activity

A Coverage Activity groups the policy and authorization acts within a Payers
Section to order the payment sources. A Coverage Activity contains one or more
policy activities, each of which contains zero or more authorization activities.
The Coverage Activity id is the Id from the patient's insurance card. The
sequenceNumber/@value shows the policy order of preference.
Table 151: Coverage Activity Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.60']
@classCode

1..1

SHALL

8872

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

8873

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10492

id

1..*

SHALL

8874

code

1..1

SHALL

statusCode

1..1

entryRelationship

@root

SET

CE

8897
2.16.840.1.113883.10.20.22.4.60

8876

2.16.840.1.113883.6.1 (LOINC) =
48768-6

SHALL

8875

2.16.840.1.113883.5.14 (ActStatus)
= completed

1..*

SHALL

8878

@typeCode

1..1

SHALL

8879

act

1..1

SHALL

15528

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = COMP

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8872).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8873).
3. SHALL contain exactly one [1..1] templateId (CONF:8897) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.60" (CONF:10492).
4. SHALL contain at least one [1..*] id (CONF:8874).
5. SHALL contain exactly one [1..1] code="48768-6" Payment Sources with
@xsi:type="CE" (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:8876).

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6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:8875).
7. SHALL contain at least one [1..*] entryRelationship (CONF:8878) such that
it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:8879).
b. SHALL contain exactly one [1..1] Policy Activity
(templateId:2.16.840.1.113883.10.20.22.4.61) (CONF:15528).
Figure 170: Coverage activity example










...




6.18 Deceased Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.79 (open)]
Table 152: Deceased Observation Contexts
Used By:

Contains Entries:
Problem Observation

This clinical statement represents the observation that a patient has expired. It
also represents the cause of death, indicated by an entryRelationship type
of “CAUS”.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Table 153: Deceased Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.79']
@classCode

1..1

SHALL

14851

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

14852

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

14871

1..1

SHALL

14872

id

1..*

SHALL

14873

code

1..1

SHALL

14853

2.16.840.1.113883.5.4
(ActCode) = ASSERTION

statusCode

1..1

SHALL

14854

2.16.840.1.113883.5.14
(ActStatus) = completed

effectiveTime

1..1

SHALL

14855

low

1..1

SHALL

14874

value

1..1

SHALL

1..1

SHALL

15142

0..1

SHOULD

14868

@typeCode

1..1

SHALL

14875

observation

1..1

SHALL

14870

@root

@code
entryRelationship

CD

2.16.840.1.113883.10.20.22.4
.79

14857
2.16.840.1.113883.6.96
(SNOMED-CT) = 419099009
2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
CAUS

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC)
(CONF:14851).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14852).
3. SHALL contain exactly one [1..1] templateId (CONF:14871) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.79" (CONF:14872).
4. SHALL contain at least one [1..*] id (CONF:14873).
5. SHALL contain exactly one [1..1] code="ASSERTION" Assertion (CodeSystem:
ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:14853).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:14854).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:14855).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:14874).
8. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:14857).
a. This value SHALL contain exactly one [1..1] @code="419099009" Dead
(CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:15142).
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9. SHOULD contain zero or one [0..1] entryRelationship (CONF:14868) such
that it
a. SHALL contain exactly one [1..1] @typeCode="CAUS" Is etiology for
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14875).
b. SHALL contain exactly one [1..1] Problem Observation
(templateId:2.16.840.1.113883.10.20.22.4.4) (CONF:14870).
Figure 171: Deceased observation example












6.19 Discharge Medication
[act: templateId 2.16.840.1.113883.10.20.22.4.35(open)]
Table 154: Discharge Medication Contexts
Used By:

Contains Entries:

Hospital Discharge Medications Section (entries required)
Hospital Discharge Medications Section (entries optional)

Medication Activity

The Discharge Medications entry codes medications that the patient is intended
to take (or stop) after discharge.

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Table 155: Discharge Medication Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.35']
@classCode

1..1

SHALL

7689

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

7690

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

16760

1..1

SHALL

16761

2.16.840.1.113883.10.20.22.4.35

code

1..1

SHALL

7691

2.16.840.1.113883.6.1 (LOINC) =
10183-2

entryRelationship

1..1

SHALL

7692

1..1

SHALL

7693

1..1

SHALL

15525

@root

@typeCode

CD

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ

substanceAdministration

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7689).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7690).
3. SHALL contain exactly one [1..1] templateId (CONF:16760) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.35" (CONF:16761).
4. SHALL contain exactly one [1..1] code="10183-2" Discharge medication
(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7691).
5. SHALL contain at least one [1..*] entryRelationship (CONF:7692) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:7693).
b. SHALL contain exactly one [1..1] Medication Activity
(templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:15525).

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Figure 172: Discharge medication entry example














...





6.20 Drug Vehicle
[participantRole: templateId 2.16.840.1.113883.10.20.22.4.24(open)]
Table 156: Drug Vehicle Contexts
Used By:

Contains Entries:

Medication Activity
Immunization Activity

This template represents the vehicle (e.g., saline, dextrose) for administering a
medication.

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Table 157: Drug Vehicle Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

participantRole[templateId/@root = '2.16.840.1.113883.10.20.22.4.24']
@classCode

1..1

SHALL

templateId

1..1

SHALL

@root

7490
SET

2.16.840.1.113883.5.110 (RoleClass) =
MANU

7495

1..1

SHALL

10493

2.16.840.1.113883.10.20.22.4.24

code

1..1

SHALL

7491

2.16.840.1.113883.6.96 (SNOMED-CT)
= 412307009

playingEntity

1..1

SHALL

7492

code

1..1

SHALL

7493

name

0..1

MAY

7494

1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem:
RoleClass 2.16.840.1.113883.5.110) (CONF:7490).
2. SHALL contain exactly one [1..1] templateId (CONF:7495) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.24" (CONF:10493).
3. SHALL contain exactly one [1..1] code="412307009" Drug Vehicle
(CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:7491).
4. SHALL contain exactly one [1..1] playingEntity (CONF:7492).
This playingEntity/code is used to supply a coded term for the drug vehicle.
a. This playingEntity SHALL contain exactly one [1..1] code
(CONF:7493).
b. This playingEntity MAY contain zero or one [0..1] name (CONF:7494).
i.

This playingEntity/name MAY be used for the vehicle name in
text, such as Normal Saline (CONF:10087).
Figure 173: Drug vehicle entry example






Normal Saline



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July 2012

6.21 Encounter Activities
[encounter: templateId 2.16.840.1.113883.10.20.22.4.49(open)]
Table 158: Encounter Activities Contexts
Used By:

Contains Entries:

Encounters Section (entries optional) (optional)
Encounters Section (entries required) (required)

Encounter Diagnosis
Indication
Service Delivery Location

This clinical statement describes the interactions between the patient and
clinicians. Interactions include in-person encounters, telephone conversations,
and email exchanges.
Table 159: Encounter Activities Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF
#

Fixed Value

Green
Encounter
Activities

encounter[templateId/@root = '2.16.840.1.113883.10.20.22.4.49']

@classCode

1..1

SHALL

8710

2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

8711

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

encounter
ID

id

1..*

SHALL

8713

encounter
Type

code

0..1

SHOULD

8714

originalText

0..1

SHOULD

8719

reference

0..1

SHOULD

15970

@value

0..1

SHOULD

15971

0..1

SHOULD

8720

effectiveTime

1..1

SHALL

performer

0..*

MAY

8725

1..1

SHALL

8726

code

0..1

MAY

8727

participant

0..*

MAY

8738

1..1

SHALL

8740

encounter
FreeText
Type
encounter
DateTime

encounter
Provider
facility
Location

reference/@value

assignedEntity

@typeCode

SET<
II>

TS or
IVL<
TS>

8712

2.16.840.1.113883.3.88.1
2.80.32
(EncounterTypeCode)

8715

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)

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Name

XPath

Card.

Verb

Data
Type

CONF
#

Fixed Value
= LOC

reasonFor
Visit

participantRole

1..1

SHALL

14903

entryRelationship

0..*

MAY

8722

@typeCode

1..1

SHALL

8723

observation

1..1

SHALL

14899

0..*

MAY

15492

1..1

SHALL

15973

entryRelationship
act

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= RSON

1. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8710).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:8711).
3. SHALL contain exactly one [1..1] templateId (CONF:8712) such that it
4. SHALL contain at least one [1..*] id (CONF:8713).
5. SHOULD contain zero or one [0..1] code, which SHOULD be selected from
ValueSet EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32
DYNAMIC (CONF:8714).
a. The code, if present, SHOULD contain zero or one [0..1] originalText
(CONF:8719).
i.

The originalText, if present, SHOULD contain zero or one [0..1]
reference (CONF:15970).
1. The reference, if present, SHOULD contain zero or one
[0..1] @value (CONF:15971).
a. This reference/@value SHALL begin with a '#'
and SHALL point to its corresponding narrative
(using the approach defined in CDA Release 2,
section 4.3.5.1) (CONF:15972).

ii. The originalText, if present, SHOULD contain zero or one [0..1]
reference/@value (CONF:8720).
6. SHALL contain exactly one [1..1] effectiveTime (CONF:8715).
7. MAY contain zero or more [0..*] performer (CONF:8725).
a. The performer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:8726).
i.

This assignedEntity MAY contain zero or one [0..1] code
(CONF:8727).

8. MAY contain zero or more [0..*] participant (CONF:8738) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:8740).

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b. SHALL contain exactly one [1..1] Service Delivery Location
(templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:14903).
9. MAY contain zero or more [0..*] entryRelationship (CONF:8722) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:8723).
b. SHALL contain exactly one [1..1] Indication
(templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:14899).
10. MAY contain zero or more [0..*] entryRelationship (CONF:15492) such that
it
a. SHALL contain exactly one [1..1] Encounter Diagnosis
(templateId:2.16.840.1.113883.10.20.22.4.80 )
(CONF:15973).
11. MAY contain zero or one [0..1] sdtc:dischargeDispositionCode, which SHALL
be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04
FL17-Patient Status DYNAMIC or, if access to NUBC is unavailable, from
CodeSystem 2.16.840.1.113883.12.112 HL7 Discharge Disposition. 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
dischargeDispositionCode element (CONF:9929).
Table 160: Encounter Type Value Set
Value Set: EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32 DYNAMIC
Code System: CPT-4 2.16.840.1.113883.6.12
This value set includes only the codes of the Current Procedure and Terminology designated for
Evaluation and Management (99200 – 99607) (subscription to AMA Required
http://www.amacodingonline.com/)
Code

Code System

Print Name

99201

CPT-4

Office or other outpatient visit (problem
focused)

99202

CPT-4

Office or other outpatient visit (expanded
problem (expanded)

99203

CPT-4

Office or other outpatient visit (detailed)

99204

CPT-4

Office or other outpatient visit
(comprehensive, (comprehensive moderate)

99205

CPT-4

Office or other outpatient visit
(comprehensive, comprehensive-high)

…

CPT-4

…

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Figure 174: Encounter activities example






Checkup Examination












...






...





6.22 Encounter Diagnosis
[act: templateId 2.16.840.1.113883.10.20.22.4.80 (open)]
Table 161: Encounter Diagnosis Contexts
Used By:

Contains Entries:

Encounter Activities (optional)

Problem Observation

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This template wraps relevant problems or diagnoses at the close of a visit or that
need to be followed after the visit. If the encounter is associated with a Hospital
Discharge, the Hospital Discharge Diagnosis must be used. This entry requires
at least one Problem Observation entry.
Table 162: Encounter Diagnosis Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.80 ']
@classCode

1..1

SHALL

14889

2.16.840.1.113883.5.6 (HL7ActClass) =
ACT

@moodCode

1..1

SHALL

14890

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

14895

1..1

SHALL

14896

@root
code

1..1

SHALL

@code

1..1

SHALL

CE

14897

entry
Relationship

1..*

SHALL

14892

1..1

SHALL

14893

1..1

SHALL

14898

2.16.840.1.113883.10.20.22.4.80

14891

@typeCode

2.16.840.1.113883.6.1 (LOINC) = 29308-4

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

observation

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:14889).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14890).
3. SHALL contain exactly one [1..1] templateId (CONF:14895) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.80" (CONF:14896).
4. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:14891).
a. This code SHALL contain exactly one [1..1] @code="29308-4"
Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:14897).
5. SHALL contain at least one [1..*] entryRelationship (CONF:14892) such
that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:14893).
b. SHALL contain exactly one [1..1] Problem Observation
(templateId:2.16.840.1.113883.10.20.22.4.4) (CONF:14898).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Figure 175: Encounter diagnosis act example













...




6.23 Estimated Date of Delivery
[observation: templateId 2.16.840.1.113883.10.20.15.3.1(closed)]
Table 163: Estimated Date of Delivery Contexts
Used By:

Contains Entries:

Pregnancy Observation

This clinical statement represents the anticipated date when a woman will give
birth.
Table 164: Estimated Date of Delivery Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.15.3.1']
@classCode

1..1

SHALL

444

2.16.840.1.113883.5.6 (HL7ActClass) = OBS

@moodCode

1..1

SHALL

445

2.16.840.1.113883.5.1001 (ActMood) = EVN

templateId

1..1

SHALL

16762

1..1

SHALL

16763

2.16.840.1.113883.10.20.15.3.1

code

1..1

SHALL

446

2.16.840.1.113883.6.1 (LOINC) = 11778-8

statusCode

1..1

SHALL

448

2.16.840.1.113883.5.14 (ActStatus) =
completed

value

1..1

SHALL

@root

CE

TS

450

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1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:444).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:445).
3. SHALL contain exactly one [1..1] templateId (CONF:16762) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.15.3.1" (CONF:16763).
4. SHALL contain exactly one [1..1] code="11778-8" Estimated date of delivery
(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:446).
5. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:448).
6. SHALL contain exactly one [1..1] value with @xsi:type="TS" (CONF:450).
Figure 176: Estimated date of delivery example






20110919


6.24 Family History Death Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.47(open)]
Table 165: Family History Death Observation Contexts
Used By:

Contains Entries:

Family History Observation

This clinical statement records whether the family member is deceased.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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© 2012 Health Level Seven, Inc. All rights reserved.

Table 166: Family History Death Observation Constraints Overview
Name

XPath

Card
.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.47']
@classCode

1..1

SHALL

8621

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8622

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10495

2.16.840.1.113883.10.20.22.4.4
7

code

1..1

SHALL

16889

2.16.840.1.113883.5.4 (ActCode)
= ASSERTION

statusCode

1..1

SHALL

8625

2.16.840.1.113883.5.14
(ActStatus) = completed

value

1..1

SHALL

8626

2.16.840.1.113883.6.96
(SNOMED-CT) = 419099009

@root

SET

CD

8623

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8621).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8622).
3. SHALL contain exactly one [1..1] templateId (CONF:8623) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.47" (CONF:10495).
4. SHALL contain exactly one [1..1] code="ASSERTION" Assertion (CodeSystem:
ActCode 2.16.840.1.113883.5.4) (CONF:16889).
5. SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem:
ActStatus 2.16.840.1.113883.5.14) (CONF:8625).
6. SHALL contain exactly one [1..1] value="419099009" Dead with
@xsi:type="CD" (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96)
(CONF:8626).
Figure 177: Family history death observation example









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July 2012

6.25 Family History Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.46(open)]
Table 167: Family History Observation Contexts
Used By:

Contains Entries:

Family History Organizer (optional)

Age Observation
Family History Death Observation

Family History Observations related to a particular family member are contained
within a Family History Organizer. The effectiveTime in the Family History
Observation is the biologically or clinically relevant time of the observation. The
biologically or clinically relevant time is the time at which the observation holds
(is effective) for the family member (the subject of the observation).
Table 168: Family History Observation Constraints Overview

Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

Green Family
History
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.46']

@classCode

1..1

SHALL

8586

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8587

2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10496

id

1..*

SHALL

8592

code

1..1

SHALL

8589

2.16.840.1.113883.3.88.1
2.3221.7.2 (Problem
Type)

statusCode

1..1

SHALL

8590

2.16.840.1.113883.5.14
(ActStatus) = completed

effectiveTime

0..1

SHOULD

TS or
IVL<
TS>

8593

value

1..1

SHALL

CD

8591

entryRelationship

0..1

MAY

8675

@typeCode

1..1

SHALL

8676

2.16.840.1.113883.5.90
(HL7ParticipationType) =
SUBJ

@inversionInd

1..1

SHALL

8677

true

observation

1..1

SHALL

15526

@root

SET<
II>

8599
2.16.840.1.113883.10.20.
22.4.46

2.16.840.1.113883.3.88.1
2.3221.7.4 (Problem)

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Name

XPath

Card.

Verb

0..1

MAY

8678

@typeCode

1..1

SHALL

8679

observation

1..1

SHALL

15527

entryRelationship

Data
Type

CONF#

Fixed Value

2.16.840.1.113883.5.90
(HL7ParticipationType) =
CAUS

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8586).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8587).
3. SHALL contain exactly one [1..1] templateId (CONF:8599) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.46" (CONF:10496).
4. SHALL contain at least one [1..*] id (CONF:8592).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from
ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC
2012-06-01 (CONF:8589).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:8590).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:8593).
8. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHALL be selected from ValueSet Problem
2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:8591).
9. MAY contain zero or one [0..1] entryRelationship (CONF:8675) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Subject
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8676).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:8677).
c. SHALL contain exactly one [1..1] Age Observation
(templateId:2.16.840.1.113883.10.20.22.4.31) (CONF:15526).
10. MAY contain zero or one [0..1] entryRelationship (CONF:8678) such that it
a. SHALL contain exactly one [1..1] @typeCode="CAUS" Causal or
Contributory (CodeSystem: HL7ParticipationType
2.16.840.1.113883.5.90) (CONF:8679).
b. SHALL contain exactly one [1..1] Family History Death
Observation (templateId:2.16.840.1.113883.10.20.22.4.47)
(CONF:15527).

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Figure 178: Family history observation scenario
SCENARIO
A patient's father was diagnosed with diabetes at the age of 40. He died
of Myocardial Infarction at the age of 57. If the patient's father was
born in 1910, the family history organizer for the father would contain
the following items:
The Date of Birth
RelatedSubject/subject/birthTime

=>

1910

The Date of Death
RelatedSubject/subject/sdtc:deceasedInd => true
RelatedSubject/subject/sdtc:deceasedTime => 1967
The Diabetes Diagnosis
component/observation/effectiveTime => 1950
component/observation/value => contains the code and displayName for
diabetes
component/observation/entryRelationship/observation/value/@value => 40
with the unit set to "a" to indicate years
The Myocardial Infarction Diagnosis and Cause of Death
component/observation/effectiveTime => 1967
component/observation/value => contains the code and displayName for MI
component/observation/entryRelationship/observation/value/@value => 57
with the unit set to "a" to indicate years
component/observation/entryRelationship/@typeCode => "CAUS". This
second entryRelationship shows that the MI was the cause of death.

The next example uses the above scenario .

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Figure 179: Family history observation example






Father (deceased)



Diagnosis
Age At Onset




Myocardial Infarction (cause of death)
57


Diabetes
40























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******** Family history death observation template
******** --

>



























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6.26 Family History Organizer
[organizer: templateId 2.16.840.1.113883.10.20.22.4.45(open)]
Table 169: Family History Organizer Contexts
Used By:

Contains Entries:

Family History Section

Family History Observation

The Family History Organizer associates a set of observations with a family
member. For example, the Family History Organizer can group a set of
observations about the patient’s father.
Table 170: Family History Organizer Constraints Overview

Name

XPath

Green Family
History
Organizer

organizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.45']

Verb

Data
Type

CONF#

Fixed Value

@classCode

1..1

SHALL

8600

2.16.840.1.113883.5.6
(HL7ActClass) = CLUSTER

@moodCode

1..1

SHALL

8601

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10497

2.16.840.1.113883.10.20.2
2.4.45

statusCode

1..1

SHALL

8602

2.16.840.1.113883.5.14
(ActStatus) = completed

subject

1..1

SHALL

8609

@root

familyMember
Demographics

Card.

SET<
II>

8604

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Name

XPath

Card.

Verb

Data
Type

CONF#

1..1

SHALL

15244

@classCode

1..1

SHALL

15245

code

1..1

SHALL

15246

@code

0..1

SHALL

15247

subject

0..1

SHOULD

15248

1..1

SHALL

15974

@code

1..1

SHALL

15975

birthTime

0..1

SHOULD

15976

1..1

SHALL

8610

Fixed Value

relatedSubject
2.16.840.1.113883.5.41
(EntityClass) = PRS
2.16.840.1.113883.1.11.19
579
(FamilyHistoryRelatedSubje
ctCode)

administrative
GenderCode

relatedSubject
/@classCode
familyMember
Relationship
ToPatient

code

1..1

SHALL

familyMember
Person
Information

subject

0..1

SHOULD

1..1

SHALL

CE

8614

0..1

SHOULD

TS

8615

1..*

SHALL

8607

1..1

SHOULD

16888

familyMember
Administrative
Gender
familyMember
DateOfBirth
familyMember
MedicalHistory

CE

component
observation

2.16.840.1.113883.5.41
(EntityClass) = PRS

8611

8613

administrative
GenderCode
birthTime

2.16.840.1.113883.1.11.1
(Administrative Gender
(HL7 V3))

2.16.840.1.113883.1.11.1
(Administrative Gender
(HL7 V3))

1. SHALL contain exactly one [1..1] @classCode="CLUSTER" Cluster
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8600).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8601).
3. SHALL contain exactly one [1..1] templateId (CONF:8604) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.45" (CONF:10497).
4. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:8602).
5. SHALL contain exactly one [1..1] subject (CONF:8609).

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a. This subject SHALL contain exactly one [1..1] relatedSubject
(CONF:15244).
i.

This relatedSubject SHALL contain exactly one [1..1]
@classCode="PRS" Person (CodeSystem: EntityClass
2.16.840.1.113883.5.41) (CONF:15245).

ii. This relatedSubject SHALL contain exactly one [1..1] code
(CONF:15246).
1. This code SHALL contain zero or one [0..1] @code,
which SHOULD be selected from ValueSet
FamilyHistoryRelatedSubjectCode
2.16.840.1.113883.1.11.19579 DYNAMIC
(CONF:15247).
iii. This relatedSubject SHOULD contain zero or one [0..1] subject
(CONF:15248).
1. The subject, if present, SHALL contain exactly one [1..1]
administrativeGenderCode (CONF:15974).
a. This administrativeGenderCode SHALL contain
exactly one [1..1] @code, which SHALL be
selected from ValueSet Administrative
Gender (HL7 V3)
2.16.840.1.113883.1.11.1 (CONF:15975).
2. The subject, if present, SHOULD contain zero or one
[0..1] birthTime (CONF:15976).
3. The subject SHOULD contain zero or more [0..*] sdtc:id.
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 id
element (CONF:15249).
4. The subject MAY contain zero or one sdtc:deceasedInd.
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
deceasedInd element (CONF:15981).
5. The subject MAY contain zero or one
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
(CONF:15982).
6. The age of a relative at the time of a family history
observation SHOULD be inferred by comparing
RelatedSubject/subject/birthTime with
Observation/effectiveTime (CONF:15983).
6. SHALL contain at least one [1..*] component (CONF:8607).
a. Such components SHALL contain exactly one [1..1] Family History
Observation (templateId:2.16.840.1.113883.10.20.22.4.46)
(CONF:16888).

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Table 171: Family History Related Subject Value Set (excerpt)

Value Set: FamilyHistoryRelatedSubjectCode 2.16.840.1.113883.1.11.19579 DYNAMIC
Code System: RoleCode 2.16.840.1.113883.5.111 (any subtype of RoleCode: FAMMEMB)
See HL7 Vocabulary Domains included in the CDA R2 Normative Web Edition

http://www.hl7.org/documentcenter/private/standards/cda/r2/cda_r2_normativewebeditio
n2010.zip
Code

Code System

Print Name

CHILD

RoleCode

Child

CHLDADOPT

RoleCode

Adopted Child

DAUADOPT

RoleCode

Adopted Daughter

SONADOPT

RoleCode

Adopted Son

CHLDINLAW

RoleCode

Child in-law

…

Figure 180: Family history organizer example




















...





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6.27 Functional Status Problem Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.68 (open)]
Table 172: Functional Status Problem Observation Contexts
Used By:

Contains Entries:

Functional Status Section (optional)

Assessment Scale Observation
Caregiver Characteristics
Non-Medicinal Supply Activity

A functional status problem observation is a clinical statement that represents a
patient’s functional perfomance and ability.
Table 173: Functional Status Problem Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.68']
@classCode

1..1

SHALL

14282

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

14283

2.16.840.1.113883.5.1001
(ActMood) = EVN

@negationInd

0..1

MAY

14307

templateId

1..1

SHALL

14312

1..1

SHALL

14313

id

@root

1..*

SHALL

14284

code

1..1

SHALL

14314

0..1

SHOULD

14315

0..1

SHOULD

14304

reference

1..1

SHOULD

15552

@value

@code
text

0..1

SHOULD

15553

statusCode

1..1

SHALL

14286

effectiveTime

0..1

SHOULD

TS or
IVL

14287

value

1..1

SHALL

CD

14291

0..1

MAY

14292

methodCode

0..1

MAY

14316

entryRelationship

0..*

MAY

14294

@nullFlavor

2.16.840.1.113883.10.20.22.4.68

2.16.840.1.113883.6.96
(SNOMED-CT) = 248536006

2.16.840.1.113883.5.14
(ActStatus) = completed

2.16.840.1.113883.3.88.12.3221.7
.4 (Problem)

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Name

XPath

Card.

Verb

@typeCode

1..1

supply

CONF#

Fixed Value

SHALL

14584

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = REFR

1..1

SHALL

14317

0..*

MAY

14298

@typeCode

1..1

SHALL

14586

observation

1..1

SHALL

14318

0..*

MAY

14463

@typeCode

1..1

SHALL

14587

observation

1..1

SHALL

14464

entryRelationship

entryRelationship

Data
Type

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = COMP

1. Conforms to Problem Observation template
(2.16.840.1.113883.10.20.22.4.4).
2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:14282).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14283).
Use negationInd="true" to indicate that the problem was not observed.
4. MAY contain zero or one [0..1] @negationInd (CONF:14307).
5. SHALL contain exactly one [1..1] templateId (CONF:14312) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.68" (CONF:14313).
6. SHALL contain at least one [1..*] id (CONF:14284).
7. SHALL contain exactly one [1..1] code (CONF:14314).
a. This code SHOULD contain zero or one [0..1] @code="248536006"
finding of functional performance and activity (CodeSystem: SNOMEDCT 2.16.840.1.113883.6.96) (CONF:14315).
8. SHOULD contain zero or one [0..1] text (CONF:14304).
a. The text, if present, SHOULD contain exactly one [1..1] reference
(CONF:15552).
i.

This reference SHOULD contain zero or one [0..1] @value
(CONF:15553).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15554).

9. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:14286).
10. SHOULD contain zero or one [0..1] effectiveTime (CONF:14287).
a. The onset date SHALL be recorded in the low element of the
effectiveTime element when known (CONF:14288).

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b. The resolution date SHALL be recorded in the high element of the
effectiveTime element when known (CONF:14289).
c. If the problem is known to be resolved, but the date of resolution is
not known, then the high element SHALL be present, and the
nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of
an high element within a problem does indicate that the problem has
been resolved (CONF:14290).
11. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHOULD be selected from ValueSet Problem
2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:14291).
a. This value MAY contain zero or one [0..1] @nullFlavor
(CONF:14292).
i.

If the diagnosis is unknown or the SNOMED code is
unknown, @nullFlavor SHOULD be “UNK”. If the code is
something other than SNOMED, @nullFlavor SHOULD be
“OTH” and the other code SHOULD be placed in the translation
element (CONF:14293).

12. MAY contain zero or one [0..1] methodCode (CONF:14316).
13. MAY contain zero or more [0..*] entryRelationship (CONF:14294) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14584).
b. SHALL contain exactly one [1..1] Non-Medicinal Supply Activity
(templateId:2.16.840.1.113883.10.20.22.4.50) (CONF:14317).
14. MAY contain zero or more [0..*] entryRelationship (CONF:14298) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14586).
b. SHALL contain exactly one [1..1] Caregiver Characteristics
(templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14318).
15. MAY contain zero or more [0..*] entryRelationship (CONF:14463) such that
it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:14587).
b. SHALL contain exactly one [1..1] Assessment Scale Observation
(templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14464).

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Figure 181: Functional status problem observation example






...










...






...




6.28 Functional Status Result Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.67 (open)]
Table 174: Functional Status Result Observation Contexts
Used By:

Contains Entries:

Functional Status Result Organizer (required)
Functional Status Section (optional)

Assessment Scale Observation
Caregiver Characteristics
Non-Medicinal Supply Activity

This clinical statement represents details of an evaluation or assessment of a
patient's functional status. The evaluation may include assessment of a patient's
language, vision, hearing, activities of daily living, behavior, general function,
mobility, and self-care status. The statement, if present, will include supporting
caregivers, non-medical devices, and the time period for which the evaluation
and assessment were performed.

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Table 175: Functional Status Result Observation Constraints Overview

Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.67']
@classCode

1..1

SHALL

13905

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

13906

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

13889

1..1

SHALL

13890

id

1..*

SHALL

code

1..1

SHALL

text

0..1

SHOULD

13926

reference

0..1

SHOULD

13927

statusCode

1..1

SHALL

13929

effectiveTime

1..1

SHALL

13930

value

1..1

SHALL

13932

interpretationCode

0..*

SHOULD

13933

methodCode

0..1

MAY

13934

targetSiteCode

0..1

MAY

13935

author

0..1

MAY

13936

entryRelationship

0..1

MAY

13892

@typeCode

1..1

SHALL

14596

supply

1..1

SHALL

14218

@root

entryRelationship

13907
CE

13908

0..1

MAY

13895

@typeCode

1..1

SHALL

14597

observation

1..1

SHALL

13897

0..1

MAY

14465

@typeCode

1..1

SHALL

14598

observation

1..1

SHALL

14466

referenceRange

0..*

SHOULD

13937

1..1

SHALL

13938

entryRelationship

observationRange

2.16.840.1.113883.10.20.22.
4.67
2.16.840.1.113883.6.1
(LOINC)

Completed

REFR

REFR

COMP

1. Conforms to Result Observation template
(2.16.840.1.113883.10.20.22.4.2).
2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:13905).
3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:13906).
4. SHALL contain exactly one [1..1] templateId (CONF:13889) such that it
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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.67" (CONF:13890).
5. SHALL contain at least one [1..*] id (CONF:13907).
6. SHALL contain exactly one [1..1] code with @xsi:type="CE", where the @code
SHOULD be selected from CodeSystem LOINC (2.16.840.1.113883.6.1)
(CONF:13908).
7. SHOULD contain zero or one [0..1] text (CONF:13926).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:13927).
i.

This reference/@value SHALL begin with a '#' and SHALL point
to its corresponding narrative (using the approach defined in
CDA Release 2, section 4.3.5.1) (CONF:13928).

8. SHALL contain exactly one [1..1] statusCode="Completed" (CONF:13929).
Represents clinically effective time of the measurement, which may be when the
measurement was performed (e.g., a BP measurement), or may be when sample
was taken (and measured some time afterwards)
9. SHALL contain exactly one [1..1] effectiveTime (CONF:13930).
10. SHALL contain exactly one [1..1] value (CONF:13932).
a. If xsi:type=“CD”, SHOULD contain a code from SNOMED CT
(CodeSystem: 2.16.840.1.113883.6.96) (CONF:14234).
11. SHOULD contain zero or more [0..*] interpretationCode (CONF:13933).
12. MAY contain zero or one [0..1] methodCode (CONF:13934).
13. MAY contain zero or one [0..1] targetSiteCode (CONF:13935).
14. MAY contain zero or one [0..1] author (CONF:13936).
15. MAY contain zero or one [0..1] entryRelationship (CONF:13892) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CONF:14596).
b. SHALL contain exactly one [1..1] Non-Medicinal Supply Activity
(templateId:2.16.840.1.113883.10.20.22.4.50) (CONF:14218).
16. MAY contain zero or one [0..1] entryRelationship (CONF:13895) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" refers to
(CONF:14597).
b. SHALL contain exactly one [1..1] Caregiver Characteristics
(templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:13897).
17. MAY contain zero or one [0..1] entryRelationship (CONF:14465) such that
it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component
(CONF:14598).
b. SHALL contain exactly one [1..1] Assessment Scale Observation
(templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14466).
18. SHOULD contain zero or more [0..*] referenceRange (CONF:13937).
a. The referenceRange, if present, SHALL contain exactly one [1..1]
observationRange (CONF:13938).
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i.

This observationRange SHALL NOT contain [0..0] code
(CONF:13939).

Figure 182: Functional status result observation example













...






...




6.29 Functional Status Result Organizer
[organizer: templateId 2.16.840.1.113883.10.20.22.4.66 (open)]
Table 176: Functional Status Result Organizer Contexts
Used By:

Contains Entries:

Functional Status Section (optional)

Functional Status Result Observation

This clinical statement identifies a set of functional status result observations. It
contains information applicable to all of the contained functional status result
observations. A functional status organizer may group self-care observations
related to a patient's ability to feed, bathe, and dress.
An appropriate nullFlavor can be used when the organizer/code or
organizer/id is unknown.

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Table 177: Functional Status Result Organizer Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

organizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.66']
@classCode

1..1

SHALL

14355

2.16.840.1.113883.5.6 (HL7ActClass)
= CLUSTER

1..1

SHALL

14357

2.16.840.1.113883.5.1001 (ActMood)
= EVN

1..1

SHALL

1..1

SHALL

14362

id

1..*

SHALL

14363

code

1..1

SHALL

14364

0..1

SHOULD

14747

statusCode

1..1

SHALL

14358

component

1..*

SHALL

14359

1..1

SHALL

14368

@mood
Code
templateId
@root

@code

SET

14361
2.16.840.1.113883.10.20.22.4.66

2.16.840.1.113883.5.14 (ActStatus) =
completed

observation

1. Conforms to Result Organizer template
(2.16.840.1.113883.10.20.22.4.1).
2. SHALL contain exactly one [1..1] @classCode, which SHALL be selected from
CodeSystem HL7ActClass (2.16.840.1.113883.5.6)="CLUSTER"
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:14355).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:14357).
4. SHALL contain exactly one [1..1] templateId (CONF:14361) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.66" (CONF:14362).
5. SHALL contain at least one [1..*] id (CONF:14363).
6. SHALL contain exactly one [1..1] code (CONF:14364).
a. This code SHOULD contain zero or one [0..1] @code (CONF:14747).
i.

be selected from ICF (codeSystem
2.16.840.1.113883.6.254) or SNOMED CT (codeSystem
2.16.840.1.113883.6.96) (CONF:14748).
SHOULD

7. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:14358).
8. SHALL contain at least one [1..*] component (CONF:14359) such that it
a. SHALL contain exactly one [1..1] Functional Status Result
Observation (templateId:2.16.840.1.113883.10.20.22.4.67)
(CONF:14368).

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Figure 183: Functional status result organizer example










...






...




6.30 Health Status Observation
[Observation: templateId 2.16.840.1.113883.10.20.22.4.5(open)]
Table 178: Health Status Observation Contexts
Used By:

Contains Entries:

Problem Observation

The Health Status Observation records information about the current health
status of the patient.
Table 179: Health Status Observation Constraints Overview

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Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.5']
@classCode

1..1

SHALL

9057

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

9072

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

16756

1..1

SHALL

16757

2.16.840.1.113883.10.20.22.4.5

code

1..1

SHALL

9073

2.16.840.1.113883.6.1 (LOINC) =
11323-3

text

0..1

SHOULD

9270

reference

0..1

SHOULD

15529

@value

0..1

SHOULD

15530

statusCode

1..1

SHALL

9074

2.16.840.1.113883.5.14 (ActStatus) =
completed

value

1..1

SHALL

9075

2.16.840.1.113883.1.11.20.12
(HealthStatus)

@root

CE

CD

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9057).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9072).
3. SHALL contain exactly one [1..1] templateId (CONF:16756) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.5" (CONF:16757).
4. SHALL contain exactly one [1..1] code="11323-3" Health status with
@xsi:type="CE" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC)
(CONF:9073).
5. SHOULD contain zero or one [0..1] text (CONF:9270).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15529).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15530).
1. SHALL begin with a '#' and SHALL point to its
corresponding narrative (using the approach defined
in CDA Release 2, section 4.3.5.1) (CONF:15531).

6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:9074).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHALL be selected from ValueSet HealthStatus
2.16.840.1.113883.1.11.20.12 DYNAMIC (CONF:9075).
Table 180: HealthStatus Value Set

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Value Set: HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC
Code System(s):
Description:
Code

SNOMED CT 2.16.840.1.113883.6.96
Represents the general health status of the patient.
Code System

Print Name

81323004

SNOMED CT

Alive and well

313386006

SNOMED CT

In remission

162467007

SNOMED CT

Symptom free

161901003

SNOMED CT

Chronically ill

271593001

SNOMED CT

Severely ill

21134002

SNOMED CT

Disabled

161045001

SNOMED CT

Severely disabled

Figure 184: Health status observation example








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6.31 Highest Pressure Ulcer Stage
[observation: templateId 2.16.840.1.113883.10.20.22.4.77 (open)]
Table 181: Highest Pressure Ulcer Stage Contexts
Used By:

Contains Entries:

Functional Status Section (optional)
Physical Exam Section (optional)

This observation contains a description of the wound tissue of the most severe
or highest staged pressure ulcer observed on a patient.

Table 182: Highest Pressure Ulcer Stage Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.77']
@classCode

1..1

SHALL

14726

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

14727

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

14728

1..1

SHALL

14729

id

1..*

SHALL

14730

code

1..1

SHALL

14731

1..1

SHALL

14732

1..1

SHALL

14733

@root

@code
value

2.16.840.1.113883.10.20.22.4.77

2.16.840.1.113883.6.96 (SNOMED-CT) =
420905001

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:14726).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14727).
3. SHALL contain exactly one [1..1] templateId (CONF:14728) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.77" (CONF:14729).
4. SHALL contain at least one [1..*] id (CONF:14730).
5. SHALL contain exactly one [1..1] code (CONF:14731).
a. This code SHALL contain exactly one [1..1] @code="420905001"
Highest Pressure Ulcer Stage (CodeSystem: SNOMED-CT
2.16.840.1.113883.6.96) (CONF:14732).
6. SHALL contain exactly one [1..1] value (CONF:14733).

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6.32 Hospital Admission Diagnosis
[act: templateId 2.16.840.1.113883.10.20.22.4.34(open)
Table 183: Hospital Admission Diagnosis Contexts
Used By:

Contains Entries:

Hospital Admission Diagnosis Section

Problem Observation

The Hospital Admission Diagnosis entry describes the relevant problems or
diagnoses at the time of admission.
Table 184: Hospital Admission Diagnosis Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.34']
@classCode

1..1

SHALL

7671

2.16.840.1.113883.5.6 (HL7ActClass)
= ACT

@moodCode

1..1

SHALL

7672

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

16747

1..1

SHALL

16748

2.16.840.1.113883.10.20.22.4.34

code

1..1

SHALL

7673

2.16.840.1.113883.6.1 (LOINC) =
46241-6

entryRelationship

1..*

SHALL

7674

@typeCode

1..1

SHALL

7675

observation

1..1

SHALL

15535

@root

CE

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7671).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7672).
3. SHALL contain exactly one [1..1] templateId (CONF:16747) such that it

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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.34" (CONF:16748).
4. SHALL contain exactly one [1..1] code="46241-6" Admission diagnosis
(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7673).
5. SHALL contain at least one [1..*] entryRelationship (CONF:7674) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:7675).
b. SHALL contain exactly one [1..1] Problem Observation
(templateId:2.16.840.1.113883.10.20.22.4.4) (CONF:15535).
Figure 185: Hospital admission diagnosis example













...




6.33 Hospital Discharge Diagnosis
[act: templateId 2.16.840.1.113883.10.20.22.4.33(open)
Table 185: Hospital Discharge Diagnosis Contexts
Used By:

Contains Entries:

Hospital Discharge Diagnosis Section

Problem Observation

The Hospital Discharge Diagnosis act wraps relevant problems or diagnoses at
the time of discharge that occurred during the hospitalization or that need to be
followed after hospitalization. This entry requires at least one Problem
Observation entry.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Table 186: Hospital Discharge Diagnosis Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.33']
@classCode

1..1

SHALL

7663

2.16.840.1.113883.5.6 (HL7ActClass)
= ACT

@moodCode

1..1

SHALL

7664

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

16764

1..1

SHALL

16765

2.16.840.1.113883.10.20.22.4.33

code

1..1

SHALL

7665

2.16.840.1.113883.6.1 (LOINC) =
11535-2

entryRelationship

1..*

SHALL

7666

@typeCode

1..1

SHALL

7667

observation

1..1

SHALL

15536

@root

CE

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7663).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7664).
3. SHALL contain exactly one [1..1] templateId (CONF:16764) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.33" (CONF:16765).
4. SHALL contain exactly one [1..1] code="11535-2" Hospital discharge
diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7665).
5. SHALL contain at least one [1..*] entryRelationship (CONF:7666) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:7667).
b. SHALL contain exactly one [1..1] Problem Observation
(templateId:2.16.840.1.113883.10.20.22.4.4) (CONF:15536).

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Figure 186: Hospital discharge diagnosis act example













...




6.34 Immunization Activity
[substanceAdministration: templateId
2.16.840.1.113883.10.20.22.4.52 (open)]
Table 187: Immunization Activity Contexts
Used By:

Contains Entries:

Immunizations Section (entries optional) (optional)
Immunizations Section (entries required) (required)

Drug Vehicle
Immunization Medication Information
Immunization Refusal Reason
Indication
Instructions
Medication Dispense
Medication Supply Order
Precondition for Substance
Administration
Reaction Observation

An Immunization Activity describes immunization substance administrations
that have actually occurred or are intended to occur. Immunization Activities in
"INT" mood are reflections of immunizations a clinician intends a patient to
receive. Immunization Activities in "EVN" mood reflect immunizations actually
received.
An Immunization Activity is very similar to a Medication Activity with some key
differentiators. The drug code system is constrained to CVX codes.
Administration timing is less complex. Patient refusal reasons should be
captured. All vaccines administered should be fully documented in the patient's

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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permanent medical record. Healthcare providers who administer vaccines
covered by the National Childhood Vaccine Injury Act are required to ensure
that the permanent medical record of the recipient indicates:
1)
2)
3)
4)

Date of administration
Vaccine manufacturer
Vaccine lot number
Name and title of the person who administered the vaccine and the
address of the clinic or facility where the permanent record will reside
5) Vaccine information statement (VIS)
a. date printed on the VIS
b. date VIS given to patient or parent/guardian.
This information should be included in an Immunization Activity when available.
33

Table 188: Immunization Activity Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

Green
Immunization
Activity

substanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.22.4.52']

@classCode

1..1

SHALL

8826

2.16.840.1.113883.5.6
(HL7ActClass) = SBADM

@moodCode

1..1

SHALL

8827

2.16.840.1.113883.11.20.9.
18 (MoodCodeEvnInt)

@negationInd

1..1

SHALL

templateId

1..1

SHALL

1..1

SHALL

10498

id

1..*

SHALL

8829

code

0..1

MAY

text

0..1

SHOULD

8831

reference

0..1

SHOULD

15543

@value

0..1

SHOULD

15544

statusCode

1..1

SHALL

8833

administered
Date

effectiveTime

1..1

SHALL

TS or
IVL<
TS>

8834

medication
SeriesNumber

repeatNumber

0..1

MAY

IVL

8838

routeCode

0..1

MAY

approachSiteCode

0..1

MAY

refusal

@root

33

8985
SET<
II>

CE

SET<

8828
2.16.840.1.113883.10.20.2
2.4.52

8830

8839

2.16.840.1.113883.3.88.12.
3221.8.7 (Medication Route
FDA Value Set)

8840

2.16.840.1.113883.3.88.12.
3221.8.9 (Body Site Value

Vaccine Administration Guidelines.

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/vacc_admin.
pdf
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July 2012

Name

XPath

Card.

Verb

Data
Type

CONF#

CD>
doseQuantity

SHOULD

0..1

SHOULD

8842

2.16.840.1.113883.1.11.12
839 (UCUM Units of
Measure (case sensitive)) =
1

0..1

MAY

8846

2.16.840.1.113883.3.88.12.
3221.8.11 (Medication
Product Form)

1..1

SHALL

8847

1..1

SHALL

15546

performer

0..1

SHOULD

8849

participant

0..*

MAY

8850

@typeCode

1..1

SHALL

8851

participantRole

1..1

SHALL

15547

entryRelationship

0..*

MAY

8853

@typeCode

1..1

SHALL

8854

observation

1..1

SHALL

15537

0..1

MAY

8856

@typeCode

1..1

SHALL

8857

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

8858

true

act

1..1

SHALL

15538

0..1

MAY

8860

@typeCode

1..1

SHALL

8861

supply

1..1

SHALL

15539

0..1

MAY

8863

@typeCode

1..1

SHALL

8864

supply

1..1

SHALL

15540

0..1

MAY

8866

1..1

SHALL

8867

administrationUni
tCode
medication
Information

Set)

0..1

@unit

consumable

IVL<
PQ>

Fixed Value

8841

manufacturedPro
duct
performer

entryRelationship

entryRelationship

entryRelationship

reaction

entryRelationship
@typeCode

2.16.840.1.113883.5.90
(HL7ParticipationType) =
CSM

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
RSON

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
CAUS

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Name

XPath

Card.

Verb

1..1

SHALL

15541

0..1

MAY

8988

@typeCode

1..1

SHALL

8989

observation

1..1

SHALL

15542

precondition

0..*

MAY

8869

@typeCode

1..1

SHALL

8870

criterion

1..1

SHALL

15548

observation
refusal
Reason

entryRelationship

Data
Type

CONF#

Fixed Value

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
RSON

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
PRCN

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8826).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC
(CONF:8827).
Use negationInd="true" to indicate that the immunization was not given.
3. SHALL contain exactly one [1..1] @negationInd (CONF:8985).
4. SHALL contain exactly one [1..1] templateId (CONF:8828) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.52" (CONF:10498).
5. SHALL contain at least one [1..*] id (CONF:8829).
6. MAY contain zero or one [0..1] code with @xsi:type="CE" (CONF:8830).
7. SHOULD contain zero or one [0..1] text (CONF:8831).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15543).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15544).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1
(CONF:15545).

8. SHALL contain exactly one [1..1] statusCode (CONF:8833).
9. SHALL contain exactly one [1..1] effectiveTime (CONF:8834).
In "INT" (intent) mood, the repeatNumber defines the number of allowed
administrations. For example, a repeatNumber of "3" means that the substance
can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is
the number of occurrences. For example, a repeatNumber of "3" in a dispense
act means that the current dispensation is the 3rd. A repeatNumber of "3" in a
substance administration event means that the current administration is the
3rd in a series.

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10. MAY contain zero or one [0..1] repeatNumber (CONF:8838).
11. MAY contain zero or one [0..1] routeCode, which SHALL be selected from
ValueSet Medication Route FDA Value Set
2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:8839).
12. MAY contain zero or one [0..1] approachSiteCode, where the @code SHALL be
selected from ValueSet Body Site Value Set
2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:8840).
13. SHOULD contain zero or one [0..1] doseQuantity (CONF:8841).
a. The doseQuantity, if present, SHOULD contain zero or one [0..1]
@unit="1", which SHALL be selected from ValueSet UCUM Units of
Measure (case sensitive) 2.16.840.1.113883.1.11.12839
DYNAMIC (CONF:8842).
14. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be
selected from ValueSet Medication Product Form
2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC (CONF:8846).
15. SHALL contain exactly one [1..1] consumable (CONF:8847).
a. This consumable SHALL contain exactly one [1..1] Immunization
Medication Information
(templateId:2.16.840.1.113883.10.20.22.4.54) (CONF:15546).
16. SHOULD contain zero or one [0..1] performer (CONF:8849).
17. MAY contain zero or more [0..*] participant (CONF:8850).
a. The participant, if present, SHALL contain exactly one [1..1]
@typeCode="CSM" (CodeSystem: HL7ParticipationType
2.16.840.1.113883.5.90 STATIC) (CONF:8851).
b. The participant, if present, SHALL contain exactly one [1..1] Drug
Vehicle (templateId:2.16.840.1.113883.10.20.22.4.24)
(CONF:15547).
18. MAY contain zero or more [0..*] entryRelationship (CONF:8853) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8854).
b. SHALL contain exactly one [1..1] Indication
(templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:15537).
19. MAY contain zero or one [0..1] entryRelationship (CONF:8856) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8857).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:8858).
c. SHALL contain exactly one [1..1] Instructions
(templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:15538).
20. MAY contain zero or one [0..1] entryRelationship (CONF:8860) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8861).

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b. SHALL contain exactly one [1..1] Medication Supply Order
(templateId:2.16.840.1.113883.10.20.22.4.17) (CONF:15539).
21. MAY contain zero or one [0..1] entryRelationship (CONF:8863) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8864).
b. SHALL contain exactly one [1..1] Medication Dispense
(templateId:2.16.840.1.113883.10.20.22.4.18) (CONF:15540).
22. MAY contain zero or one [0..1] entryRelationship (CONF:8866) such that it
a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8867).
b. SHALL contain exactly one [1..1] Reaction Observation
(templateId:2.16.840.1.113883.10.20.22.4.9) (CONF:15541).
23. MAY contain zero or one [0..1] entryRelationship (CONF:8988) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8989).
b. SHALL contain exactly one [1..1] Immunization Refusal Reason
(templateId:2.16.840.1.113883.10.20.22.4.53) (CONF:15542).
24. MAY contain zero or more [0..*] precondition (CONF:8869) such that it
a. SHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8870).
b. SHALL contain exactly one [1..1] Precondition for Substance
Administration
(templateId:2.16.840.1.113883.10.20.22.4.25) (CONF:15548).

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Figure 187: Immunization activity example
















...







...






...




6.35 Immunization Medication Information
[manufacturedProduct: templateId
2.16.840.1.113883.10.20.22.4.54(open)]
Table 189: Immunization Medication Information Contexts
Used By:

Contains Entries:

Immunization Activity
Medication Dispense
Medication Supply Order

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The Immunization Medication Information represents product information about
the immunization substance. The vaccine manufacturer and vaccine lot number
are typically recorded in the medical record and should be included if known. 34
Table 190: Immunization Medication Information Constraints Overview
Name

XPath

Card.

Green
Immunization
Medication
Information

manufacturedProduct[templateId/@root = '2.16.840.1.113883.10.20.22.4.54']

SHALL

templateId

1..1

SHALL

1..1

SHALL

10499

0..*

MAY

9005

1..1

SHALL

9006

1..1

SHALL

9007

originalText

0..1

SHOULD

9008

reference

0..1

SHOULD

15555

@value

0..1

SHOULD

15556

translation

0..*

MAY

lotNumberText

0..1

SHOULD

9014

0..1

SHOULD

9012

manufactured
Material

lotNumber
drug
Manufacturer

CONF#

1..1

id

freeText
ProductName

Data
Type

@classCode

@root

codedProduct
Name

Verb

code

manufacturer
Organization

9002
SET<
II>

SET<
PQR
>

Fixed Value

2.16.840.1.113883.5.11
0 (RoleClass) = MANU

9004
2.16.840.1.113883.10.2
0.22.4.54

2.16.840.1.113883.3.88
.12.80.22 (Vaccine
Administered Value Set)

9011

1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem:
RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:9002).
2. SHALL contain exactly one [1..1] templateId (CONF:9004) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.54" (CONF:10499).
3. MAY contain zero or more [0..*] id (CONF:9005).
4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:9006).
a. This manufacturedMaterial SHALL contain exactly one [1..1] code,
which SHALL be selected from ValueSet Vaccine Administered

34

Vaccine Administration Guidelines.

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/vacc_admin.
pdf
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July 2012

Value Set 2.16.840.1.113883.3.88.12.80.22 DYNAMIC
(CONF:9007).
i.

This code SHOULD contain zero or one [0..1] originalText
(CONF:9008).
1. The originalText, if present, SHOULD contain zero or one
[0..1] reference (CONF:15555).
a. The reference, if present, SHOULD contain zero
or one [0..1] @value (CONF:15556).
i.

This reference/@value SHALL begin with
a '#' and SHALL point to its
corresponding narrative (using the
approach defined in CDA Release 2,
section 4.3.5.1) (CONF:15557).

Translations can be used to represent generic product name, packaged product
code, etc.
ii. This code MAY contain zero or more [0..*] translation
(CONF:9011).
b. This manufacturedMaterial SHOULD contain zero or one [0..1]
lotNumberText (CONF:9014).
5. SHOULD contain zero or one [0..1] manufacturerOrganization (CONF:9012).
Table 191: Vaccine Administered (Hepatitis B) Value Set (excerpt)

Value Set: Vaccine Administered Value Set 2.16.840.1. 113883.3.88.12.80.22 DYNAMIC
Code System(s):

Vaccines administered (CVX) 2.16.840.1.113883.12.292
http://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.12.292

Code

Code System

Print Name

82

CVX

adenovirus vaccine, NOS

54

CVX

adenovirus vaccine, type 4, live, oral

55

CVX

adenovirus vaccine, type 7, live, oral

24

CVX

anthrax vaccine

…

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Figure 188: Immunization medication information example





Tetanus and diphtheria toxoids - preservative
free





6.36 Immunization Refusal Reason
[observation: templateId 2.16.840.1.113883.10.20.22.4.53(open)]
Table 192: Immunization Refusal Reason Contexts
Used By:

Contains Entries:

Immunization Activity

The Immunization Refusal Reason Observation documents the rationale for the
patient declining an immunization.
Table 193: Immunization Refusal Reason Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.53']
@classCode

1..1

SHALL

8991

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

8992

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

1..1

SHALL

id

1..*

SHALL

II

8994

code

1..1

SHALL

CD

8995

2.16.840.1.113883.1.11.19717 (No
Immunization Reason Value Set)

statusCode

1..1

SHALL

CS

8996

2.16.840.1.113883.5.14 (ActStatus) =
completed

@root

SET

8993
10500

2.16.840.1.113883.10.20.22.4.53

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1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8991).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8992).
3. SHALL contain exactly one [1..1] templateId (CONF:8993) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.53" (CONF:10500).
4. SHALL contain at least one [1..*] id (CONF:8994).
5. SHALL contain exactly one [1..1] code, where the @code SHALL be selected
from ValueSet No Immunization Reason Value Set
2.16.840.1.113883.1.11.19717 DYNAMIC (CONF:8995).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:8996).
Table 194: No Immunization Reason Value Set
Value Set: No Immunization Reason Value Set 2.16.840.1.113883.1.11.19717 DYNAMIC
Code System(s): ActReason 2.16.840.1.113883.5.8
Code

Code System

Print Name

IMMUNE

ActReason

Immunity

MEDPREC

ActReason

Medical precaution

OSTOCK

ActReason

Out of stock

PATOBJ

ActReason

Patient objection

PHILISOP

ActReason

Philosophical objection

RELIG

ActReason

Religious objection

VACEFF

ActReason

Vaccine efficacy concerns

VACSAF

ActReason

Vaccine safety concerns

Figure 189: Immunization refusal reason








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6.37 Indication
[observation: templateId 2.16.840.1.113883.10.20.22.4.19 (open)]
Table 195: Indication Contexts
Used By:

Contains Entries:

Encounter Activities (optional)
Procedure Indications Section (optional)
Immunization Activity (optional)
Procedure Activity Act (optional)
Procedure Activity Observation (optional)
Procedure Activity Procedure (optional)
Medication Activity (optional)

The Indication Observation documents the rationale for an activity. It can do
this with the id element to reference a problem recorded elsewhere in the
document or with a code and value to record the problem type and problem
within the Indication. For example, the indication for a prescription of a
painkiller might be a headache that is documented in the Problems Section.
Table 196: Indication Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.19']
@classCode

1..1

SHALL

7480

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

7481

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

@root

SET

7482

1..1

SHALL

10502

id

1..1

SHALL

7483

2.16.840.1.113883.10.20.22.4.19

code

1..1

SHALL

16886

2.16.840.1.113883.3.88.12.3221.7.2
(Problem Type)

statusCode

1..1

SHALL

7487

2.16.840.1.113883.5.14 (ActStatus) =
completed

effectiveTime

0..1

SHOULD

TS or
IVL

7488

value

0..1

SHOULD

CD

7489

0..1

MAY

15990

0..1

SHOULD

15985

@nullFlavor
@code

2.16.840.1.113883.3.88.12.3221.7.4
(Problem)

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7480).

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2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7481).
3. SHALL contain exactly one [1..1] templateId (CONF:7482) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.19" (CONF:10502).
4. SHALL contain exactly one [1..1] id (CONF:7483).
a. Set the observation/id equal to an ID on the problem list to signify
that problem as an indication (CONF:16885).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from
ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC
2012-06-01 (CONF:16886).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7487).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:7488).
8. SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:7489).
a. The value, if present, MAY contain zero or one [0..1] @nullFlavor
(CONF:15990).
i.

If the diagnosis is unknown or the SNOMED code is
unknown, @nullFlavor SHOULD be “UNK”. If the code is
something other than SNOMED, @nullFlavor SHOULD be
“OTH” and the other code SHOULD be placed in the translation
element (CONF:15991).

b. The value, if present, SHOULD contain zero or one [0..1] @code
(ValueSet: Problem 2.16.840.1.113883.3.88.12.3221.7.4
DYNAMIC) (CONF:15985).
Figure 190: Indication entry example









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6.38 Instructions
[act: templateId 2.16.840.1.113883.10.20.22.4.20(open)]
Table 197: Instructions Contexts
Used By:

Contains Entries:

Medication Supply Order
Medication Activity
Procedure Activity Procedure
Procedure Activity Observation
Procedure Activity Act
Immunization Activity
Instructions Section
Plan of Care Section

The Instructions template can be used in several ways, such as to record patient
instructions within a Medication Activity or to record fill instructions within a
supply order. The act/code defines the type of instruction. Though not defined
in this template, a Vaccine Information Statement (VIS) document could be
referenced through act/reference/externalDocument, and patient awareness of
the instructions can be represented with the generic participant and the
participant/awarenessCode.
Table 198: Instructions Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.20']
@classCode

1..1

SHALL

7391

2.16.840.1.113883.5.6 (HL7ActClass)
= ACT

@moodCode

1..1

SHALL

7392

2.16.840.1.113883.5.1001 (ActMood)
= INT

templateId

1..1

SHALL

1..1

SHALL

code

1..1

SHALL

text

0..1

SHOULD

7395

reference

1..1

SHOULD

15577

@value

1..1

SHOULD

15578

1..1

SHALL

7396

@root

statusCode

SET
CE

7393
10503

2.16.840.1.113883.10.20.22.4.20

7394

2.16.840.1.113883.11.20.9.34
(Patient Education)

2.16.840.1.113883.5.14 (ActStatus) =
completed

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7391).
2. SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7392).
3. SHALL contain exactly one [1..1] templateId (CONF:7393) such that it
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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.20" (CONF:10503).
4. SHALL contain exactly one [1..1] code with @xsi:type="CE", where the @code
SHOULD be selected from ValueSet Patient Education
2.16.840.1.113883.11.20.9.34 DYNAMIC (CONF:7394).
5. SHOULD contain zero or one [0..1] text (CONF:7395).
a. The text, if present, SHOULD contain exactly one [1..1] reference
(CONF:15577).
i.

This reference SHOULD contain exactly one [1..1] @value
(CONF:15578).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15579).

6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7396).
Figure 191: Instructions entry example





Patient may have low grade fever, mild joint pain and injection
area tenderness .



Table 199: Patient Education Value Set

Value Set: Patient Education 2.16.840.1.113883.11.20.9.34 DYNAMIC
Code System(s):

SNOMED CT 2.16.840.1.113883.6.96

Description:

Limited to terms descending from the Education (409073007) hierarchy.
Code system browser: https://uts.nlm.nih.gov/snomedctBrowser.html

Code

Code System

Print Name

311401005

SNOMED CT

Patient Education

171044003

SNOMED CT

Immunization Education

243072006

SNOMED CT

Cancer Education

…

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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6.39 Medication Activity
[substanceAdministration: templateId
2.16.840.1.113883.10.20.22.4.16(open)]
Table 200: Medication Activity Contexts
Used By:

Contains Entries:

Reaction Observation
Medications Section (entries required)
Discharge Medication
Admission Medication
Medications Section (entries optional)
Procedure Activity Procedure
Anesthesia Section
Medications Administered Section
Procedure Activity Observation
Procedure Activity Act

Drug Vehicle
Indication
Instructions
Medication Dispense
Medication Information
Medication Supply Order
Precondition for Substance Administration
Reaction Observation

A medication activity describes substance administrations that have actually
occurred (e.g. pills ingested or injections given) or are intended to occur (e.g.
"take 2 tablets twice a day for the next 10 days"). Medication activities in "INT"
mood are reflections of what a clinician intends a patient to be taking.
Medication activities in "EVN" mood reflect actual use.
Medication timing is complex. This template requires that there be a
substanceAdministration/effectiveTime valued with a time interval, representing
the start and stop dates. Additional effectiveTime elements are optional, and can
be used to represent frequency and other aspects of more detailed dosing
regimens.
Table 201: Medication Activity Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF
#

Fixed Value

Green
Medication
Activity

substanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.22.4.16']

@classCode

1..1

SHALL

7496

2.16.840.1.113883.5.6
(HL7ActClass) = SBADM

@moodCode

1..1

SHALL

7497

2.16.840.1.113883.11.20.
9.18 (MoodCodeEvnInt)

templateId

1..1

SHALL

1..1

SHALL

10504

id

1..*

SHALL

7500

delivery
Method

code

0..1

MAY

7506

freeTextSig

text

0..1

SHOULD

7501

@root

SET<
II>

7499
2.16.840.1.113883.10.20.
22.4.16

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Name

XPath

Card.

Verb

Data
Type

CONF
#

reference

0..1

SHOULD

15977

@value

0..1

SHOULD

15978

statusCode

1..1

SHALL

7507

effectiveTime

1..1

SHALL

TS or
IVL<
TS>

7508

indicate
Medication
Started

low

1..1

SHALL

TS

7511

indicate
Medication
Stopped

high

1..1

SHALL

TS

7512

effectiveTime

0..1

SHOULD

TS or
IVL<
TS>

7513

administrationTiming

@operator

1..1

SHALL

repeatNumber

0..1

MAY

route

routeCode

0..1

MAY

site

approachSiteCode

0..1

MAY

dose

doseQuantity

0..1

SHOULD

0..1

SHOULD

0..1

MAY

1..1

SHALL

maxDoseQuantity

0..1

MAY

administrationUni
tCode

0..1

MAY

7519

1..1

SHALL

7520

1..1

SHALL

16085

0..1

MAY

7522

@unit

rateQuantity
@unit

dose
Restriction
product
Form
medication
Information

consumable

9106
IVL

Fixed Value

A

7555
7514

2.16.840.1.113883.3.88.1
2.3221.8.7 (Medication
Route FDA Value Set)

SET<
CD>

7515

2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site
Value Set)

IVL<
PQ>

7516
7526

IVL<
PQ>

7517
7525

RTO<
PQ,
PQ>

2.16.840.1.113883.1.11.1
2839 (UCUM Units of
Measure (case sensitive)) =
1

2.16.840.1.113883.1.11.1
2839 (UCUM Units of
Measure (case sensitive)) =
1

7518

2.16.840.1.113883.3.88.1
2.3221.8.11 (Medication
Product Form)

manufacturedPro
duct
performer

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Name

XPath

vehicle

Verb

0..*

MAY

7523

@typeCode

1..1

SHALL

7524

participantRole

1..1

SHALL

16086

entryRelationship

participant

indication

patient
Instructions

order
Information

fulfillment
Instructions

reaction

Card.

Data
Type

CONF
#

Fixed Value

2.16.840.1.113883.5.90
(HL7ParticipationType) =
CSM

0..*

MAY

7536

@typeCode

1..1

SHALL

7537

observation

1..1

SHALL

16087

0..1

MAY

7539

@typeCode

1..1

SHALL

7540

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= SUBJ

@inversionInd

1..1

SHALL

7542

true

act

1..1

SHALL

16088

0..1

MAY

7543

@typeCode

1..1

SHALL

7547

supply

1..1

SHALL

16089

0..*

MAY

7549

@typeCode

1..1

SHALL

7553

supply

1..1

SHALL

16090

0..1

MAY

7552

@typeCode

1..1

SHALL

7544

observation

1..1

SHALL

16091

precondition

0..*

MAY

7546

@typeCode

1..1

SHALL

7550

criterion

1..1

SHALL

16092

entryRelationship

entryRelationship

entryRelationship

entryRelationship

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= RSON

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= CAUS

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= PRCN

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7496).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 201104-03 (CONF:7497).
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3. SHALL contain exactly one [1..1] templateId (CONF:7499) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.16" (CONF:10504).
4. SHALL contain at least one [1..*] id (CONF:7500).
5. MAY contain zero or one [0..1] code (CONF:7506).
6. SHOULD contain zero or one [0..1] text (CONF:7501).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15977).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15978).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15979).

7. SHALL contain exactly one [1..1] statusCode (CONF:7507).
8. SHALL contain exactly one [1..1] effectiveTime (CONF:7508) such that it
a. SHALL contain exactly one [1..1] low (CONF:7511).
b. SHALL contain exactly one [1..1] high (CONF:7512).
9. SHOULD contain zero or one [0..1] effectiveTime (CONF:7513) such that it
a. SHALL contain exactly one [1..1] @operator="A" (CONF:9106).
b. SHALL contain exactly one [1..1] @xsi:type=”PIVL_TS” or “EIVL_TS”
(CONF:9105).
10. MAY contain zero or one [0..1] repeatNumber (CONF:7555).
a. In "INT" (intent) mood, the repeatNumber defines the number of
allowed administrations. For example, a repeatNumber of "3" means
that the substance can be administered up to 3 times. In "EVN"
(event) mood, the repeatNumber is the number of occurrences. For
example, a repeatNumber of "3" in a substance administration event
means that the current administration is the 3rd in a series
(CONF:16877).
11. MAY contain zero or one [0..1] routeCode, which SHALL be selected from
ValueSet Medication Route FDA Value Set
2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:7514).
12. MAY contain zero or one [0..1] approachSiteCode, where the @code SHALL be
selected from ValueSet Body Site Value Set
2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:7515).
13. SHOULD contain zero or one [0..1] doseQuantity (CONF:7516).
a. The doseQuantity, if present, SHOULD contain zero or one [0..1]
@unit="1", which SHALL be selected from ValueSet UCUM Units of
Measure (case sensitive) 2.16.840.1.113883.1.11.12839
DYNAMIC (CONF:7526).
b. Pre-coordinated consumable: If the consumable code is a
precoordinated unit dose (e.g. "metoprolol 25mg tablet") then
doseQuantity is a unitless number that indicates the number of
products given per administration (e.g. "2", meaning 2 x "metoprolol
25mg tablet") (CONF:16878).

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c. Not pre-coordinated consumable: If the consumable code is not precoordinated (e.g. is simply "metoprolol"), then doseQuantity must
represent a physical quantity with @unit, e.g. "25" and "mg",
specifying the amount of product given per administration
(CONF:16879).
14. MAY contain zero or one [0..1] rateQuantity (CONF:7517).
a. The rateQuantity, if present, SHALL contain exactly one [1..1]
@unit="1", which SHALL be selected from ValueSet UCUM Units of
Measure (case sensitive) 2.16.840.1.113883.1.11.12839
DYNAMIC (CONF:7525).
15. MAY contain zero or one [0..1] maxDoseQuantity (CONF:7518).
16. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be
selected from ValueSet Medication Product Form
2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC (CONF:7519).
17. SHALL contain exactly one [1..1] consumable (CONF:7520).
a. This consumable SHALL contain exactly one [1..1] Medication
Information (templateId:2.16.840.1.113883.10.20.22.4.23)
(CONF:16085).
18. MAY contain zero or one [0..1] performer (CONF:7522).
19. MAY contain zero or more [0..*] participant (CONF:7523) such that it
a. SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:7524).
b. SHALL contain exactly one [1..1] Drug Vehicle
(templateId:2.16.840.1.113883.10.20.22.4.24) (CONF:16086).
20. MAY contain zero or more [0..*] entryRelationship (CONF:7536) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7537).
b. SHALL contain exactly one [1..1] Indication
(templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:16087).
21. MAY contain zero or one [0..1] entryRelationship (CONF:7539) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7540).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:7542).
c. SHALL contain exactly one [1..1] Instructions
(templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:16088).
22. MAY contain zero or one [0..1] entryRelationship (CONF:7543) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7547).
b. SHALL contain exactly one [1..1] Medication Supply Order
(templateId:2.16.840.1.113883.10.20.22.4.17) (CONF:16089).

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23. MAY contain zero or more [0..*] entryRelationship (CONF:7549) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7553).
b. SHALL contain exactly one [1..1] Medication Dispense
(templateId:2.16.840.1.113883.10.20.22.4.18) (CONF:16090).
24. MAY contain zero or one [0..1] entryRelationship (CONF:7552) such that it
a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7544).
b. SHALL contain exactly one [1..1] Reaction Observation
(templateId:2.16.840.1.113883.10.20.22.4.9) (CONF:16091).
25. MAY contain zero or more [0..*] precondition (CONF:7546) such that it
a. SHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7550).
b. SHALL contain exactly one [1..1] Precondition for Substance
Administration
(templateId:2.16.840.1.113883.10.20.22.4.25) (CONF:16092).
26. Medication Activity SHOULD include doseQuantity OR rateQuantity
(CONF:7529).
Table 202: MoodCodeEvnInt Value Set
Value Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03
Code System(s): ActMood 2.16.840.1.113883.5.1001
Description:

Subset of HL7 ActMood codes, constrained to represent event (EVN) and
intent (INT) moods

Code

Code System

Print Name

EVN

ActMood

Event

INT

ActMood

Intent

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Table 203: Medication Route FDA Value Set (excerpt)
Value Set: Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC
Code System(s): National Cancer Institute (NCI) Thesaurus 2.16.840.1.113883.3.26.1.1
Description:

This indicates the method for the medication received by the individual (e.g.,
by mouth, intravenously, topically, etc.). NCI concept code for route of
administration: C38114
http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling
/ucm162034.htm

Code

Code System

Print Name

C38229

INTRACAUDAL

C38276

NCI Thesaurus
NCI Thesaurus

C38288

NCI Thesaurus

ORAL

C38295

NCI Thesaurus

RECTAL

INTRAVENOUS

…

Table 204: Body Site Value Set (excerpt)
Value Set: Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC
Code System(s): SNOMED CT 2.16.840.1.113883.6.96
Description:

Contains values descending from the SNOMED CT® Anatomical Structure
(91723000) hierarchy or Acquired body structure (body structure)
(280115004) or Anatomical site notations for tumor staging (body structure)
(258331007) or Body structure, altered from its original anatomical structure
(morphologic abnormality) (118956008) or Physical anatomical entity (body
structure) (91722005) This indicates the anatomical site.
http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html

Code

Code System

Print Name

361316009

SNOMED CT

entire embryonic artery

38033009

SNOMED CT

amputation stump

9550003

SNOMED CT

bronchogenic cyst

302509004

SNOMED CT

heart

…

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Table 205: Medication Product Form Value Set (excerpt)
Value Set: Medication Product Form 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC
Code System(s): National Cancer Institute (NCI) Thesaurus 2.16.840.1.113883.3.26.1.1
Description:

This is the physical form of the product as presented to the individual.
For example: tablet, capsule, liquid or ointment.
http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling
/ucm162038.htm

Code

Code System

Print Name

C42887

NCI Thesaurus

AEROSOL

C42909

NCI Thesaurus

GRANULE, EFFERVESCENT

C42998

NCI Thesaurus

TABLET

…

Table 206: Unit of Measure Value Set (excerpt)
Value Set: UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC
Code System(s): Unified Code for Units of Measure (UCUM) 2.16.840.1.113883.6.8
Description:

UCUM codes include all units of measures being contemporarily used in
international science, engineering, and business. The purpose is to facilitate
unambiguous electronic communication of quantities together with their
units. The focus is on electronic communication, as opposed to
communication between humans.
http://www.regenstrief.org/medinformatics/ucum

Code

Code System

Print Name

mmol/kg

UCUM

MilliMolesPerKiloGram

fL

UCUM

FemtoLiter

ug/mL

UCUM

MicroGramsPerMilliLiter

…

Figure 192: Medication activity example













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...





...





...






...






...




...





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...





...



6.40 Medication Dispense
[supply: templateId 2.16.840.1.113883.10.20.22.4.18(open)]
Table 207: Medication Dispense Contexts
Used By:

Contains Entries:

Medication Activity
Immunization Activity

Immunization Medication Information
Medication Information
Medication Supply Order

This template records the act of supplying medications (i.e., dispensing).

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Table 208: Medication Dispense Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF
#

Green
Medication
Dispense

supply[templateId/@root = '2.16.840.1.113883.10.20.22.4.18']

Fixed Value

@classCode

1..1

SHALL

7451

2.16.840.1.113883.5.6
(HL7ActClass) = SPLY

@moodCode

1..1

SHALL

7452

2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10505

id

1..*

SHALL

7454

statusCode

1..1

SHALL

7455

dispense
Date

effectiveTime

0..1

SHOULD

TS or
IVL

7456

fillNumber

repeatNumber

0..1

SHOULD

IVL

7457

quantity
Dispensed

quantity

0..1

SHOULD

7458

product

0..1

MAY

7459

1..1

SHALL

15607

0..1

MAY

9331

1..1

SHALL

15608

0..1

MAY

7461

1..1

SHALL

7467

0..1

SHOULD

0..1

MAY

7473

@typeCode

1..1

SHALL

7474

supply

1..1

SHALL

15606

@root
prescriptio
nNumber

manufactured
Product
product
manufactured
Product
performer
provider

assignedEntity
addr

order
Information

entryRelationship

SET

SET

7453
2.16.840.1.113883.10.20
.22.4.18

2.16.840.1.113883.3.88.
12.80.64 (Medication Fill
Status)

7468

2.16.840.1.113883.5.100
2
(HL7ActRelationshipType)
= REFR

1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7451).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7452).
3. SHALL contain exactly one [1..1] templateId (CONF:7453) such that it
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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.18" (CONF:10505).
4. SHALL contain at least one [1..*] id (CONF:7454).
5. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from
ValueSet Medication Fill Status 2.16.840.1.113883.3.88.12.80.64
DYNAMIC (CONF:7455).
6. SHOULD contain zero or one [0..1] effectiveTime (CONF:7456).
7. SHOULD contain zero or one [0..1] repeatNumber (CONF:7457).
a. In "EVN" (event) mood, the repeatNumber is the number of
occurrences. For example, a repeatNumber of "3" in a dispense act
means that the current dispensation is the 3rd (CONF:16876).
8. SHOULD contain zero or one [0..1] quantity (CONF:7458).
9. MAY contain zero or one [0..1] product (CONF:7459) such that it
a. SHALL contain exactly one [1..1] Medication Information
(templateId:2.16.840.1.113883.10.20.22.4.23) (CONF:15607).
10. MAY contain zero or one [0..1] product (CONF:9331) such that it
a. SHALL contain exactly one [1..1] Immunization Medication
Information (templateId:2.16.840.1.113883.10.20.22.4.54)
(CONF:15608).
11. MAY contain zero or one [0..1] performer (CONF:7461).
a. The performer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:7467).
i.

This assignedEntity SHOULD contain zero or one [0..1] addr
(CONF:7468).
1. 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:10565).

12. MAY contain zero or one [0..1] entryRelationship (CONF:7473) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:7474).
b. SHALL contain exactly one [1..1] Medication Supply Order
(templateId:2.16.840.1.113883.10.20.22.4.17) (CONF:15606).
13. A supply act SHALL contain one product/Medication Information or one
product/Immunization Medication Information template (CONF:9333).
Table 209: Medication Fill Status Value Set

Value Set: Medication Fill Status 2.16.840.1.113883.3.88.12.80.64 DYNAMIC
Code System: ActStatus 2.16.840.1.113883.5.14
Code

Code System

Print Name

aborted

ActStatus

Aborted

completed

ActStatus

Completed

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Figure 193: Medication dispense example












17 Daws Rd.
Blue Bell
MA
02368
US




Dr.
Robert
Michaels




Good Health Clinic







6.41 Medication Information
[manufacturedProduct: templateId
2.16.840.1.113883.10.20.22.4.23(open)]
Table 210: Medication Information Contexts
Used By:

Contains Entries:

Medication Supply Order
Medication Dispense
Medication Activity

The medication can be recorded as a precoordinated product strength, product
form, or product concentration (e.g., "metoprolol 25mg tablet", "amoxicillin
400mg/5mL suspension"); or not pre-coordinated (e.g., "metoprolol product").
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Table 211: Medication Information Constraints Overview
Name

XPath

Card.

Green
Medication
Information

manufacturedProduct[templateId/@root = '2.16.840.1.113883.10.20.22.4.23']

SHALL

templateId

1..1

SHALL

1..1

SHALL

10506

0..*

MAY

7410

1..1

SHALL

7411

1..1

SHALL

7412

originalText

0..1

SHOULD

7413

reference

0..1

SHOULD

15986

@value

0..1

SHOULD

15987

translation

0..*

MAY

Manufacturer
Organization

0..1

MAY

manufactured
Material

codedBrand
Name
drug
Manufacturer

CONF
#

1..1

id

freeText
ProductName

Data
Type

@classCode

@root

codedProduct
Name

Verb

code

7408
SET<
II>

SET<
PQR>

Fixed Value

2.16.840.1.113883.5.110
(RoleClass) = MANU

7409
2.16.840.1.113883.10.20.2
2.4.23

2.16.840.1.113883.3.88.12.
80.17 (Medication Clinical
Drug)

7414
7416

1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem:
RoleClass 2.16.840.1.113883.5.110) (CONF:7408).
2. SHALL contain exactly one [1..1] templateId (CONF:7409) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.23" (CONF:10506).
3. MAY contain zero or more [0..*] id (CONF:7410).
4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:7411).
a. This manufacturedMaterial SHALL contain exactly one [1..1] code,
which SHALL be selected from ValueSet Medication Clinical Drug
2.16.840.1.113883.3.88.12.80.17 DYNAMIC (CONF:7412).
i.

This code SHOULD contain zero or one [0..1] originalText
(CONF:7413).
1. The originalText, if present, SHOULD contain zero or one
[0..1] reference (CONF:15986).
a. The reference, if present, SHOULD contain zero
or one [0..1] @value (CONF:15987).
i.

This reference/@value SHALL begin with
a '#' and SHALL point to its
corresponding narrative (using the

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approach defined in CDA Release 2,
section 4.3.5.1) (CONF:15988).
ii. This code MAY contain zero or more [0..*] translation
(CONF:7414).
1. Translations can be used to represent generic product
name, packaged product code, etc (CONF:16875).
5. MAY contain zero or one [0..1] manufacturerOrganization (CONF:7416).
Figure 194: Medication information example




















...



...





...




6.43 Medication Use – None Known (deprecated)
[observation: templateId 2.16.840.1.113883.10.20.22.4.29(open)]
The recommended approach to stating no known medications is to use the
appropriate nullFlavor instead of this template. See "Unknown Information" in
Section 1.
This template indicates that the subject is not known to be on any medications.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:7557).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:7558).
3. SHALL contain exactly one [1..1] templateId (CONF:7559) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.29" (CONF:10508).
4. SHALL contain at least one [1..*] id (CONF:7560).
5. SHALL contain exactly one [1..1] code="ASSERTION" (CodeSystem: ActCode
2.16.840.1.113883.5.4) (CONF:7561).
6. MAY contain zero or one [0..1] text (CONF:7565).

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a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15580).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15581).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15582).

7. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7562).
8. SHOULD contain zero or one [0..1] effectiveTime (CONF:7563).
9. SHALL contain exactly one [1..1] value with @xsi:type="ANY"="182904002"
Drug treatment unknown (CodeSystem: SNOMEDCT
2.16.840.1.113883.6.96) (CONF:7564).
Figure 196: Medication use – none known example










6.44 Non-Medicinal Supply Activity
[supply: templateId 2.16.840.1.113883.10.20.22.4.50(open)]
Table 214: Non-Medicinal Supply Activity Contexts
Used By:

Contains Entries:

Medical Equipment Section
Functional Status Result Observation (optional)
Cognitive Status Problem Observation
Cognitive Status Result Observation
Functional Status Problem Observation
Functional Status Result Observation

Product Instance

This template records non-medicinal supplies provided, such as medical
equipment.

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Table 215: Non-Medicinal Supply Activity Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

supply[templateId/@root = '2.16.840.1.113883.10.20.22.4.50']
@classCode

1..1

SHALL

8745

2.16.840.1.113883.5.6
(HL7ActClass) = SPLY

@moodCode

1..1

SHALL

8746

2.16.840.1.113883.11.20.9.18
(MoodCodeEvnInt)

templateId

1..1

SHALL

1..1

SHALL

10509

id

1..*

SHALL

8748

statusCode

1..1

SHALL

8749

effectiveTime

0..1

SHOULD

quantity

0..1

SHOULD

8751

participant

0..1

MAY

8752

@typeCode

1..1

SHALL

8754

participantRole

1..1

SHALL

15900

@root

SET<
II>

IVL_T
S

8747
2.16.840.1.113883.10.20.22.4.50

15498

2.16.840.1.113883.5.90
(HL7ParticipationType) = PRD

1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8745).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 201104-03 (CONF:8746).
3. SHALL contain exactly one [1..1] templateId (CONF:8747) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.50" (CONF:10509).
4. SHALL contain at least one [1..*] id (CONF:8748).
5. SHALL contain exactly one [1..1] statusCode (CONF:8749).
6. SHOULD contain zero or one [0..1] effectiveTime (CONF:15498).
a. The effectiveTime, if present, SHOULD contain zero or one [0..1] high
(CONF:16867).
7. SHOULD contain zero or one [0..1] quantity (CONF:8751).
8. MAY contain zero or one [0..1] participant (CONF:8752) such that it
a. SHALL contain exactly one [1..1] @typeCode="PRD" Product
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8754).
b. SHALL contain exactly one [1..1] Product Instance
(templateId:2.16.840.1.113883.10.20.22.4.37) (CONF:15900).

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Figure 197: Non-medicinal supply activity example













...




6.45 Number of Pressure Ulcers Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.76 (open)]
Table 216: Number of Pressure Ulcers Observation Contexts
Used By:

Contains Entries:

Functional Status Section (optional)

This clinical statement enumerates the number of pressure ulcers observed in a
particular stage.
Table 217: Number of Pressure Ulcers Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.76']
@classCode

1..1

SHALL

14705

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

14706

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

14707

1..1

SHALL

14708

id

1..*

SHALL

14709

code

1..1

SHALL

14767

1..1

SHALL

14768

2264892003

statusCode

1..1

SHALL

14714

2.16.840.1.113883.5.14 (ActStatus) =
completed

effectiveTime

1..1

SHALL

14715

value

1..1

SHALL

@root

@code

INT

2.16.840.1.113883.10.20.22.4.76

14771

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Name

XPath

Card.

Verb

0..1

MAY

14717

1..1

SHALL

14718

@typeCode

1..1

SHALL

14719

observation

1..1

SHALL

14720

1..1

SHALL

14721

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

1..1

SHALL

14722

2.16.840.1.113883.5.1001 (ActMood) =
EVN

1..1

SHALL

14725

2.16.840.1.113883.11.20.9.35 (Pressure
Ulcer Stage)

author
entry
Relationship

Data
Type

CONF#

@classCode
@moodCode
value

CD

Fixed Value

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:14705).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14706).
3. SHALL contain exactly one [1..1] templateId (CONF:14707) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.76" (CONF:14708).
4. SHALL contain at least one [1..*] id (CONF:14709).
5. SHALL contain exactly one [1..1] code (CONF:14767).
a. This code SHALL contain exactly one [1..1] @code="2264892003"
number of pressure ulcers (CONF:14768).
6. SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem:
ActStatus 2.16.840.1.113883.5.14) (CONF:14714).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:14715).
8. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:14771).
9. MAY contain zero or one [0..1] author (CONF:14717).
10. SHALL contain exactly one [1..1] entryRelationship (CONF:14718).
a. This entryRelationship SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:14719).
b. This entryRelationship SHALL contain exactly one [1..1] observation
(CONF:14720).
i.

This observation SHALL contain exactly one [1..1]
@classCode="OBS" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6) (CONF:14721).

ii. This observation SHALL contain exactly one [1..1]
@moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14722).
iii. This observation SHALL contain exactly one [1..1] value with
@xsi:type="CD", where the @code SHOULD be selected from
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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ValueSet Pressure Ulcer Stage
2.16.840.1.113883.11.20.9.35 (CONF:14725).
Figure 198: Number of pressure ulcers example
















6.46 Plan of Care Activity Act
[act: templateId 2.16.840.1.113883.10.20.22.4.39(open)]
Table 218: Plan of Care Activity Act Contexts
Used By:

Contains Entries:

Assessment and Plan Section
Plan of Care Section

This is the generic template for the Plan of Care Activity.
Table 219: Plan of Care Activity Act Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.39']
@classCode

1..1

SHALL

8538

2.16.840.1.113883.5.6 (HL7ActClass) =
ACT

@moodCode

1..1

SHALL

8539

2.16.840.1.113883.11.20.9.23 (Plan of
Care moodCode
(Act/Encounter/Procedure))

templateId

1..1

SHALL

1..1

SHALL

1..*

SHALL

@root
id

SET

8544
10510

II

2.16.840.1.113883.10.20.22.4.39

8546

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1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8538).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet Plan of Care moodCode (Act/Encounter/Procedure)
2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:8539).
3. SHALL contain exactly one [1..1] templateId (CONF:8544) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.39" (CONF:10510).
4. SHALL contain at least one [1..*] id (CONF:8546).
Table 220: Plan of Care moodCode (Act/Encounter/Procedure)
Value Set: Plan of Care moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23
STATIC 2011-09-30
Code System(s):

HL7 ActMood 2.16.840.1.113883.5.1001

Code

Code System

Print Name

INT

HL7 ActMood

Intent

ARQ

HL7 ActMood

Appointment Request

PRMS

HL7 ActMood

Promise

PRP

HL7 ActMood

Proposal

RQO

HL7 ActMood

Request

Figure 199: Plan of care activity act example











6.47 Plan of Care Activity Encounter
[encounter: templateId 2.16.840.1.113883.10.20.22.4.40(open)]
Table 221: Plan of Care Activity Encounter Contexts
Used By:

Contains Entries:

Plan of Care Section

This is the template for the Plan of Care Activity Encounter.

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Table 222: Plan of Care Activity Encounter Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

encounter[templateId/@root = '2.16.840.1.113883.10.20.22.4.40']
@classCode

1..1

SHALL

8564

2.16.840.1.113883.5.6 (HL7ActClass) =
ENC

@moodCode

1..1

SHALL

8565

2.16.840.1.113883.11.20.9.23 (Plan of
Care moodCode
(Act/Encounter/Procedure))

templateId

1..1

SHALL

1..1

SHALL

1..*

SHALL

@root
id

SET

8566
10511

II

2.16.840.1.113883.10.20.22.4.40

8567

1. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8564).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet Plan of Care moodCode (Act/Encounter/Procedure)
2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:8565).
3. SHALL contain exactly one [1..1] templateId (CONF:8566) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.40" (CONF:10511).
4. SHALL contain at least one [1..*] id (CONF:8567).
Figure 200: Plan of care activity encounter example




6.48 Plan of Care Activity Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.44(open)]
Table 223: Plan of Care Activity Observation Contexts
Used By:

Contains Entries:

Plan of Care Section

This is the template for the Plan of Care Activity Observation.

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Table 224: Plan of Care Activity Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.44']
@classCode

1..1

SHALL

8581

2.16.840.1.113883.5.6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

8582

2.16.840.1.113883.11.20.9.25 (Plan of
Care moodCode (Observation))

templateId

1..1

SHALL

1..1

SHALL

1..*

SHALL

@root
id

SET

8583
10512

II

2.16.840.1.113883.10.20.22.4.44

8584

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8581).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet Plan of Care moodCode (Observation)
2.16.840.1.113883.11.20.9.25 STATIC 2011-09-30 (CONF:8582).
3. SHALL contain exactly one [1..1] templateId (CONF:8583) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.44" (CONF:10512).
4. SHALL contain at least one [1..*] id (CONF:8584).
Table 225: Plan of Care moodCode (Observation) Value Set
Value Set: Plan of Care moodCode (Observation) 2.16.840.1.113883.11.20.9.25 STATIC 201109-30
Code System(s):

HL7 ActMood 2.16.840.1.113883.5.1001

Code

Code System

Print Name

INT

ActMood

Intent

GOL

ActMood

Goal

PRMS

ActMood

Promise

PRP

ActMood

Proposal

RQO

ActMood

Request

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Figure 201: Plan of care activity observation example











6.49 Plan of Care Activity Procedure
[procedure: templateId 2.16.840.1.113883.10.20.22.4.41(open)]
Table 226: Plan of Care Activity Procedure Contexts
Used By:

Contains Entries:

Planned Procedure Section
Plan of Care Section

This is the template for the Plan of Care Activity Procedure.
Table 227: Plan of Care Activity Procedure Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

procedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.41']
@classCode

1..1

SHALL

8568

2.16.840.1.113883.5.6 (HL7ActClass) =
PROC

@moodCode

1..1

SHALL

8569

2.16.840.1.113883.11.20.9.23 (Plan of
Care moodCode
(Act/Encounter/Procedure))

templateId

1..1

SHALL

1..1

SHALL

1..*

SHALL

@root
id

SET

8570
10513

II

2.16.840.1.113883.10.20.22.4.41

8571

1. SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8568).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet Plan of Care moodCode (Act/Encounter/Procedure)
2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:8569).
3. SHALL contain exactly one [1..1] templateId (CONF:8570) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.41" (CONF:10513).
4. SHALL contain at least one [1..*] id (CONF:8571).
Page 416
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Figure 202: Plan of care activity procedure example











6.50 Plan of Care Activity Substance Administration
[substanceAdministration: templateId
2.16.840.1.113883.10.20.22.4.42(open)]
Table 228: Plan of Care Activity Substance Administration Contexts
Used By:

Contains Entries:

Plan of Care Section

This is the template for the Plan of Care Activity Substance Administration
Table 229: Plan of Care Activity Substance Administration Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

substanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.22.4.42']
@classCode

1..1

SHALL

8572

2.16.840.1.113883.5.6
(HL7ActClass) = SBADM

@moodCode

1..1

SHALL

8573

2.16.840.1.113883.11.20.9.24
(Plan of Care moodCode
(SubstanceAdministration/Supply))

templateId

1..1

SHALL

1..1

SHALL

1..*

SHALL

@root
id

SET

8574
10514

II

2.16.840.1.113883.10.20.22.4.42

8575

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8572).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet Plan of Care moodCode (SubstanceAdministration/Supply)
2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:8573).
3. SHALL contain exactly one [1..1] templateId (CONF:8574) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.42" (CONF:10514).
4. SHALL contain at least one [1..*] id (CONF:8575).
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Table 230: Plan of Care moodCode (SubstanceAdministration/Supply) Value Set
Value Set: Plan of Care moodCode (SubstanceAdministration/Supply)
2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30
Code System(s):

HL7 ActMood 2.16.840.1.113883.5.1001

Code

Code System

Print Name

INT

ActMood

Intent

PRMS

ActMood

Promise

PRP

ActMood

Proposal

RQO

ActMood

Request

Figure 203: Plan of care activity substance administration example











6.51 Plan of Care Activity Supply
[supply: templateId 2.16.840.1.113883.10.20.22.4.43(open)]
Table 231: Plan of Care Activity Supply Contexts
Used By:

Contains Entries:

Plan of Care Section

This is the template for the Plan of Care Activity Supply.

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Table 232: Plan of Care Activity Supply Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

supply[templateId/@root = '2.16.840.1.113883.10.20.22.4.43']
@classCode

1..1

SHALL

8577

2.16.840.1.113883.5.6 (HL7ActClass) =
SPLY

@moodCode

1..1

SHALL

8578

2.16.840.1.113883.11.20.9.24 (Plan of
Care moodCode
(SubstanceAdministration/Supply))

templateId

1..1

SHALL

1..1

SHALL

1..*

SHALL

@root
id

SET

8579
10515

II

2.16.840.1.113883.10.20.22.4.43

8580

1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8577).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet Plan of Care moodCode (SubstanceAdministration/Supply)
2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:8578).
3. SHALL contain exactly one [1..1] templateId (CONF:8579) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.43" (CONF:10515).
4. SHALL contain at least one [1..*] id (CONF:8580).
Figure 204: Plan of care activity supply example







6.52 Policy Activity
[act: templateId 2.16.840.1.113883.10.20.22.4.61 (closed)]
Table 233: Policy Activity Contexts
Used By:

Contains Entries:

Coverage Activity (required)

A policy activity represents the policy or program providing the coverage. The
person for whom payment is being provided (i.e., the patient) is the covered
party. The subscriber of the policy or program is represented as a participant
that is the holder the coverage. The payer is represented as the performer of the
policy activity.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Table 234: Policy Activity Constraints Overview
Name

XPath

Card.

Green Policy
Activity

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.61']

health
InsuranceType

Data
Type

CONF#

Fixed Value

@classCode

1..1

SHALL

8898

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

8899

2.16.840.1.113883.5.1
001 (ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10516

id

1..*

SHALL

8901

code

0..1

SHOULD

@code

0..1

SHOULD

15993

2.16.840.1.113883.3.8
8.12.3221.5.2 (Health
Insurance Type Value
Set)

code

0..1

SHOULD

8904

2.16.840.1.113883.3.8
8.12.3221.5.2 (Health
Insurance Type Value
Set)

statusCode

1..1

SHALL

8902

2.16.840.1.113883.5.1
4 (ActStatus) =
completed

performer

1..1

SHALL

8906

@typeCode

1..1

SHALL

8907

templateId

1..1

SHALL

16808

1..1

SHALL

16809

1..1

SHALL

8908

id

1..*

SHALL

8909

code

0..1

SHOULD

8914

0..1

SHALL

15992

0..1

MAY

@root
resultId

Verb

@root
payer

SET<
II>

CE

8900
2.16.840.1.113883.10.
20.22.4.61

8903

2.16.840.1.113883.5.9
0
(HL7ParticipationType)
= PRF
2.16.840.1.113883.10.
20.22.4.87

assignedEntity
healthPlan
Insurance
Information
SourceId

@code

healthPlan
Insurance
Information
SourceAddress

addr

SET<
AD>

2.16.840.1.113883.1.1
1.10416
(HL7FinanciallyRespo
nsiblePartyType)

8910

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Name
healthPlan
Insurance
Information
SourcePhone
EmailURL

XPath
telecom

Card.

Verb

Data
Type

CONF#

0..1

MAY

SET<
TEL>

8911

0..1

SHOULD

0..1

SHOULD

0..1

SHOULD

8961

1..1

SHALL

16810

1..1

SHALL

16811

0..1

SHOULD

1..1

SHALL

8962

1..1

SHALL

8968

1..1

SHALL

16096

Fixed Value

8912

representedOr
ganization
healthPlan
Insurance
Information
SourceName
guarantorInfor
mation

name

performer

templateId
@root
effectiveDateOf
Financial
Responsibility

time

PN

IVL<
TS>

8913

2.16.840.1.113883.5.9
0
(HL7ParticipationType)
= PRF
2.16.840.1.113883.10.
20.22.4.88

8963

assignedEntity
code
@code
financial
Responsibility
PartyAddress

addr

0..1

SHOULD

SET<
AD>

8964

financial
Responsibility
PartyPhone
EmailURL

telecom

0..1

SHOULD

SET<
TEL>

8965

participant

1..1

SHALL

8916

@typeCode

1..1

SHALL

8917

templateId

1..1

SHALL

16812

1..1

SHALL

16814

0..1

SHOULD

IVL<
TS>

8918

low

0..1

SHOULD

TS

8919

high

0..1

SHOULD

TS

8920

1..1

SHALL

member
Information

@root
healthPlan
CoverageDates

time

patient

2.16.840.1.113883.5.1
11 (RoleCode) = GUAR

2.16.840.1.113883.5.9
0
(HL7ParticipationType)
= COV
2.16.840.1.113883.10.
20.22.4.89

8921

participantRole
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Name

XPath

memberId

patient
RelationshipTo
Subscriber
patientAddress

Card.

Verb

id

1..*

SHALL

8922

code

1..1

SHALL

8923

@code

0..1

SHOULD

16078

2.16.840.1.113883.1.1
1.18877 (Coverage
Role Type Value Set)

code

1..1

SHALL

CE

8924

2.16.840.1.113883.1.1
1.18877 (Coverage
Role Type Value Set)

0..1

SHOULD

SET<
AD>

8956

0..1

SHOULD

8932

name

1..1

SHALL

8930

participant

0..1

SHOULD

8934

@typeCode

1..1

SHALL

8935

templateId

1..1

SHALL

16813

1..1

SHALL

16815

0..1

MAY

1..1

SHALL

8936
8937

addr

Data
Type

CONF#

Fixed Value

playingEntity
patientName

@root
time
subscriber
Information

IVL<
TS>

2.16.840.1.113883.10.
20.22.4.90

8938

participantRole

subscriberId

id

1..*

SHALL

subscriber
Address

addr

0..1

SHOULD

1..*

SHALL

8939

1..1

SHALL

8940

healthPlan

2.16.840.1.113883.5.9
0
(HL7ParticipationType)
= HLD

entryRelations
hip
@typeCode

SET<
AD>

8925

2.16.840.1.113883.5.1
002
(HL7ActRelationshipTy
pe) = REFR

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:8898).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8899).
3. SHALL contain exactly one [1..1] templateId (CONF:8900) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.61" (CONF:10516).
This id is a unique identifier for the policy or program providing the coverage
4. SHALL contain at least one [1..*] id (CONF:8901).
5. SHOULD contain zero or one [0..1] code with @xsi:type="CE" (CONF:8903).
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a. The code, if present, SHOULD contain zero or one [0..1] @code
(ValueSet: Health Insurance Type Value Set
2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC) (CONF:15993).
b. The code, if present, SHOULD contain zero or one [0..1] code, which
SHOULD be selected from ValueSet Health Insurance Type Value
Set 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC (CONF:8904).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:8902).
This performer represents the Payer.
7. SHALL contain exactly one [1..1] performer (CONF:8906) such that it
a. SHALL contain exactly one [1..1] @typeCode="PRF" Performer
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8907).
b. SHALL contain exactly one [1..1] templateId (CONF:16808) such that
it
i.

contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.87" Payer
Performer (CONF:16809).
SHALL

c. SHALL contain exactly one [1..1] assignedEntity (CONF:8908).
i.

This assignedEntity SHALL contain at least one [1..*] id
(CONF:8909).

ii. This assignedEntity SHOULD contain zero or one [0..1] code
(CONF:8914).
1. The code, if present, SHALL contain zero or one [0..1]
@code (ValueSet:
HL7FinanciallyResponsiblePartyType
2.16.840.1.113883.1.11.10416 DYNAMIC)
(CONF:15992).
iii. This assignedEntity MAY contain zero or one [0..1] addr
(CONF:8910).
1. 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:10481).
iv. This assignedEntity MAY contain zero or one [0..1] telecom
(CONF:8911).
v. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:8912).
1. The representedOrganization, if present, SHOULD
contain zero or one [0..1] name (CONF:8913).
This performer represents the Guarantor.
8. SHOULD contain zero or one [0..1] performer="PRF" Performer (CodeSystem:
HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:8961) such that
it
a. SHALL contain exactly one [1..1] templateId (CONF:16810) such that
it

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i.

contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.88" Guarantor
Performer (CONF:16811).
SHALL

b. SHOULD contain zero or one [0..1] time (CONF:8963).
c. SHALL contain exactly one [1..1] assignedEntity (CONF:8962).
i.

This assignedEntity SHALL contain exactly one [1..1] code
(CONF:8968).
1. This code SHALL contain exactly one [1..1]
@code="GUAR" Guarantor (CodeSystem: RoleCode
2.16.840.1.113883.5.111) (CONF:16096).

ii. This assignedEntity SHOULD contain zero or one [0..1] addr
(CONF:8964).
1. 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:10482).
iii. This assignedEntity SHOULD contain zero or one [0..1] telecom
(CONF:8965).
iv. SHOULD include assignedEntity/assignedPerson/name
AND/OR assignedEntity/representedOrganization/name
(CONF:8967).
9. SHALL contain exactly one [1..1] participant (CONF:8916) such that it
a. SHALL contain exactly one [1..1] @typeCode="COV" Coverage target
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8917).
b. SHALL contain exactly one [1..1] templateId (CONF:16812) such that
it
i.

contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.89" Covered Party
Participant (CONF:16814).
SHALL

c. SHOULD contain zero or one [0..1] time (CONF:8918).
i.

The time, if present, SHOULD contain zero or one [0..1] low
(CONF:8919).

ii. The time, if present, SHOULD contain zero or one [0..1] high
(CONF:8920).
d. SHALL contain exactly one [1..1] participantRole (CONF:8921).
i.

This participantRole SHALL contain at least one [1..*] id
(CONF:8922).
1. This id is a unique identifier for the covered party
member. Implementers SHOULD use the same GUID for
each instance of a member identifier from the same
health plan (CONF:8984).

ii. This participantRole SHALL contain exactly one [1..1] code
(CONF:8923).
1. This code SHOULD contain zero or one [0..1] @code
(ValueSet: Coverage Role Type Value Set

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2.16.840.1.113883.1.11.18877 DYNAMIC)
(CONF:16078).
2. This code SHALL contain exactly one [1..1] code with
@xsi:type="CE", where the @code SHOULD be selected
from ValueSet Coverage Role Type Value Set
2.16.840.1.113883.1.11.18877 DYNAMIC
(CONF:8924).
iii. This participantRole SHOULD contain zero or one [0..1] addr
(CONF:8956).
1. 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:10484).
iv. This participantRole SHOULD contain zero or one [0..1]
playingEntity (CONF:8932).
1. The playingEntity, if present, SHALL contain exactly
one [1..1] name (CONF:8930).
a. If the member name as recorded by the health
plan differs from the patient name as recorded
in the registration/medication summary (e.g.,
due to marriage or for other reasons), then the
member name SHALL be recorded in the name
element (CONF:8931).
2. If the member date of birth as recorded by the health
plan differs from the patient date of birth as recorded
in the registration/medication summary, then the
member date of birth SHALL be recorded in
sdwg:birthTime. 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 birthTime element (CONF:8933).
When the Subscriber is the patient, the participant element describing the
subscriber SHALL NOT be present. This information will be recorded instead in
the data elements used to record member information.
10. SHOULD contain zero or one [0..1] participant (CONF:8934) such that it
a. SHALL contain exactly one [1..1] @typeCode="HLD" Holder
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90)
(CONF:8935).
b. SHALL contain exactly one [1..1] templateId (CONF:16813) such that
it
i.

contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.90" Policy Holder
Participant (CONF:16815).
SHALL

c. MAY contain zero or one [0..1] time (CONF:8938).
d. SHALL contain exactly one [1..1] participantRole (CONF:8936).
i.

This participantRole SHALL contain at least one [1..*] id
(CONF:8937).

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1. This id is a unique identifier for the subscriber of the
coverage (CONF:10120).
ii. This participantRole SHOULD contain zero or one [0..1] addr
(CONF:8925).
1. 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:10483).
11. SHALL contain at least one [1..*] entryRelationship (CONF:8939) such that
it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:8940).
b. The target of a policy activity with
act/entryRelationship/@typeCode="REFR" SHALL be an authorization
activity (templateId 2.16.840.1.113883.10.20.1.19) OR an act, with
act[@classCode="ACT"] and act[@moodCode="DEF"], representing a
description of the coverage plan (CONF:8942).
c. A description of the coverage plan SHALL contain one or more act/id,
to represent the plan identifier, and an act/text with the name of the
plan (CONF:8943).
Table 235: Health Insurance Type Value Set (excerpt)
Value Set: Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC
Code System(s):
Code

ASC X12 2.16.840.1.113883.6.255.1336
The full value set is available in HITSP C80 (see HITSP.org).
Code System

Print Name

12

ASC X12

Medicare Secondary Working Aged Beneficiary or
Spouse with Employer Group Health Plan

13

ASC X12

Medicare Secondary End-Stage Renal Disease
Beneficiary in the 12 month coordination period with
an employer’s group health plan

14

ASC X12

Medicare Secondary, No-fault Insurance including Auto
is Primary

…

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Table 236: Coverage Type Value Set
Value Set: Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877 DYNAMIC
Code System(s):
Code

RoleCode 2.16.840.1.113883.5.111
Code System

Print Name

FAMDEP

RoleCode

Family dependent

FSTUD

RoleCode

Full-time student

HANDIC

RoleCode

Handicapped dependent

INJ

RoleCode

Injured plaintiff

PSTUD

RoleCode

Part-time student

SELF

RoleCode

Self

SPON

RoleCode

Sponsored dependent

STUD

RoleCode

Student

Table 237: Financially Responsible Party Value Set (excerpt)
Value Set: FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416 DYNAMIC
Code System(s):
Code

RoleCode 2.16.840.1.113883.5.110
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008
Code System

Print Name

EMP

RoleCode

employee

GUAR

RoleCode

guarantor

INVSBJ

RoleCode

Investigation Subject

COVPTY

RoleCode

Covered party

…

Figure 205: Policy activity example








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123 Insurance Road
Blue Bell
MA
02368
US




Good Health Insurance








17 Daws Rd.
Blue Bell
MA
02368
US




Mr.
Frank
A.
Everyman








17 Daws Rd.
Blue Bell
MA
02368
US







...


...



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6.53 Postprocedure Diagnosis
[act: templateId 2.16.840.1.113883.10.20.22.4.51 (open)]

Table 238: Postprocedure Diagnosis Contexts
Used By:

Contains Entries:

Postprocedure Diagnosis Section (optional)

Problem Observation

The Postprocedure Diagnosis entry encodes the diagnosis or diagnoses
discovered or confirmed during the procedure. Often it is the same as the preprocedure diagnosis or indication.
Table 239: Postprocedure Diagnosis Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.51']
@classCode

1..1

SHALL

8756

ACT

@moodCode

1..1

SHALL

8757

EVN

templateId

1..1

SHALL

16766

1..1

SHALL

16767

2.16.840.1.113883.10.20.22.4.51

code

1..1

SHALL

8758

2.16.840.1.113883.6.1 (LOINC) =
59769-0

entryRelationship

1..*

SHALL

8759

@typeCode

1..1

SHALL

8760

observation

1..1

SHALL

15583

@root

CE

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

1. SHALL contain exactly one [1..1] @classCode="ACT" (CONF:8756).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:8757).
3. SHALL contain exactly one [1..1] templateId (CONF:16766) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.51" (CONF:16767).
4. SHALL contain exactly one [1..1] code="59769-0" Postprocedure Diagnosis
with @xsi:type="CE" (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:8758).
5. SHALL contain at least one [1..*] entryRelationship (CONF:8759).
a. Such entryRelationships SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:8760).
b. Such entryRelationships SHALL contain exactly one [1..1] Problem
Observation (templateId:2.16.840.1.113883.10.20.22.4.4)
(CONF:15583).

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Figure 206: Postprocedure diagnosis example








...




6.54 Precondition for Substance Administration
[precondition: templateId 2.16.840.1.113883.10.20.22.4.25(open)]
Table 240: Precondition for Substance Administration Contexts
Used By:

Contains Entries:

Medication Activity
Immunization Activity

A criterion for administration can be used to record that the medication is to be
administered only when the associated criteria are met.
Table 241: Precondition for Substance Administration Constraints Overview
Name

XPath

Card.

Verb

Data Type

CONF#

Fixed Value

criterion[templateId/@root = '2.16.840.1.113883.10.20.22.4.25']
templateId

1..1

SHALL

1..1

SHALL

10517

code

0..1

SHOULD

16854

text

0..1

MAY

7373

value

0..1

SHOULD

@root

SET

CD

7372
2.16.840.1.113883.10.20.22.4.25

7369

1. SHALL contain exactly one [1..1] templateId (CONF:7372) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.25" (CONF:10517).
2. SHOULD contain zero or one [0..1] code (CONF:16854).
3. MAY contain zero or one [0..1] text (CONF:7373).
4. SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:7369).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Figure 207: Precondition for substance administration example




...




6.55 Pregnancy Observation
[observation: templateId 2.16.840.1.113883.10.20.15.3.8 (open)]
Table 242: Pregnancy Observation Contexts
Used By:

Contains Entries:

Social History Section (optional)

Estimated Date of Delivery

This clinical statement represents current and/or prior pregnancy dates
enabling investigators to determine if the subject of the case report was
pregnant during the course of a condition.
Table 243: Pregnancy Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF
#

Fixed Value

Green
Pregnancy
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.15.3.8']

@classCode

1..1

SHALL

451

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

452

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

16768

1..1

SHALL

16868

2.16.840.1.113883.10.20.15.3.
8

code

1..1

SHALL

454

2.16.840.1.113883.5.4
(ActCode) = ASSERTION

statusCode

1..1

SHALL

455

2.16.840.1.113883.5.14
(ActStatus) = completed

effectiveTime

0..1

SHOULD

@root

CE

TS or
IVL<
TS>

2018

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Name
pregnancy

XPath

Card.

Verb

Data
Type

CONF
#

Fixed Value

value

1..1

SHALL

CD

457

2.16.840.1.113883.6.96
(SNOMED-CT) = 77386006

entryRelationship

0..1

MAY

458

@typeCode

1..1

SHALL

459

observation

1..1

SHALL

15584

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
REFR

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:451).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:452).
3. SHALL contain exactly one [1..1] templateId (CONF:16768) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.15.3.8" (CONF:16868).
4. SHALL contain exactly one [1..1] code="ASSERTION" Assertion with
@xsi:type="CE" (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC)
(CONF:454).
5. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:455).
6. SHOULD contain zero or one [0..1] effectiveTime (CONF:2018).
7. SHALL contain exactly one [1..1] value="77386006" Pregnant with
@xsi:type="CD" (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96 STATIC)
(CONF:457).
8. MAY contain zero or one [0..1] entryRelationship (CONF:458) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:459).
b. SHALL contain exactly one [1..1] Estimated Date of Delivery
(templateId:2.16.840.1.113883.10.20.15.3.1) (CONF:15584).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Figure 208: Pregnancy observation example













...



6.56 Preoperative Diagnosis
[act: templateId 2.16.840.1.113883.10.20.22.4.65 (open)]
Table 244: Preoperative Diagnosis Contexts
Used By:

Contains Entries:

Preoperative Diagnosis Section (optional)

Problem Observation

The Preoperative Diagnosis entry encodes the surgical diagnosis or diagnoses
assigned to the patient before the surgical procedure and is the reason for the
surgery. The preoperative diagnosis is, in the opinion of the surgeon, the
diagnosis that will be confirmed during surgery.

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Table 245: Preoperative Diagnosis Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.65']
@classCode

1..1

SHALL

10090

ACT

@moodCode

1..1

SHALL

10091

EVN

templateId

1..1

SHALL

16770

1..1

SHALL

16771

2.16.840.1.113883.10.20.22.4.65

code

1..1

SHALL

10092

2.16.840.1.113883.6.1 (LOINC) =
10219-4

entryRelationship

1..*

SHALL

10093

@typeCode

1..1

SHALL

10094

observation

1..1

SHALL

15605

@root

CE

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SUBJ

1. SHALL contain exactly one [1..1] @classCode="ACT" (CONF:10090).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:10091).
3. SHALL contain exactly one [1..1] templateId (CONF:16770) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.65" (CONF:16771).
4. SHALL contain exactly one [1..1] code="10219-4" Preoperative Diagnosis
with @xsi:type="CE" (CodeSystem: LOINC 2.16.840.1.113883.6.1)
(CONF:10092).
5. SHALL contain at least one [1..*] entryRelationship (CONF:10093).
a. Such entryRelationships SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:10094).
b. Such entryRelationships SHALL contain exactly one [1..1] Problem
Observation (templateId:2.16.840.1.113883.10.20.22.4.4)
(CONF:15605).

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Figure 209: Preoperative diagnosis example








...




6.57 Pressure Ulcer Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.70 (open)]
Table 246: Pressure Ulcer Observation Contexts
Used By:

Contains Entries:

Functional Status Section (optional)

The pressure ulcer observation contains details about the pressure ulcer such
as the stage of the ulcer, location, and dimensions. If the pressure ulcer is a
diagnosis, you may find this on the problem list. An example of how this would
appear is in the Problem Section.
Table 247: Pressure Ulcer Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.70']
@classCode

1..1

SHALL

14383

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

14384

2.16.840.1.113883.5.1001 (ActMood)
= EVN

@negationInd

0..1

MAY

14385

templateId

1..1

SHALL

14387

1..1

SHALL

14388

id

1..*

SHALL

14389

code

1..1

SHALL

14759

1..1

SHOULD

14760

0..1

SHOULD

14391

0..1

SHOULD

14392

@root

@code
text
reference

2.16.840.1.113883.10.20.22.4.70

2.16.840.1.113883.5.4 (ActCode) =
ASSERTION

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Name

XPath

Card.

Verb

1..1

SHALL

15585

statusCode

1..1

SHALL

14394

effectiveTime

1..1

SHALL

14395

value

1..1

SHALL

@nullFlavor

0..1

MAY

14397

targetSiteCode

1..*

SHOULD

14797

@code

1..1

SHALL

14798

qualifier

1..1

MAY

14799

name

1..1

SHALL

14800

1..1

MAY

14801

1..1

SHALL

14802

@code

1..1

SHOULD

14803

entry
Relationship

0..1

SHOULD

14410

@typeCode

1..1

SHALL

14411

observation

1..1

SHALL

14619

1..1

SHALL

14685

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

1..1

SHALL

14686

2.16.840.1.113883.5.1001 (ActMood)
= EVN

1..1

SHALL

14620

1..1

SHALL

14621

1..1

SHALL

0..1

SHOULD

14601

@typeCode

1..1

SHALL

14602

observation

1..1

SHALL

14623

1..1

SHALL

14687

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

1..1

SHALL

14688

2.16.840.1.113883.5.1001 (ActMood)
= EVN

1..1

SHALL

14624

1..1

SHALL

14625

1..1

SHALL

0..1

SHOULD

@value

@code
value

Data
Type

CD

CONF#

14396

@classCode
@moodCode
code
@code
value
entry
Relationship

PQ

@moodCode
@code
value
entry
Relationship

PQ

2.16.840.1.113883.5.14 (ActStatus) =
completed
2.16.840.1.113883.11.20.9.35
(Pressure Ulcer Stage)

2.16.840.1.113883.11.20.9.36
(Pressure Point )

2.16.840.1.113883.6.96 (SNOMEDCT) = 272741003
2.16.840.1.113883.11.20.9.37
(TargetSite Qualifiers )

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = COMP

2.16.840.1.113883.6.96 (SNOMEDCT) = 401238003

14622

@classCode

code

Fixed Value

COMP

2.16.840.1.113883.6.96 (SNOMEDCT) = 401239006

14626
14605

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Name

XPath

Card.

Verb

@typeCode

1..1

observation

Data
Type

CONF#

Fixed Value

SHALL

14606

COMP

1..1

SHALL

14627

1..1

SHALL

14689

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

1..1

SHALL

14690

2.16.840.1.113883.5.1001 (ActMood)
= EVN

1..1

SHALL

14628

1..1

SHALL

14629

1..1

SHALL

@classCode
@moodCode
code
@code
value

PQ

2.16.840.1.113883.6.96 (SNOMEDCT) = 425094009

14630

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:14383).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14384).
3. MAY contain zero or one [0..1] @negationInd (CONF:14385).
a. NegationInd="true" SHALL be used to represent that the problem was
not observed (CONF:14386).
4. SHALL contain exactly one [1..1] templateId (CONF:14387) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.70" (CONF:14388).
5. SHALL contain at least one [1..*] id (CONF:14389).
6. SHALL contain exactly one [1..1] code (CONF:14759).
a. This code SHOULD contain exactly one [1..1] @code="ASSERTION"
Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4)
(CONF:14760).
7. SHOULD contain zero or one [0..1] text (CONF:14391).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:14392).
i.

The reference, if present, SHALL contain exactly one [1..1]
@value (CONF:15585).
1. This reference/@value SHALL begin with a '#' and
SHALL point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15586).

8. SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem:
ActStatus 2.16.840.1.113883.5.14) (CONF:14394).
9. SHALL contain exactly one [1..1] effectiveTime (CONF:14395).
10. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHOULD be selected from ValueSet Pressure Ulcer Stage
2.16.840.1.113883.11.20.9.35 (CONF:14396).
a. This value MAY contain zero or one [0..1] @nullFlavor
(CONF:14397).

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i.

If the stage unknown or the SNOMED code is unknown,
@nullFlavor SHOULD be “UNK”. If the code is something other
than SNOMED, @nullFlavor SHOULD be “OTH” and the other
code SHOULD be placed in the translation element
(CONF:14398).

11. SHOULD contain at least one [1..*] targetSiteCode (CONF:14797).
a. Such targetSiteCodes SHALL contain exactly one [1..1] @code, which
SHOULD be selected from ValueSet Pressure Point
2.16.840.1.113883.11.20.9.36 (CONF:14798).
b. Such targetSiteCodes MAY contain exactly one [1..1] qualifier
(CONF:14799).
i.

This qualifier SHALL contain exactly one [1..1] name
(CONF:14800).
1. This name MAY contain exactly one [1..1]
@code="272741003" laterality (CodeSystem: SNOMEDCT 2.16.840.1.113883.6.96) (CONF:14801).

ii. This qualifier SHALL contain exactly one [1..1] value
(CONF:14802).
1. This value SHOULD contain exactly one [1..1] @code,
which SHOULD be selected from ValueSet TargetSite
Qualifiers 2.16.840.1.113883.11.20.9.37
(CONF:14803).
12. SHOULD contain zero or one [0..1] entryRelationship (CONF:14410) such
that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002)
(CONF:14411).
b. SHALL contain exactly one [1..1] observation (CONF:14619).
i.

This observation SHALL contain exactly one [1..1]
@classCode="OBS" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6) (CONF:14685).

ii. This observation SHALL contain exactly one [1..1]
@moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14686).
iii. This observation SHALL contain exactly one [1..1] code
(CONF:14620).
1. This code SHALL contain exactly one [1..1]
@code="401238003" Length of Wound (CodeSystem:
SNOMED-CT 2.16.840.1.113883.6.96)
(CONF:14621).
iv. This observation SHALL contain exactly one [1..1] value with
@xsi:type="PQ" (CONF:14622).
13. SHOULD contain zero or one [0..1] entryRelationship (CONF:14601) such
that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:14602).
b. SHALL contain exactly one [1..1] observation (CONF:14623).

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i.

This observation SHALL contain exactly one [1..1]
@classCode="OBS" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6) (CONF:14687).

ii. This observation SHALL contain exactly one [1..1]
@moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14688).
iii. This observation SHALL contain exactly one [1..1] code
(CONF:14624).
1. This code SHALL contain exactly one [1..1]
@code="401239006" Width of Wound (CodeSystem:
SNOMED-CT 2.16.840.1.113883.6.96)
(CONF:14625).
iv. This observation SHALL contain exactly one [1..1] value with
@xsi:type="PQ" (CONF:14626).
14. SHOULD contain zero or one [0..1] entryRelationship (CONF:14605) such
that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:14606).
b. SHALL contain exactly one [1..1] observation (CONF:14627).
i.

This observation SHALL contain exactly one [1..1]
@classCode="OBS" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6) (CONF:14689).

ii. This observation SHALL contain exactly one [1..1]
@moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:14690).
iii. This observation SHALL contain exactly one [1..1] code
(CONF:14628).
1. This code SHALL contain exactly one [1..1]
@code="425094009" Depth of Wound (CodeSystem:
SNOMED-CT 2.16.840.1.113883.6.96)
(CONF:14629).
iv. This observation SHALL contain exactly one [1..1] value with
@xsi:type="PQ" (CONF:14630).
Table 248 Pressure Ulcer Stage Value Set
Value Set: Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 DYNAMIC
Code System: SNOMED CT 2.16.840.1.113883.6.96
Descriptions: This value set enumerates the type of a pressure ulcer.
Code

Code System

Print Name

421076008

SNOMED CT

Pressure Ulcer Stage 1

420324007

SNOMED CT

Pressure Ulcer Stage 2

421927004

SNOMED CT

Pressure Ulcer Stage 3

420597008

SNOMED CT

Pressure Ulcer Stage 4

421594008

SNOMED CT

Nonstageable pressure ulcer

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The Pressure Point Value Set contains a list of body structures from the
Pressure Ulcer Prevention Domain Analysis Model (DAM), Informative Ballot
published May 2011 35by HL7 combined with a list of structures suggested in
the DAM currently available on HL7. 36 HL7 is consulting with the National Skin
Assessment team to reconcile the DAM. The vocabulary is in review by the
International Health Terminology Standards Development Organisation
(IHTSDO) Nursing Sig for international standardization.
Table 249: Pressure Point Value Set
Value Set: Pressure Point 2.16.840.1.113883.11.20.9.36 DYNAMIC
Code System: SNOMED CT 2.16.840.1.113883.6.96
Description: This value set represents points on the body that are susceptible to pressure ulcer
development
Code (CID)

Code System

Print Name

79951008

SNOMED CT

skin of occipital region (body structure)

23747009

SNOMED CT

skin structure of chin (body structure)

76552005

SNOMED CT

skin structure of shoulder (body structure)

45980000

SNOMED CT

skin structure of scapular region of back (body structure)

74757004

SNOMED CT

skin structure of elbow (body structure)

51027004

SNOMED CT

skin structure of sacral region (body structure)

304037003

SNOMED CT

thoracic region back structure (body structure)

286591006

SNOMED CT

skin of lumbar region (body structure)

49812005

SNOMED CT

skin structure of hip (body structure)

29850006

SNOMED CT

iliac crest structure (body structure)*

22180002

SNOMED CT

skin structure of buttock (body structure)

63464009

SNOMED CT

skin structure of knee (body structure)

84607009

SNOMED CT

skin structure of heel (body structure)

67269001

SNOMED CT

skin structure of ankle (body structure)

50938007

SNOMED CT

skin structure of sacrococcygeal region (body structure)

181512003

SNOMED CT

skin of dorsal region (body structure)

1902009

SNOMED CT

skin structure of ear (body structure)

36141000

SNOMED CT

skin structure of cheek (body structure)

113179006

SNOMED CT

skin structure of nose (body structure)

6141000

SNOMED CT

skin structure of cheek (body structure)

113179006

SNOMED CT

skin structure of nose (body structure)

1797002

SNOMED CT

structure of anterior naris (body structure)

…

*mapped to parent and not to “posterior” iliac crest structure

35
http://wiki.hl7.org/images/b/be/PressureUlcerPreventionDomainAnalysisModel_May2011.pdf
Accessed May 2, 2012
36 Domain Analysis Model, HL7 http://pressureulcerpreventionmodel.com/DAM20110325/
Accessed May 2, 2012.
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Table 250: Target Site Qualifiers Value Set
Value Set: TargetSite Qualifiers 2.16.840.1.113883.11.20.9.37 DYNAMIC
Code System: SNOMED CT 2.16.840.1.113883.6.96
Code

Code System

Print Name

255549009

SNOMED CT

anterior

7771000

SNOMED CT

left

255561001

SNOMED CT

medial

255551008

SNOMED CT

posterior

24028007

SNOMED CT

right

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Figure 210: Pressure ulcer observation example










































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6.58 Problem Concern Act (Condition)
[act: templateId 2.16.840.1.113883.10.20.22.4.3(open)]
Table 251: Problem Concern Act (Condition) Contexts
Used By:

Contains Entries:

Problem Section (entries optional)
Problem Section (entries required)

Problem Observation

Observations of problems or other clinical statements captured at a point in
time are wrapped in a "Concern" act, which represents the ongoing process
tracked over time. This allows for binding related observations of problems. For
example, the observation of "Acute MI" in 2004 can be related to the observation
of "History of MI" in 2006 because they are the same concern. The conformance
statements in this section define an outer "problem act" (representing the
"Concern") that can contain a nested "problem observation" or other nested
clinical statements.
Table 252: Problem Concern Act (Condition) Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.3']
@classCode

1..1

SHALL

9024

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

9025

2.16.840.1.113883.5.1001
(ActMood) = EVN

id

1..*

SHALL

II

9026

code

1..1

SHALL

CD

9027

1..1

SHALL

statusCode

1..1

SHALL

effectiveTime

1..1

low
high

@code

9440

2.16.840.1.113883.5.6
(HL7ActClass) = CONC

CS

9029

2.16.840.1.113883.11.20.9.19
(ProblemAct statusCode)

SHALL

TS or
IVL

9030

1..1

SHALL

TS

9032

0..1

SHOULD

TS

9033

1..*

SHALL

9034

@typeCode

1..1

SHALL

9035

observation

1..1

SHALL

15980

entryRelationship

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:9024).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9025).

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3. SHALL contain exactly one [1..1] templateId (CONF:16772) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.3" (CONF:16773).
4. SHALL contain at least one [1..*] id (CONF:9026).
5. SHALL contain exactly one [1..1] code (CONF:9027).
a. This code SHALL contain exactly one [1..1] @code="CONC" Concern
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9440).
6. SHALL contain exactly one [1..1] statusCode, where the @code SHALL be
selected from ValueSet ProblemAct statusCode
2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09 (CONF:9029).
The effectiveTime element records the starting and ending times during which the
concern was active on the Problem List.
7. SHALL contain exactly one [1..1] effectiveTime (CONF:9030).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:9032).
b. This effectiveTime SHOULD contain zero or one [0..1] high
(CONF:9033).
8. SHALL contain at least one [1..*] entryRelationship (CONF:9034) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9035).
b. SHALL contain exactly one [1..1] Problem Observation
(2.16.840.1.113883.10.20.22.4.4) (CONF:15980).
Figure 211: Problem concern act (condition) example













...




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6.59 Problem Observation
[Observation: templateId 2.16.840.1.113883.10.20.22.4.4(open)]
Table 253: Problem Observation Contexts
Used By:

Contains Entries:

Hospital Discharge Diagnosis
Hospital Admission Diagnosis
Procedure Findings Section
Postprocedure Diagnosis
History of Past Illness Section
Complications Section
Problem Concern Act (Condition)
Functional Status Section
Preoperative Diagnosis

Age Observation
Health Status Observation
Problem Status

A problem is a clinical statement that a clinician has noted. In health care it is a
condition that requires monitoring or diagnostic, therapeutic, or educational
action. It also refers to any unmet or partially met basic human need.
A Problem Observation is required to be wrapped in an act wrapper in locations
such as the Problem Section, Allergies Section, and Hospital Discharge
Diagnosis Section, where the type of problem needs to be identified or the
condition tracked.
A Problem Observation can be a valid "standalone" template instance in cases
where a simple problem observation is to be sent.
The negationInd attribute, if true, specifies that the problem indicated was
observed to not have occurred (which is subtly but importantly different from
having not been observed). NegationInd='true' is an acceptable way to make a
clinical assertion that something did not occur, for example, "no diabetes".
Table 254: Problem Observation Constraints Overview
Name

XPath

Green
Problem
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.4']

Verb

Data
Type

CONF#

Fixed Value

@classCode

1..1

SHALL

9041

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

9042

2.16.840.1.113883.5.1001
(ActMood) = EVN

@negationInd

0..1

MAY

10139

templateId

1..1

SHALL

14926

1..1

SHALL

14927

id

1..*

SHALL

9043

code

1..1

SHALL

9045

@root

problem

Card.

2.16.840.1.113883.10.20.
22.4.4
2.16.840.1.113883.3.88.1

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Name

XPath

Card.

Verb

Data
Type

CONF#

Type

2.3221.7.2 (Problem Type)

problem
Name

text

problem
Date

problem
Code

0..1

SHOULD

9185

reference

0..1

SHOULD

15587

@value

1..1

SHALL

15588

statusCode

1..1

SHALL

9049

effectiveTime

0..1

SHOULD

low

1..1

SHALL

15603

high

0..1

SHOULD

15604

1..1

SHALL

@nullFlavor

0..1

MAY

10141

translation

0..*

MAY

16749

0..1

MAY

16750

0..1

MAY

9059

@typeCode

1..1

SHALL

9060

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= SUBJ

@inversionInd

1..1

SHALL

9069

true

observation

1..1

SHALL

15590

0..1

MAY

9063

@typeCode

1..1

SHALL

9068

observation

1..1

SHALL

15591

0..1

MAY

9067

@typeCode

1..1

SHALL

9064

observation

1..1

SHALL

15592

value

@code
ageAtOnset

problem
Status

Fixed Value

entryRelationship

entryRelationship

entryRelationship

TS or
IVL

CD

2.16.840.1.113883.5.14
(ActStatus) = completed

9050

9058

2.16.840.1.113883.3.88.1
2.3221.7.4 (Problem)

2.16.840.1.113883.6.3
(ICD10)

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= REFR

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= REFR

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9041).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9042).
3. MAY contain zero or one [0..1] @negationInd (CONF:10139).
a. Use negationInd="true" to indicate that the problem was not observed
(CONF:16880).
4. SHALL contain exactly one [1..1] templateId (CONF:14926) such that it
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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.4" (CONF:14927).
5. SHALL contain at least one [1..*] id (CONF:9043).
6. SHALL contain exactly one [1..1] code, which SHOULD be selected from
ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC
2012-06-01 (CONF:9045).
7. SHOULD contain zero or one [0..1] text (CONF:9185).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15587).
i.

The reference, if present, SHALL contain exactly one [1..1]
@value (CONF:15588).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15589).

8. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:9049).
9. SHOULD contain zero or one [0..1] effectiveTime (CONF:9050).
a. The effectiveTime, if present, SHALL contain exactly one [1..1] low
(CONF:15603).
i.

This field represents the onset date (CONF:16882).

b. The effectiveTime, if present, SHOULD contain zero or one [0..1] high
(CONF:15604).
i.

This field represents the resolution date (CONF:16883).

c. If the problem is known to be resolved, but the date of resolution is
not known, then the high element SHALL be present, and the
nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of
an high element within a problem does indicate that the problem has
been resolved (CONF:16881).
10. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHOULD be selected from ValueSet Problem
2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).
a. This value MAY contain zero or one [0..1] @nullFlavor
(CONF:10141).
i.

If the diagnosis is unknown or the SNOMED code is
unknown, @nullFlavor SHOULD be “UNK”. If the code is
something other than SNOMED, @nullFlavor SHOULD be
“OTH” and the other code SHOULD be placed in the translation
element (CONF:10142).

b. This value MAY contain zero or more [0..*] translation
(CONF:16749).
i.

The translation, if present, MAY contain zero or one [0..1]
@code (CodeSystem: ICD10 2.16.840.1.113883.6.3)
(CONF:16750).

11. MAY contain zero or one [0..1] entryRelationship (CONF:9059) such that it

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a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:9060).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:9069).
c. SHALL contain exactly one [1..1] Age Observation
(templateId:2.16.840.1.113883.10.20.22.4.31) (CONF:15590).
12. MAY contain zero or one [0..1] entryRelationship (CONF:9063) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:9068).
b. SHALL contain exactly one [1..1] Problem Status
(templateId:2.16.840.1.113883.10.20.22.4.6) (CONF:15591).
13. MAY contain zero or one [0..1] entryRelationship (CONF:9067) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:9064).
b. SHALL contain exactly one [1..1] Health Status Observation
(templateId:2.16.840.1.113883.10.20.22.4.5) (CONF:15592).

Figure 212: Problem observation example






...










...



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...




Figure 213: Problem observation with specific problem not observed


 No known problems




Figure 214: Problem observation for no known problems








Figure 215: NullFlavor example




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6.60 Problem Status
[observation: templateId 2.16.840.1.113883.10.20.22.4.6(open)]
Table 255: Problem Status Contexts
Used By:

Contains Entries:

Problem Observation

The Problem Status records whether the indicated problem is active, inactive, or
resolved.
Table 256: Problem Status Constraints Overview

Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.6']
@classCode

1..1

SHALL

7357

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

7358

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

1..1

SHALL

code

1..1

SHALL

text

0..1

SHOULD

7362

reference

0..1

SHOULD

15593

@value

1..1

SHALL

15594

statusCode

1..1

SHALL

7364

2.16.840.1.113883.5.14 (ActStatus) =
completed

value

1..1

SHALL

7365

2.16.840.1.113883.3.88.12.80.68
(HITSPProblemStatus)

@root

SET
CE

CD

7359
10518

2.16.840.1.113883.10.20.22.4.6

7361

2.16.840.1.113883.6.1 (LOINC) =
33999-4

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7357).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7358).
3. SHALL contain exactly one [1..1] templateId (CONF:7359) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.6" (CONF:10518).
4. SHALL contain exactly one [1..1] code="33999-4" Status with @xsi:type="CE"
(CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:7361).
5. SHOULD contain zero or one [0..1] text (CONF:7362).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15593).

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i.

The reference, if present, SHALL contain exactly one [1..1]
@value (CONF:15594).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15595).

6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:7364).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHALL be selected from ValueSet HITSPProblemStatus
2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:7365).

Figure 216: Problem status example








6.61 Procedure Activity Act
[act: templateId 2.16.840.1.113883.10.20.22.4.12(open)]
Table 257: Procedure Activity Act Contexts
Used By:

Contains Entries:

Procedures Section (entries required)
Procedures Section (entries optional)

Indication
Instructions
Medication Activity
Service Delivery Location

The common notion of "procedure" is broader than that specified by the HL7
Version 3 Reference Information Model (RIM). Therefore procedure templates can
be represented with various RIM classes: act (e.g., dressing change), observation
(e.g., EEG), procedure (e.g. splenectomy).
This clinical statement represents any procedure that cannot be classified as an
observation or a procedure according to the HL7 RIM. Examples of these

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procedures are a dressing change, teaching or feeding a patient or providing
comfort measures.

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Table 258: Procedure Activity Act Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Green
Procedure
Activity
Act

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.12']

@classCode

1..1

SHALL

8289

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

8290

2.16.840.1.113883.11.20.
9.18 (MoodCodeEvnInt)

templateId

1..1

SHALL

1..1

SHALL

10519
8292

@root

SET

8291

procedure
Id

id

1..*

SHALL

procedure
Type

code

1..1

SHALL

originalText

0..1

SHOULD

8295

reference

0..1

MAY

15596

@value

procedure
FreeText
Type

procedure
DateTime

procedure
Performer

Fixed Value

CE

8293

0..1

MAY

15597

statusCode

1..1

SHALL

8298

effectiveTime

0..1

SHOULD

priorityCode

0..1

MAY

8300

performer

0..*

SHOULD

8301

1..1

SHALL

8302

id

1..*

SHALL

addr

1..1

SHALL

SET

8304

telecom

1..1

SHALL

SET

8305

represented
Organization

0..1

SHOULD

8306

id

0..*

SHOULD

8307

name

0..*

MAY

PN

8308

telecom

1..1

SHALL

SET

8310

addr

1..1

SHALL

SET

8309

0..*

MAY

assignedEntity

participant

TS or
IVL

2.16.840.1.113883.10.20.
22.4.12

2.16.840.1.113883.11.20.
9.22 (ProcedureAct
statusCode)

8299
2.16.840.1.113883.1.11.1
6866 (ActPriority)

8303

8311

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Name

XPath

CONF#

Fixed Value

SHALL

8312

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= LOC

1..1

SHALL

15599

0..*

MAY

8314

@typeCode

1..1

SHALL

8315

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= COMP

@inversionInd

1..1

SHALL

8316

true

encounter

1..1

SHALL

8317

@classCode

1..1

SHALL

8318

2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

8319

2.16.840.1.113883.5.1001
(ActMood) = EVN

id

1..1

SHALL

8320

entry
Relationship

0..1

MAY

8322

@typeCode

1..1

SHALL

8323

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= SUBJ

@inversionInd

1..1

SHALL

8324

true

act

1..1

SHALL

15600

0..*

MAY

8326

@typeCode

1..1

SHALL

8327

observation

1..1

SHALL

15601

0..1

MAY

8329

1..1

SHALL

8330

1..1

SHALL

15602

@typeCode

Card.

Verb

1..1

Data
Type

participantRole
entry
Relationship

entry
Relationship

entry
Relationship
@typeCode

substance
Administration

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= RSON

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= COMP

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8289).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 201104-03 (CONF:8290).
3. SHALL contain exactly one [1..1] templateId (CONF:8291) such that it

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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.12" (CONF:10519).
4. SHALL contain at least one [1..*] id (CONF:8292).
5. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:8293).
a. This code SHOULD contain zero or one [0..1] originalText
(CONF:8295).
i.

The originalText, if present, MAY contain zero or one [0..1]
reference (CONF:15596).
1. The reference, if present, MAY contain zero or one [0..1]
@value (CONF:15597).
a. This reference/@value SHALL begin with a '#'
and SHALL point to its corresponding narrative
(using the approach defined in CDA Release 2,
section 4.3.5.1) (CONF:15598).

b. This code in a procedure activity observation SHOULD be selected from
LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT
(CodeSystem: 2.16.840.1.113883.6.96) (CONF:8294).
6. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from
ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22
DYNAMIC (CONF:8298).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:8299).
8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from
ValueSet ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC
(CONF:8300).
9. SHOULD contain zero or more [0..*] performer (CONF:8301).
a. The performer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:8302).
i.

This assignedEntity SHALL contain at least one [1..*] id
(CONF:8303).

ii. This assignedEntity SHALL contain exactly one [1..1] addr
(CONF:8304).
iii. This assignedEntity SHALL contain exactly one [1..1] telecom
(CONF:8305).
iv. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:8306).
1. The representedOrganization, if present, SHOULD
contain zero or more [0..*] id (CONF:8307).
2. The representedOrganization, if present, MAY contain
zero or more [0..*] name (CONF:8308).
3. The representedOrganization, if present, SHALL contain
exactly one [1..1] telecom (CONF:8310).
4. The representedOrganization, if present, SHALL contain
exactly one [1..1] addr (CONF:8309).
10. MAY contain zero or more [0..*] participant (CONF:8311).

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a. The participant, if present, SHALL contain exactly one [1..1]
@typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:8312).
b. The participant, if present, SHALL contain exactly one [1..1] Service
Delivery Location
(templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:15599).
11. MAY contain zero or more [0..*] entryRelationship (CONF:8314).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8315).
b. The entryRelationship, if present, SHALL contain exactly one [1..1]
@inversionInd="true" true (CONF:8316).
c. The entryRelationship, if present, SHALL contain exactly one [1..1]
encounter (CONF:8317).
i.

This encounter SHALL contain exactly one [1..1]
@classCode="ENC" Encounter (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6 STATIC) (CONF:8318).

ii. This encounter SHALL contain exactly one [1..1]
@moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001 STATIC) (CONF:8319).
iii. This encounter SHALL contain exactly one [1..1] id
(CONF:8320).
1. Set the encounter ID to the ID of an encounter in
another section to signify they are the same encounter
(CONF:16849).
12. MAY contain zero or one [0..1] entryRelationship (CONF:8322).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8323).
b. The entryRelationship, if present, SHALL contain exactly one [1..1]
@inversionInd="true" true (CONF:8324).
c. The entryRelationship, if present, SHALL contain exactly one [1..1]
Instructions
(templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:15600).
13. MAY contain zero or more [0..*] entryRelationship (CONF:8326).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8327).
b. The entryRelationship, if present, SHALL contain exactly one [1..1]
Indication (templateId:2.16.840.1.113883.10.20.22.4.19)
(CONF:15601).
14. MAY contain zero or one [0..1] entryRelationship (CONF:8329).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="COMP" Has Component (CodeSystem:
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HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8330).
b. The entryRelationship, if present, SHALL contain exactly one [1..1]
Medication Activity
(templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:15602).
Table 259: Procedure Act Status Code Value Set
Value Set: ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC
Code System(s):

ActStatus 2.16.840.1.113883.5.14

Description:

A ValueSet of HL7 actStatus codes for use with a procedure activity

Code

Code System

Print Name

completed

ActStatus

Completed

active

ActStatus

Active

aborted

ActStatus

Aborted

cancelled

ActStatus

Cancelled

Table 260: Act Priority Value Set
Value Set: ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC
Code System(s):
Description:

ActPriority 2.16.840.1.113883.5.7
A code or set of codes (e.g., for routine, emergency,) specifying the urgency under
which the Act happened, can happen, is happening, is intended to happen, or is
requested/demanded to happen.

Code

Code System

Print Name

A

ActPriority

ASAP

CR

ActPriority

Callback results

CS

ActPriority

Callback for scheduling

CSP

ActPriority

Callback placer for scheduling

CSR

ActPriority

Contact recipient for scheduling

EL

ActPriority

Elective

EM

ActPriority

Emergency

P

ActPriority

Preoperative

PRN

ActPriority

As needed

R

ActPriority

Routine

RR

ActPriority

Rush reporting

S

ActPriority

Stat

T

ActPriority

Timing critical

UD

ActPriority

Use as directed

UR

ActPriority

Urgent

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Figure 217: Procedure activity act example















17 Daws Rd.
Blue Bell
MA
02368
US




Good Health Clinic









...






...




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6.62 Procedure Activity Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.13(open)]
Table 261: Procedure Activity Observation Contexts
Used By:

Contains Entries:

Procedures Section (entries optional)
Procedures Section (entries required)

Indication
Instructions
Medication Activity
Service Delivery Location

The common notion of "procedure" is broader than that specified by the HL7
Version 3 Reference Information Model (RIM). Therefore procedure templates can
be represented with various RIM classes: act (e.g., dressing change), observation
(e.g., EEG), procedure (e.g. splenectomy).
This clinical statement represents procedures that result in new information
about the patient that cannot be classified as a procedure according to the HL7
RIM. Examples of these procedures are diagnostic imaging procedures, EEGs
and EKGs.
Table 262: Procedure Activity Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Green
Procedure
Activity
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.13']

@classCode

1..1

SHALL

8282

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8237

2.16.840.1.113883.11.20.9.
18 (MoodCodeEvnInt)

templateId

1..1

SHALL

1..1

SHALL

10520
8239

@root

SET

8238

procedureId

id

1..*

SHALL

procedure
Type

code

1..1

SHALL

originalText

0..1

SHOULD

8242

reference

0..1

SHOULD

15901

@value

0..1

SHOULD

15902

statusCode

1..1

SHALL

8245

effectiveTime

0..1

SHOULD

procedure
FreeText
Type

procedure

Fixed Value

CE

TS or
IVL
priorityCode

0..1

MAY

8247

value

1..1

SHALL

16846

methodCode

0..1

MAY

SET<
CE>

8248

targetSiteCode

0..*

SHOULD

SET<
CD>

8250

@code

1..1

SHALL

16071

performer

0..*

SHOULD

8251

1..1

SHALL

8252

id

1..*

SHALL

8253

addr

1..1

SHALL

SET

8254

telecom

1..1

SHALL

SET

8255

0..1

SHOULD

8256

id

0..*

SHOULD

8257

name

0..*

MAY

PN

8258

telecom

1..1

SHALL

SET

8260

addr

1..1

SHALL

SET

8259

0..*

MAY

8261

1..1

SHALL

8262

1..1

SHALL

15904

0..*

MAY

8264

1..1

SHALL

8265

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
COMP

1..1

SHALL

8266

true

1..1

SHALL

8267

@classCode

1..1

SHALL

8268

2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

8269

2.16.840.1.113883.5.1001
(ActMood) = EVN

2.16.840.1.113883.3.88.12.
3221.8.9 (Body Site Value
Set)

assignedEntity

representedOrg
anization

participant
@typeCode

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
LOC

participantRole
entryRelations
hip
@typeCode

@inversionInd
encounter

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Name

XPath

Card.

Verb

1..1

SHALL

8270

0..1

MAY

8272

1..1

SHALL

8273

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ

1..1

SHALL

8274

true

1..1

SHALL

15905

0..*

MAY

8276

@typeCode

1..1

SHALL

8277

observation

1..1

SHALL

15906

0..1

MAY

8279

1..1

SHALL

8280

1..1

SHALL

15907

id
entryRelations
hip
@typeCode

Data
Type

CONF#

Fixed Value

@inversionInd
act
entryRelations
hip

entryRelations
hip
@typeCode

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
RSON

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
COMP

substanceAdmi
nistration

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8282).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 201104-03 (CONF:8237).
3. SHALL contain exactly one [1..1] templateId (CONF:8238) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.13" (CONF:10520).
4. SHALL contain at least one [1..*] id (CONF:8239).
5. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:8240).
a. This code SHOULD contain zero or one [0..1] originalText
(CONF:8242).
i.

The originalText, if present, SHOULD contain zero or one [0..1]
reference (CONF:15901).
1. The reference, if present, SHOULD contain zero or one
[0..1] @value (CONF:15902).
a. This reference/@value SHALL begin with a '#'
and SHALL point to its corresponding narrative
(using the approach defined in CDA Release 2,
section 4.3.5.1) (CONF:15903).

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b. This code in a procedure activity SHOULD be selected from LOINC
(CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem:
2.16.840.1.113883.6.96), and MAY be selected from CPT-4
(CodeSystem: 2.16.840.1.113883.6.12), ICD9 Procedures
(CodeSystem: 2.16.840.1.113883.6.4) (CONF:8241).
6. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from
ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22
DYNAMIC (CONF:8245).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:8246).
8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from
ValueSet ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC
(CONF:8247).
9. SHALL contain exactly one [1..1] value (CONF:16846).
10. MAY contain zero or one [0..1] methodCode (CONF:8248).
a. MethodCode SHALL NOT conflict with the method inherent in
Observation / code (CONF:8249).
11. SHOULD contain zero or more [0..*] targetSiteCode (CONF:8250).
a. The targetSiteCode, if present, SHALL contain exactly one [1..1] @code,
which SHALL be selected from ValueSet Body Site Value Set
2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:16071).
12. SHOULD contain zero or more [0..*] performer (CONF:8251).
a. The performer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:8252).
i.

This assignedEntity SHALL contain at least one [1..*] id
(CONF:8253).

ii. This assignedEntity SHALL contain exactly one [1..1] addr
(CONF:8254).
iii. This assignedEntity SHALL contain exactly one [1..1] telecom
(CONF:8255).
iv. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:8256).
1. The representedOrganization, if present, SHOULD
contain zero or more [0..*] id (CONF:8257).
2. The representedOrganization, if present, MAY contain
zero or more [0..*] name (CONF:8258).
3. The representedOrganization, if present, SHALL contain
exactly one [1..1] telecom (CONF:8260).
4. The representedOrganization, if present, SHALL contain
exactly one [1..1] addr (CONF:8259).
13. MAY contain zero or more [0..*] participant (CONF:8261).
a. The participant, if present, SHALL contain exactly one [1..1]
@typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:8262).
b. The participant, if present, SHALL contain exactly one [1..1] Service
Delivery Location
(templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:15904).
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14. MAY contain zero or more [0..*] entryRelationship (CONF:8264).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="COMP" Component (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC)
(CONF:8265).
b. The entryRelationship, if present, SHALL contain exactly one [1..1]
@inversionInd="true" true (CONF:8266).
c. The entryRelationship, if present, SHALL contain exactly one [1..1]
encounter (CONF:8267).
i.

This encounter SHALL contain exactly one [1..1]
@classCode="ENC" Encounter (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6 STATIC) (CONF:8268).

ii. This encounter SHALL contain exactly one [1..1]
@moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001 STATIC) (CONF:8269).
iii. This encounter SHALL contain exactly one [1..1] id
(CONF:8270).
1. Set encounter/id to the id of an encounter in another
section to signify they are the same encounter
(CONF:16847).
15. MAY contain zero or one [0..1] entryRelationship (CONF:8272) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:8273).
b. SHALL contain exactly one [1..1] @inversionInd="true" true
(CONF:8274).
c. SHALL contain exactly one [1..1] Instructions
(templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:15905).
16. MAY contain zero or more [0..*] entryRelationship (CONF:8276) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:8277).
b. SHALL contain exactly one [1..1] Indication
(templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:15906).
17. MAY contain zero or one [0..1] entryRelationship (CONF:8279) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:8280).
b. SHALL contain exactly one [1..1] Medication Activity
(templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:15907).

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Figure 218: Procedure activity observation example



















17 Daws Rd.
Blue Bell
MA
02368
US




Good Health Clinic









...




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6.63 Procedure Activity Procedure
[procedure: templateId 2.16.840.1.113883.10.20.22.4.14(open)]
Table 263: Procedure Activity Procedure Contexts
Used By:

Contains Entries:

Procedures Section (entries optional)
Reaction Observation
Procedures Section (entries required)
Anesthesia Section

Indication
Instructions
Medication Activity
Product Instance
Service Delivery Location

The common notion of "procedure" is broader than that specified by the HL7
Version 3 Reference Information Model (RIM). Therefore procedure templates can
be represented with various RIM classes: act (e.g., dressing change), observation
(e.g., EEG), procedure (e.g. splenectomy).
This clinical statement represents procedures whose immediate and primary
outcome (post-condition) is the alteration of the physical condition of the
patient. Examples of these procedures are an appendectomy, hip replacement
and a creation of a gastrostomy.
Table 264: Procedure Activity Procedure Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF
#

Green
Procedure
Activity
Procedure

procedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.14']

@classCode

1..1

SHALL

7652

2.16.840.1.113883.5.6
(HL7ActClass) = PROC

@moodCode

1..1

SHALL

7653

2.16.840.1.113883.11.20.
9.18 (MoodCodeEvnInt)

templateId

1..1

SHALL

1..1

SHALL

10521
7655

@root

SET<
II>

7654

procedure
Id

id

1..*

SHALL

procedure
Type

code

1..1

SHALL

originalText

0..1

SHOULD

7658

reference

0..1

SHOULD

15908

@value

0..1

SHOULD

15909

0..1

SHOULD

7659

1..1

SHALL

7661

procedure
FreeText
Type

Fixed Value

CE

2.16.840.1.113883.10.20.
22.4.14

7656

reference/@value
statusCode

2.16.840.1.113883.11.20.

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Name

XPath

Card.

Verb

Data
Type

CONF
#

Fixed Value
9.22 (ProcedureAct
statusCode)

procedure
DateTime

bodySite

effectiveTime

0..1

SHOULD

priorityCode

0..1

MAY

methodCode

0..1

MAY

targetSiteCode

0..*

SHOULD

7683

@code

1..1

SHALL

16082

specimen

0..*

MAY

7697

1..1

SHALL

7704

0..*

SHOULD

7716

0..*

SHOULD

7718

1..1

SHALL

7720

id

1..*

SHALL

addr

1..1

SHALL

SET<
AD>

7731

telecom

1..1

SHALL

SET<
TEL>

7732

represented
Organization

0..1

SHOULD

7733

id

0..*

SHOULD

7734

name

0..*

MAY

PN

7735

telecom

1..1

SHALL

SET<
TEL>

7737

addr

1..1

SHALL

SET<
AD>

7736

0..*

MAY

7751

@typeCode

1..1

SHALL

7752

participantRole

1..1

SHALL

15911

0..*

MAY

7765

@typeCode

1..1

SHALL

7766

participantRole

1..1

SHALL

15912

entryRelationship

0..*

MAY

7768

1..1

SHALL

7769

specimenRole
id
performer
procedure
Provider

assignedEntity

participant

participant

@typeCode

TS or
IVL<
TS>

7662

7668
SET<
CE>

2.16.840.1.113883.1.11.1
6866 (ActPriority)

7670

2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site
Value Set)

7722

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= DEV

2.16.840.1.113883.5.90
(HL7ParticipationType) =
LOC

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)

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Name

XPath

Card.

Verb

Data
Type

CONF
#

Fixed Value
= COMP

@inversionInd

1..1

SHALL

8009

encounter

1..1

SHALL

7770

@classCode

1..1

SHALL

7771

2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

7772

2.16.840.1.113883.5.1001
(ActMood) = EVN

id

1..1

SHALL

7773

0..1

MAY

7775

@typeCode

1..1

SHALL

7776

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= SUBJ

@inversionInd

1..1

SHALL

7777

true

act

1..1

SHALL

15913

0..*

MAY

7779

@typeCode

1..1

SHALL

7780

observation

1..1

SHALL

15914

0..1

MAY

7886

1..1

SHALL

7887

1..1

SHALL

15915

entryRelationship

entryRelationship

entryRelationship
@typeCode

substance
Administration

true

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= RSON

2.16.840.1.113883.5.1002
(HL7ActRelationshipType)
= COMP

1. SHALL contain exactly one [1..1] @classCode="PROC" Procedure
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7652).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from
ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 201104-03 (CONF:7653).
3. SHALL contain exactly one [1..1] templateId (CONF:7654) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.14" (CONF:10521).
4. SHALL contain at least one [1..*] id (CONF:7655).
5. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:7656).
a. This code SHOULD contain zero or one [0..1] originalText
(CONF:7658).
i.

The originalText, if present, SHOULD contain zero or one [0..1]
reference (CONF:15908).
1. The reference, if present, SHOULD contain zero or one
[0..1] @value (CONF:15909).
a. This reference/@value SHALL begin with a '#'
and SHALL point to its corresponding narrative

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(using the approach defined in CDA Release 2,
section 4.3.5.1) (CONF:15910).
ii. The originalText, if present, SHOULD contain zero or one [0..1]
reference/@value (CONF:7659).
b. This code in a procedure activity SHOULD be selected from LOINC
(codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem:
2.16.840.1.113883.6.96), and MAY be selected from CPT-4
(CodeSystem: 2.16.840.1.113883.6.12), ICD9 Procedures
(CodeSystem: 2.16.840.1.113883.6.104), ICD10 Procedure Coding
System (CodeSystem: 2.16.840.1.113883.6.4) (CONF:7657).
6. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from
ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22
DYNAMIC (CONF:7661).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:7662).
8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from
ValueSet ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC
(CONF:7668).
9. MAY contain zero or one [0..1] methodCode (CONF:7670).
a. MethodCode SHALL NOT conflict with the method inherent in
Procedure / code (CONF:7890).
10. SHOULD contain zero or more [0..*] targetSiteCode (CONF:7683).
a. The targetSiteCode, if present, SHALL contain exactly one [1..1] @code,
which SHALL be selected from ValueSet Body Site Value Set
2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:16082).
11. MAY contain zero or more [0..*] specimen (CONF:7697).
a. The specimen, if present, SHALL contain exactly one [1..1]
specimenRole (CONF:7704).
i.

This specimenRole SHOULD contain zero or more [0..*] id
(CONF:7716).
1. If you want to indicate that the Procedure and the
Results are referring to the same specimen, the
Procedure/specimen/specimenRole/id SHOULD be set
to equal an Organizer/specimen/ specimenRole/id
(CONF:7717).

b. This specimen is for representing specimens obtained from a
procedure (CONF:16842).
12. SHOULD contain zero or more [0..*] performer (CONF:7718) such that it
a. SHALL contain exactly one [1..1] assignedEntity (CONF:7720).
i.

This assignedEntity SHALL contain at least one [1..*] id
(CONF:7722).

ii. This assignedEntity SHALL contain exactly one [1..1] addr
(CONF:7731).
iii. This assignedEntity SHALL contain exactly one [1..1] telecom
(CONF:7732).
iv. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:7733).

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1. The representedOrganization, if present, SHOULD
contain zero or more [0..*] id (CONF:7734).
2. The representedOrganization, if present, MAY contain
zero or more [0..*] name (CONF:7735).
3. The representedOrganization, if present, SHALL contain
exactly one [1..1] telecom (CONF:7737).
4. The representedOrganization, if present, SHALL contain
exactly one [1..1] addr (CONF:7736).
13. MAY contain zero or more [0..*] participant (CONF:7751) such that it
a. SHALL contain exactly one [1..1] @typeCode="DEV" Device
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7752).
b. SHALL contain exactly one [1..1] Product Instance
(templateId:2.16.840.1.113883.10.20.22.4.37) (CONF:15911).
14. MAY contain zero or more [0..*] participant (CONF:7765) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location
(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90
STATIC) (CONF:7766).
b. SHALL contain exactly one [1..1] Service Delivery Location
(templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:15912).
15. MAY contain zero or more [0..*] entryRelationship (CONF:7768) such that
it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7769).
b. SHALL contain exactly one [1..1] @inversionInd="true" true
(CONF:8009).
c. SHALL contain exactly one [1..1] encounter (CONF:7770).
i.

This encounter SHALL contain exactly one [1..1]
@classCode="ENC" Encounter (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6 STATIC) (CONF:7771).

ii. This encounter SHALL contain exactly one [1..1]
@moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001 STATIC) (CONF:7772).
iii. This encounter SHALL contain exactly one [1..1] id
(CONF:7773).
1. Set the encounter ID to the ID of an encounter in
another section to signify they are the same encounter
(CONF:16843).
16. MAY contain zero or one [0..1] entryRelationship (CONF:7775) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7776).
b. SHALL contain exactly one [1..1] @inversionInd="true" true
(CONF:7777).

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c. SHALL contain exactly one [1..1] Instructions
(templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:15913).
17. MAY contain zero or more [0..*] entryRelationship (CONF:7779) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7780).
b. SHALL contain exactly one [1..1] Indication
(templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:15914).
18. MAY contain zero or one [0..1] entryRelationship (CONF:7886) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7887).
b. SHALL contain exactly one [1..1] Medication Activity
(templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:15915).
Figure 219: Procedure activity procedure example





Bronchoalveolar














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...






...




6.64 Procedure Context
[act: templateId 2.16.840.1.113883.10.20.6.2.5(open)]
Table 265: Procedure Context Contexts
Used By:

Contains Entries:

Diagnostic Imaging Report (optional)

The ServiceEvent Procedure Context of the document header may be overridden
in the CDA structured body if there is a need to refer to multiple imaging
procedures or acts. The selection of the Procedure or Act entry from the clinical
statement choice box depends on the nature of the imaging service that has
been performed. The Procedure entry shall be used for image-guided
interventions and minimal invasive imaging services, whereas the Act entry shall
be used for diagnostic imaging services.
Table 266: Procedure Context Constraints Overview
Name

XPath

Card.

Verb

Data Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.6.2.5']
templateId

1..1

SHALL

1..1

SHALL

code

1..1

SHALL

CD

9201

effectiveTime

0..1

SHOULD

TS

9203

1..1

SHALL

@root

@value

SET

9200
10530

2.16.840.1.113883.10.20.6.2.5

17173

1. Procedure Context SHALL be represented with the procedure or act elements
depending on the nature of the procedure (CONF:9199).
2. SHALL contain exactly one [1..1] templateId (CONF:9200) such that it

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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.5" (CONF:10530).
3. SHALL contain exactly one [1..1] code (CONF:9201).
4. SHOULD contain zero or one [0..1] effectiveTime (CONF:9203).
a. The effectiveTime, if present, SHALL contain exactly one [1..1] @value
(CONF:17173).
Figure 220: Procedure context template example








6.65 Product Instance
[participantRole: templateId 2.16.840.1.113883.10.20.22.4.37(open)]
Table 267: Product Instance Contexts
Used By:

Contains Entries:

Procedure Activity Procedure
Non-Medicinal Supply Activity

This clinical statement represents a particular device that was placed in or used
as part of a procedure or other act. This provides a record of the identifier and
other details about the given product that was used. For example, it is important
to have a record that indicates not just that a hip prostheses was placed in a
patient but that it was a particular hip prostheses number with a unique
identifier.
The FDA Amendments Act specifies the creation of a Unique Device
Identification (UDI) System that requires the label of devices to bear a unique
identifier that will standardize device identification and identify the device
through distribution and use.
The UDI should be sent in the participantRole/id.

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Table 268: Product Instance Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

participantRole[templateId/@root = '2.16.840.1.113883.10.20.22.4.37']
@classCode

1..1

SHALL

templateId

1..1

SHALL

1..1

SHALL

1..*

SHALL

1..1

SHALL

0..1

SHOULD

scoping
Entity

1..1

SHALL

id

1..*

SHALL

@root
id
playing
Device
code

7900
SET

7901
10522

II

2.16.840.1.113883.5.110 (RoleClass)
= MANU
2.16.840.1.113883.10.20.22.4.37

7902
7903

CE

7904
7905

II

7908

1. SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product
(CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:7900).
2. SHALL contain exactly one [1..1] templateId (CONF:7901) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.37" (CONF:10522).
3. SHALL contain at least one [1..*] id (CONF:7902).
4. SHALL contain exactly one [1..1] playingDevice (CONF:7903).
a. This playingDevice SHOULD contain zero or one [0..1] code
(CONF:7904).
5. SHALL contain exactly one [1..1] scopingEntity (CONF:7905).
a. This scopingEntity SHALL contain at least one [1..*] id (CONF:7908).
Figure 221: Product instance example












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6.66 Purpose of Reference Observation
[observation: templateId 2.16.840.1.113883.10.20.6.2.9(open)]
Table 269: Purpose of Reference Observation Contexts
Used By:

Contains Entries:

SOP Instance Observation

A Purpose of Reference Observation describes the purpose of the DICOM
composite object reference. Appropriate codes, such as externally defined
DICOM codes, may be used to specify the semantics of the purpose of reference.
When this observation is absent, it implies that the reason for the reference is
unknown.
Table 270: Purpose of Reference Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.6.2.9']
@classCode

1..1

SHALL

9264

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

9265

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

1..1

SHALL

1..1

SHALL

0..1

SHOULD

0..1

SHOULD

@root
code
code
value

SET

9266
10531

CD

CD

2.16.840.1.113883.10.20.6.2.9

9267
9268

2.16.840.1.113883.5.4 (ActCode) =
ASSERTION

9273

2.16.840.1.113883.11.20.9.28
(DICOMPurposeOfReference)

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9264).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9265).
3. SHALL contain exactly one [1..1] templateId (CONF:9266) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.9" (CONF:10531).
4. SHALL contain exactly one [1..1] code (CONF:9267).
a. This code SHOULD contain zero or one [0..1] code="ASSERTION"
(CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:9268).
b. For backwards compatibility with the DICOM CMET, the code MAY be
drawn from ValueSet 2.16.840.1.113883.11.20.9.28
DICOMPurposeOfReference DYNAMIC (CONF:9269).
5. SHOULD contain zero or one [0..1] value with @xsi:type="CD", where the
@code SHOULD be selected from ValueSet DICOMPurposeOfReference
2.16.840.1.113883.11.20.9.28 DYNAMIC (CONF:9273).
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a. The value element is a SHOULD to allow backwards compatibility with
the DICOM CMET. Note that the use of ASSERTION for the code
differs from the DICOM CMET. This is intentional. The DICOM CMET
was created before the Term Info guidelines describing the use of the
assertion pattern were released. It was determined that this IG
should follow the latest Term Info guidelines. Implementers using
both this IG and the DICOM CMET will need to be aware of this
difference and apply appropriate transformations (CONF:9274).
Table 271: DICOM Purpose of Reference Value Set
Value Set: DICOMPurposeOfReference 2.16.840.1.113883.11.20.9.28 DYNAMIC
Code System(s): DCM 1.2.840.10008.2.16.4
Code

Code System

Print Name

121079

DCM

Baseline

121080

DCM

Best illustration of finding

121112

DCM

Source of Measurement

Figure 222: Purpose of reference example






6.67 Quantity Measurement Observation
[observation: templateId 2.16.840.1.113883.10.20.6.2.14(open)]
Table 272: Quantity Measurement Observation Contexts
Used By:

Contains Entries:

Text Observation
Code Observations

SOP Instance Observation

A Quantity Measurement Observation records quantity measurements based on
image data such as linear, area, volume, and numeric measurements. The codes
in DIRQuantityMeasurementTypeCodes (ValueSet:
2.16.840.1.113883.11.20.9.29) are from the qualifier hierarchy of SNOMED CT
and are not valid for observation/code according to the Term Info guidelines.
These codes can be used for backwards compatibility, but going forward, codes
from the observable entity hierarchy will be requested and used.

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Table 273: Quantity Measurement Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.6.2.14']
@classCode

1..1

SHALL

9317

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

9318

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

1..1

SHALL

code

0..1

SHOULD

9322

2.16.840.1.113883.11.20.9.29
(DIRQuantityMeasurementTypeCod
es)

code

0..1

SHOULD

9323

2.16.840.1.113883.11.20.9.30
(DICOMQuantityMeasurementType
Codes)

1..1

SHALL

9324

@xsi:type

1..1

SHALL

effectiveTime

0..1

SHOULD

0..*

MAY

9327

1..1

SHALL

9328

@root
code

value

entry
Relationship
@typeCode

SET

9319
10532

CD

9320

9325
TS or
IVL

2.16.840.1.113883.10.20.6.2.14

PQ

9326

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = SPRT

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9317).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9318).
3. SHALL contain exactly one [1..1] templateId (CONF:9319) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.14" (CONF:10532).
4. SHALL contain exactly one [1..1] code (CONF:9320).
a. This code SHOULD contain zero or one [0..1] code, which SHALL be
selected from ValueSet DIRQuantityMeasurementTypeCodes
2.16.840.1.113883.11.20.9.29 DYNAMIC (CONF:9322).
b. This code SHOULD contain zero or one [0..1] code, which SHALL be
selected from ValueSet DICOMQuantityMeasurementTypeCodes
2.16.840.1.113883.11.20.9.30 DYNAMIC (CONF:9323).
c. The value set of the observation/code includes numeric measurement
types for linear dimensions, areas, volumes, and other numeric
measurements. This value set is extensible and comprises the union
of SNOMED codes for observable entities as reproduced in
DIRQuantityMeasurementTypeCodes (ValueSet:
2.16.840.1.113883.11.20.9.29) and DICOM Codes in
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DICOMQuantityMeasurementTypeCodes (ValueSet:
2.16.840.1.113883.11.20.9.30) (CONF:9330).
5. SHALL contain exactly one [1..1] value (CONF:9324).
a. This value SHALL contain exactly one [1..1] @xsi:type, where the
@code="PQ" (CONF:9325).
6. SHOULD contain zero or one [0..1] effectiveTime (CONF:9326).
7. MAY contain zero or more [0..*] entryRelationship (CONF:9327) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SPRT" Has Support
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9328).
b. SHALL contain exactly one [1..1] SOP Instance Observation
(2.16.840.1.113883.10.20.6.2.8) (CONF:9329).
Table 274: DIR Quantity Measurement Type Value Set
Value Set: DIRQuantityMeasurementTypeCodes 2.16.840.1.113883.11.20.9.29 DYNAMIC
Code System(s): SNOMED CT 2.16.840.1.113883.6.96
Code

Code System

Print Name

439932008

SNOMED CT

Length of structure

440357003

SNOMED CT

Width of structure

439934009

SNOMED CT

Depth of structure

439984002

SNOMED CT

Diameter of structure

439933003

SNOMED CT

Long axis length of structure

439428006

SNOMED CT

Short axis length of structure

439982003

SNOMED CT

Major axis length of structure

439983008

SNOMED CT

Minor axis length of structure

440356007

SNOMED CT

Perpendicular axis length of structure

439429003

SNOMED CT

Radius of structure

440433004

SNOMED CT

Perimeter of non-circular structure

439747008

SNOMED CT

Circumference of circular structure

439748003

SNOMED CT

Diameter of circular structure

439746004

SNOMED CT

Area of structure

439985001

SNOMED CT

Area of body region

439749006

SNOMED CT

Volume of structure

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Table 275: DICOM Quantity Measurement Type Value Set
Value Set: DICOMQuantityMeasurementTypeCodes 2.16.840.1.113883.11.20.9.30 DYNAMIC
Code System(s): DCM 1.2.840.10008.2.16.4
Code

Code
System

Print Name

Measurement
Type

121211

DCM

Path length

Linear

121206

DCM

Distance

Linear

121207

DCM

Height

Linear

121216

DCM

Volume estimated from single 2D region

Volume

121218

DCM

Volume estimated from two non-coplanar
2D regions

Volume

121217

DCM

Volume estimated from three or more noncoplanar 2D regions

Volume

121222

DCM

Volume of sphere

Volume

121221

DCM

Volume of ellipsoid

Volume

121220

DCM

Volume of circumscribed sphere

Volume

121219

DCM

Volume of bounding three dimensional
region

Volume

Figure 223: Quantity measurement observation example










codeSystemVersion="1.5"/>




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6.68 Reaction Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.9(open)]
Table 276: Reaction Observation Contexts
Used By:

Contains Entries:

Allergy - Intolerance Observation
Medication Activity
Immunization Activity

Medication Activity
Procedure Activity Procedure
Severity Observation

This clinical statement represents an undesired symptom, finding, etc., due to
an administered or exposed substance. A reaction can be defined with respect to
its severity, and can have been treated by one or more interventions.
Table 277: Reaction Observation Constraints Overview
Name

XPath

Green
Reaction
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.9']

reaction
Coded

Verb

Data
Type

CONF
#

Fixed Value

@classCode

1..1

SHALL

7325

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

7326

2.16.840.1.113883.5.10
01 (ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10523

id

1..1

SHALL

7329

code

1..1

SHALL

16851

text

0..1

SHOULD

7330

reference

0..1

SHOULD

15917

@value

@root

reaction
FreeText

Card.

SET

7323

0..1

SHOULD

15918

statusCode

1..1

SHALL

7328

effectiveTime

0..1

SHOULD

TS or
IVL

7332

low

0..1

SHOULD

TS

7333

high

2.16.840.1.113883.10.2
0.22.4.9

2.16.840.1.113883.5.14
(ActStatus) = completed

0..1

SHOULD

TS

7334

value

1..1

SHALL

CD

7335

entryRelationship

0..*

MAY

7337

@typeCode

1..1

SHALL

7338

2.16.840.1.113883.5.10
02
(HL7ActRelationshipTyp
e) = RSON

@inversionInd

1..1

SHALL

7343

true

2.16.840.1.113883.3.88.
12.3221.7.4 (Problem)

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Name

XPath

Card.

Verb

1..1

SHALL

15920

0..*

MAY

7340

@typeCode

1..1

SHALL

7341

2.16.840.1.113883.5.10
02
(HL7ActRelationshipTyp
e) = RSON

@inversionInd

1..1

SHALL

7344

true

1..1

SHALL

15921

0..1

SHOULD

7580

@typeCode

1..1

SHALL

7581

2.16.840.1.113883.5.10
02
(HL7ActRelationshipTyp
e) = SUBJ

@inversionInd

1..1

SHALL

10375

true

observation

1..1

SHALL

15922

procedure
entryRelationship

substance
Administration
severity

entryRelationship

Data
Type

CONF
#

Fixed Value

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7325).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7326).
3. SHALL contain exactly one [1..1] templateId (CONF:7323) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.9" (CONF:10523).
4. SHALL contain exactly one [1..1] id (CONF:7329).
5. SHALL contain exactly one [1..1] code (CONF:16851).
a. The value set for this code element has not been specified.
Implementers are allowed to use any code system, such as SNOMED
CT, a locally determined code, or a nullFlavor (CONF:16852).
6. SHOULD contain zero or one [0..1] text (CONF:7330).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15917).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15918).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15919).

7. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:7328).
8. SHOULD contain zero or one [0..1] effectiveTime (CONF:7332).
a. The effectiveTime, if present, SHOULD contain zero or one [0..1] low
(CONF:7333).

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b. The effectiveTime, if present, SHOULD contain zero or one [0..1] high
(CONF:7334).
9. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHALL be selected from ValueSet Problem
2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:7335).
10. MAY contain zero or more [0..*] entryRelationship (CONF:7337) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7338).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:7343).
c. SHALL contain exactly one [1..1] Procedure Activity Procedure
(templateId:2.16.840.1.113883.10.20.22.4.14) (CONF:15920).
i.

This procedure activity is intended to contain information
about procedures that were performed in response to an
allergy reaction (CONF:16853).

11. MAY contain zero or more [0..*] entryRelationship (CONF:7340) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002 STATIC) (CONF:7341).
b. SHALL contain exactly one [1..1] @inversionInd="true" True
(CONF:7344).
c. SHALL contain exactly one [1..1] Medication Activity
(templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:15921).
i.

This medication activity is intended to contain information
about medications that were administered in response to an
allergy reaction (CONF:16840).

12. SHOULD contain zero or one [0..1] entryRelationship (CONF:7580) such
that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:7581).
b. SHALL contain exactly one [1..1] @inversionInd="true" TRUE
(CONF:10375).
c. SHALL contain exactly one [1..1] Severity Observation
(templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:15922).

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Figure 224: Reaction observation example









6.69 Referenced Frames Observation
[observation: templateId 2.16.840.1.113883.10.20.6.2.10(open)]
A Referenced Frames Observation is used if the referenced DICOM SOP instance
is a multiframe image and the reference does not apply to all frames. The list of
integer values for the referenced frames of a DICOM multiframe image SOP
instance is contained in a Boundary Observation nested inside this class.
Table 278: Referenced Frames Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.6.2.10']
@classCode

1..1

SHALL

9276

2.16.840.1.113883.5.6
(HL7ActClass) = ROIBND

@moodCode

1..1

SHALL

9277

2.16.840.1.113883.5.1001
(ActMood) = EVN

code

1..1

SHALL

9278

1.2.840.10008.2.16.4 (DCM) =
121190

entryRelationship

1..1

SHALL

9279

@typeCode

1..1

SHALL

9280

observation

1..1

SHALL

15923

CE

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) = COMP

1. SHALL contain exactly one [1..1] @classCode="ROIBND" Bounded Region of
Interest (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass)
(CONF:9276).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
2.16.840.1.113883.5.1001 ActMood) (CONF:9277).
3. SHALL contain exactly one [1..1] code="121190" Referenced Frames
(CodeSystem: 1.2.840.10008.2.16.4 DCM) (CONF:9278).
4. SHALL contain exactly one [1..1] entryRelationship (CONF:9279).

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a. This entryRelationship SHALL contain exactly one [1..1]
@typeCode="COMP" Component (CodeSystem:
2.16.840.1.113883.5.1002 HL7ActRelationshipType)
(CONF:9280).
b. This entryRelationship SHALL contain exactly one [1..1] Boundary
Observation (templateId:2.16.840.1.113883.10.20.6.2.11)
(CONF:9281).
Figure 225: Referenced frames observation example













6.70 Result Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.2(open)]
Table 279: Result Observation Contexts
Used By:

Contains Entries:

Result Organizer
Functional Status Section

This clinical statement represents details of a lab, radiology, or other study
performed on a patient.
The result observation includes a statusCode to allow recording the status of an
observation. If a Results Observation is not completed, the Result Organizer
must include corresponding statusCode. “Pending” results (e.g., a test has been
run but results have not been reported yet) should be represented as “active”
ActStatus.

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Table 280: Result Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Green
Result
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.2']

@classCode

1..1

SHALL

7130

2.16.840.1.113883.5.
6 (HL7ActClass) =
OBS

@moodCode

1..1

SHALL

7131

2.16.840.1.113883.5.
1001 (ActMood) =
EVN

templateId

1..1

SHALL

1..1

SHALL

@root

SET<
II>

7136
9138

resultID

id

1..*

SHALL

resultType

code

1..1

SHALL

text

0..1

SHOULD

7138

reference

0..1

SHOULD

15924

@value

0..1

SHOULD

15925

1..1

SHALL

7134

1..1

SHALL

14849

resultStatus

statusCode
@code

1..1

SHALL

resultValue

value

1..1

SHALL

7143

resultInterp
retation

interpretationCode

0..*

SHOULD

7147

methodCode

0..1

MAY

SET<
CE>

7148

targetSiteCode

0..1

MAY

SET<
CD>

7153

author

0..1

MAY

7149

referenceRange

0..*

SHOULD

7150

1..1

SHALL

7151

0..0

SHALL
NOT

7152

code

TS or
IVL<
TS>

7133

effectiveTime

observationRange

2.16.840.1.113883.1
0.20.22.4.2

7137
CE

resultDate
Time

resultRefere
nceRange

Fixed Value

2.16.840.1.113883.1
1.20.9.39 (Result
Status)

7140

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7130).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7131).

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3. SHALL contain exactly one [1..1] templateId (CONF:7136) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.2" (CONF:9138).
4. SHALL contain at least one [1..*] id (CONF:7137).
5. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:7133).
a. SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or
SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:7166).
b. Laboratory results SHOULD be from LOINC (CodeSystem:
2.16.840.1.113883.6.1) or other constrained terminology named by
the US Department of Health and Human Services Office of National
Coordinator or other federal agency. Local and/or regional codes for
laboratory results are allowed. The Local and/or regional codes
SHOULD be sent in the translation element. See the Local code
example figure (CONF:9109).
6. SHOULD contain zero or one [0..1] text (CONF:7138).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15924).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15925).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15926).

7. SHALL contain exactly one [1..1] statusCode (CONF:7134).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL
be selected from ValueSet Result Status
2.16.840.1.113883.11.20.9.39 STATIC (CONF:14849).
8. SHALL contain exactly one [1..1] effectiveTime (CONF:7140).
a. Represents clinically effective time of the measurement, which may
be when the measurement was performed (e.g., a BP measurement),
or may be when sample was taken (and measured some time
afterwards) (CONF:16838).
9. SHALL contain exactly one [1..1] value (CONF:7143).
10. SHOULD contain zero or more [0..*] interpretationCode (CONF:7147).
11. MAY contain zero or one [0..1] methodCode (CONF:7148).
12. MAY contain zero or one [0..1] targetSiteCode (CONF:7153).
13. MAY contain zero or one [0..1] author (CONF:7149).
14. SHOULD contain zero or more [0..*] referenceRange (CONF:7150).
a. The referenceRange, if present, SHALL contain exactly one [1..1]
observationRange (CONF:7151).
i.

This observationRange SHALL NOT contain [0..0] code
(CONF:7152).

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Table 281: Result Status Value Set
Value Set: Result Status 2.16.840.1.113883.11.20.9.39 STATIC 2012-07-01
Code System(s):

ActStatus 2.16.840.1.113883.5.14

Description:

This value set indicates the status of the results observation or
organizer

Code

Code System

Print Name

aborted

ActStatus

aborted

active

ActStatus

active

cancelled

ActStatus

cancelled

completed

ActStatus

completed

held

ActStatus

held

suspended

ActStatus

suspended

Figure 226: Result observation example



















M 13-18 g/dl; F 12-16 g/dl




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Figure 227: No evaluation procedures (e.g., labs/x-rays) performed example



No Evaluation Procedures Performed




Figure 228: Local code example




6.71 Result Organizer
[organizer: templateId 2.16.840.1.113883.10.20.22.4.1(open)]
Table 282: Result Organizer Contexts
Used By:

Contains Entries:

Results Section (entries required)
Results Section (entries optional)

Result Observation

This clinical statement identifies set of result observations. It contains
information applicable to all of the contained result observations. Result type
codes categorize a result into one of several commonly accepted values (e.g.,
“Hematology”, “Chemistry”, “Nuclear Medicine”). These values are often implicit
in the Organizer/code (e.g., an Organizer/code of “complete blood count”
implies a ResultTypeCode of “Hematology”). This template requires
Organizer/code to include a ResultTypeCode either directly or as a
translation of a code from some other code system.
An appropriate nullFlavor can be used when the organizer/code or
organizer/id is unknown.
If any Results Observation within the organizer has a statusCode of ‘active’, the
Result Organizer must also have as statusCode of ‘active.

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Table 283: Result Organizer Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

organizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.1']
@classCode

1..1

SHALL

7121

2.16.840.1.113883.5.6 (HL7ActClass)

@moodCode

1..1

SHALL

7122

2.16.840.1.113883.5.1001 (ActMood) =
EVN

templateId

1..1

SHALL

1..1

SHALL

9134

id

1..*

SHALL

7127

code

1..1

SHALL

statusCode

1..1

SHALL

7123

1..1

SHALL

14848

1..*

SHALL

7124

1..1

SHALL

14850

@root

@code
component

SET

CE

7126
2.16.840.1.113883.10.20.22.4.1

7128
2.16.840.1.113883.11.20.9.39 (Result
Status)

observation

1. SHALL contain exactly one [1..1] @classCode (CONF:7121).
a. SHOULD contain zero or one [0..1] @classCode="CLUSTER" Cluster
(CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) OR SHOULD
contain zero or one [0..1] @classCode="BATTERY" Battery
(CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7165).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7122).
3. SHALL contain exactly one [1..1] templateId (CONF:7126) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.1" (CONF:9134).
4. SHALL contain at least one [1..*] id (CONF:7127).
5. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:7128).
a. SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1)
or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be
selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12)
(CONF:7164).
b. Laboratory results SHOULD be from LOINC (CodeSystem:
2.16.840.1.113883.6.1) or other constrained terminology named by
the US Department of Health and Human Services Office of National
Coordinator or other federal agency. Local and/or regional codes for
laboratory results SHOULD also be allowed (CONF:9108).
6. SHALL contain exactly one [1..1] statusCode (CONF:7123).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL
be selected from ValueSet Result Status
2.16.840.1.113883.11.20.9.39 STATIC 2012-04-27 (CONF:14848).
7. SHALL contain at least one [1..*] component (CONF:7124) such that it

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a. SHALL contain exactly one [1..1] Result Observation
(templateId:2.16.840.1.113883.10.20.22.4.2) (CONF:14850).
Figure 229: Result organizer example










...






...


...


6.72 Series Act
[act: templateId 2.16.840.1.113883.10.20.22.4.63 (open)]
Table 284: Series Act Contexts
Used By:

Contains Entries:

Study Act (required)

SOP Instance Observation

A Series Act contains the DICOM series information for referenced DICOM
composite objects. The series information defines the attributes that are used to
group composite instances into distinct logical sets. Each series is associated
with exactly one study. Series Act clinical statements are only instantiated in the
DICOM Object Catalog section inside a Study Act, and thus do not require a
separate templateId; in other sections, the SOP Instance Observation is included
directly.

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Table 285: Series Act Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.22.4.63']
@classCode

1..1

SHALL

9222

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

9223

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

10918

1..1

SHALL

10919

1..*

SHALL

9224

@root

1..1

SHALL

9225

@extension

0..0

SHALL
NOT

9226

1..1

SHALL

CE

9228

qualifier

1..1

SHALL

SET

9229

name

1..1

SHALL

PN

9230

value

ANY

9231

@root
id

code

1..1

SHALL

text

0..1

MAY

effectiveTime

0..1

SHOULD

entryRelationship

1..*

SHALL

9237

@typeCode

1..1

SHALL

9238

observation

1..1

SHALL

15927

2.16.840.1.113883.10.20.22.4.63

1.2.840.10008.2.16.4 (DCM) =
113015
1.2.840.10008.2.16.4 (DCM) =
121139

9233
TS or
IVL

9235

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
COMP

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:9222).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9223).
3. SHALL contain exactly one [1..1] templateId (CONF:10918) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.63" (CONF:10919).
4. SHALL contain at least one [1..*] id (CONF:9224).
The @root contains the OID of the study instance UID since DICOM study ids
consist only of an OID
a. Such ids SHALL contain exactly one [1..1] @root (CONF:9225).
b. Such ids SHALL NOT contain [0..0] @extension (CONF:9226).
5. SHALL contain exactly one [1..1] code="113015" with @xsi:type="CE"
(CodeSystem: DCM 1.2.840.10008.2.16.4) (CONF:9228).
a. This code SHALL contain exactly one [1..1] qualifier (CONF:9229).

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i.

This qualifier SHALL contain exactly one [1..1] name="121139"
Modality (CodeSystem: DCM 1.2.840.10008.2.16.4)
(CONF:9230).

The value element code contains a modality code and codeSystem is
1.2.840.10008.2.16.4
ii. This qualifier SHALL contain exactly one [1..1] value with
@xsi:type="ANY" (CONF:9231).
If present, the text element contains the description of the series
6. MAY contain zero or one [0..1] text (CONF:9233).
If present, the effectiveTime contains the time the series was started
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:9235).
8. SHALL contain at least one [1..*] entryRelationship (CONF:9237) such that
it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9238).
b. SHALL contain exactly one [1..1] SOP Instance Observation
(templateId:2.16.840.1.113883.10.20.6.2.8) (CONF:15927).
Figure 230: Series act example





 
 






...




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6.73 Service Delivery Location
[participantRole: templateId 2.16.840.1.113883.10.20.22.4.32(open)]
Table 286: Service Delivery Location Contexts
Used By:

Contains Entries:

Procedure Activity Procedure
Procedure Activity Observation
Procedure Activity Act
Encounter Activities

This clinical statement represents the location of a service event where an act,
observation or procedure took place.
Table 287: Service Delivery Location Constraints Overview

Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

participantRole[templateId/@root = '2.16.840.1.113883.10.20.22.4.32']
@classCode

1..1

SHALL

templateId

1..1

SHALL

1..1

SHALL

10524

2.16.840.1.113883.10.20.22.4.
32

code

1..1

SHALL

16850

2.16.840.1.113883.1.11.20275
(HealthcareServiceLocation)

addr

0..*

SHOULD

SET

7760

telecom

0..*

SHOULD

SET

7761

playingEntity

0..1

MAY

7762

@classCode

1..1

SHALL

7763

name

0..1

MAY

16037

@root

7758
SET

2.16.840.1.113883.5.111
(RoleCode) = SDLOC

7635

2.16.840.1.113883.5.41
(EntityClass) = PLC

1. SHALL contain exactly one [1..1] @classCode="SDLOC" (CodeSystem:
RoleCode 2.16.840.1.113883.5.111 STATIC) (CONF:7758).
2. SHALL contain exactly one [1..1] templateId (CONF:7635) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.32" (CONF:10524).
3. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet
HealthcareServiceLocation 2.16.840.1.113883.1.11.20275
(CONF:16850).
4. SHOULD contain zero or more [0..*] addr (CONF:7760).
5. SHOULD contain zero or more [0..*] telecom (CONF:7761).
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6. MAY contain zero or one [0..1] playingEntity (CONF:7762).
a. The playingEntity, if present, SHALL contain exactly one [1..1]
@classCode="PLC" (CodeSystem: EntityClass
2.16.840.1.113883.5.41 STATIC) (CONF:7763).
b. The playingEntity, if present, MAY contain zero or one [0..1] name
(CONF:16037).
Table 288: HealthcareServiceLocation Value Set (excerpt)

Value Set: HealthcareServiceLocation 2.16.840.1.113883.1.11.20275 DYNAMIC
Code System(s):

HealthcareServiceLocation 2.16.840.1.113883.6.259

Description:

A comprehensive classification of locations and settings where healthcare services
are provided. This value set is based on the National Healthcare Safety Network
(NHSN) location code system that has been developed over a number of years
through CDC's interaction with a variety of healthcare facilities and is intended to
serve a variety of reporting needs where coding of healthcare service locations is
required.
Full value set may be found at:

http://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOption
s.searchText=Healthcare+Service+Location+%28NHSN%29
Code

Code System

Print Name

1024-9

HealthcareServiceLocation

Critical Care Unit

1117-1

HealthcareServiceLocation

Family Medicine Clinic

1128-8

HealthcareServiceLocation

Pediatric Clinic

1160-1

HealthcareServiceLocation

Urgent Care Center

…

Figure 231: Service delivery location example




17 Daws Rd.
Blue Bell
MA
02368
US



Good Health Clinic



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6.74 Severity Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.8(open)]
Table 289: Severity Observation Contexts
Used By:

Contains Entries:

Reaction Observation
Allergy - Intolerance Observation

This clinical statement represents the gravity of the problem, such as allergy or
reaction, in terms of its actual or potential impact on the patient. The Severity
Observation can be associated with an Allergy Observation, Reaction
Observation or both. When the Severity Observation is associated directly with
an Allergy it characterizes the Allergy. When the Severity Observation is
associated with a Reaction Observation it characterizes a Reaction. A person
may manifest many symptoms in a reaction to a single substance, and each
reaction to the substance can be represented. However, each reaction
observation can have only one severity observation associated with it. For
example, someone may have a rash reaction observation as well as an itching
reaction observation, but each can have only one level of severity.
Table 290: Severity Observation Constraints Overview
Name

XPath

Green
Severity
Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.8']

Verb

Data
Type

CONF#

Fixed Value

@classCode

1..1

SHALL

7345

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

7346

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

code

1..1

SHALL

text

0..1

SHOULD

7350

reference

0..1

SHOULD

15928

@value

0..1

SHOULD

15929

1..1

SHALL

7352

@root

severityFree
Text

Card.

statusCode

SET<
II>

CE

7347
10525

2.16.840.1.113883.10.20.22.
4.8

7349

2.16.840.1.113883.5.4
(ActCode) = SEV

2.16.840.1.113883.5.14
(ActStatus) = completed

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Name
severity
Coded

XPath
value
interpretation
Code
@code

Card.

Verb

Data
Type

CONF#

Fixed Value

1..1

SHALL

CD

7356

2.16.840.1.113883.3.88.12.3
221.6.8 (Problem Severity)

0..*

SHOULD

9117

0..1

SHOULD

16038

2.16.840.1.113883.1.11.78
(Observation Interpretation
(HL7))

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7345).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7346).
3. SHALL contain exactly one [1..1] templateId (CONF:7347) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.8" (CONF:10525).
4. SHALL contain exactly one [1..1] code="SEV" Severity Observation with
@xsi:type="CE" (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC)
(CONF:7349).
5. SHOULD contain zero or one [0..1] text (CONF:7350).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15928).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15929).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15930).

6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:7352).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHALL be selected from ValueSet Problem Severity
2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC (CONF:7356).
8. SHOULD contain zero or more [0..*] interpretationCode (CONF:9117).
a. The interpretationCode, if present, SHOULD contain zero or one [0..1]
@code, which SHOULD be selected from ValueSet Observation
Interpretation (HL7) 2.16.840.1.113883.1.11.78 DYNAMIC
(CONF:16038).
Table 291: Problem Severity Value Set

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Value Set: Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC
Code System(s): SNOMED CT 2.16.840.1.113883.6.96
Description:

This is a description of the level of the severity of the problem.

Code

Code System

Print Name

255604002

SNOMED CT

Mild (qualifier value)

371923003

SNOMED CT

Mild to moderate (qualifier value)

6736007

SNOMED CT

Moderate (severity modifier) (qualifier value)

371924009

SNOMED CT

Moderate to severe (qualifier value)

24484000

SNOMED CT

Severe (severity modifier) (qualifier value)

399166001

SNOMED CT

Fatal (qualifier value)

Figure 232: Severity observation example











6.75 Smoking Status Observation
[observation: templateId 2.16.840.1.113883.10.22.4.78 (open)]
Table 292: Smoking Status Observation Contexts
Used By:

Contains Entries:

Social History Section (optional)

This clinical statement represents a patient’s current smoking status. The
vocabulary selected for this clinical statement is the best approximation of the
statuses in Meaningful Use (MU) Stage 1.
If the patient is a smoker (77176002), the effectiveTime/low element must be
present. If the patient is an ex-smoker (8517006), both the effectiveTime/low
and effectiveTime/high element must be present.
The smoking status value set includes a special code to communicate if the
smoking status is unknown which is different from how Consolidated CDA
generally communicates unknown information.
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Table 293: Smoking Status Observation Constraints Overview
Name

XPath

Card.

Verb

Data Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.22.4.78']
@classCode

1..1

SHALL

14806

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

14807

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

14815

1..1

SHALL

14816

2.16.840.1.113883.10.22.4.78

code

1..1

SHALL

14808

2.16.840.1.113883.5.4 (ActCode) =
ASSERTION

statusCode

1..1

SHALL

14809

2.16.840.1.113883.5.14 (ActStatus) =
completed

effectiveTime

1..1

SHALL

low

1..1

SHALL

value

1..1

SHALL

1..1

SHALL

@root

@code

TS or
IVL

14814
14818

CD

14810
14817

2.16.840.1.113883.10.22.4.78
(Smoking Status)

1. Conforms to Tobacco Use template
(2.16.840.1.113883.10.20.22.4.85).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:14806).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:14807).
4. SHALL contain exactly one [1..1] templateId (CONF:14815) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.22.4.78" (CONF:14816).
5. SHALL contain exactly one [1..1] code="ASSERTION" Assertion (CodeSystem:
ActCode 2.16.840.1.113883.5.4) (CONF:14808).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:14809).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:14814).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:14818).
8. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:14810).
a. This value SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet Smoking Status
2.16.840.1.113883.10.22.4.78 DYNAMIC (CONF:14817).

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Table 294: Smoking Status Value Set
Value Set: Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2012-07-01
Code System(s):

SNOMED CT 2.16.840.1.113883.6.96

Description:

This value set indicates the current smoking status of a patient

Code

Code System

Print Name

449868002

SNOMED CT

Current every day smoker

428041000124106

SNOMED CT

Current some day smoker

8517006

SNOMED CT

Former smoker

266919005

SNOMED CT

Never smoker (Never Smoked)

77176002

SNOMED CT

Smoker, current status unknown

266927001

SNOMED CT

Unknown if ever smoked

Figure 233: Smoking status observation example











Figure 234: Unknown if ever smoked












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6.76 Social History Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.38(open)]
Table 295: Social History Observation Contexts
Used By:

Contains Entries:

Social History Section

This Social History Observation defines the patient’s occupational, personal
(e.g., lifestyle), social, and environmental history and health risk factors, as well
as administrative data such as marital status, race, ethnicity, and religious
affiliation.
Table 296: Social History Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.38']
@classCode

1..1

SHALL

8548

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8549

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

id

1..*

SHALL

II

8551

code

0..1

SHOULD

CD

8558

code

0..1

SHOULD

original
Text

0..1

SHOULD

reference
/@value

0..1

SHOULD

statusCode

1..1

SHALL

CS

8553

value

0..1

SHOULD

ANY

8559

@root

social
History
Type
social
History
FreeText

social
History
Observed
Value

SET

8550
10526

8896

ED

2.16.840.1.113883.10.20.22.
4.38

2.16.840.1.113883.3.88.12.8
0.60 (Social History Type Set
Definition)

8893

8894
2.16.840.1.113883.5.14
(ActStatus) = completed

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8548).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:8549).
3. SHALL contain exactly one [1..1] templateId (CONF:8550) such that it

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a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.38" (CONF:10526).
4. SHALL contain at least one [1..*] id (CONF:8551).
5. SHOULD contain zero or one [0..1] code (CONF:8558).
a. The code, if present, SHOULD contain zero or one [0..1] code, where
the @code SHOULD be selected from ValueSet Social History Type
Set Definition 2.16.840.1.113883.3.88.12.80.60 STATIC
(2008-12-18 CONF:8896).
b. The code, if present, SHOULD contain zero or one [0..1] originalText
(CONF:8893).
i.

The originalText, if present, SHOULD contain zero or one [0..1]
reference/@value (CONF:8894).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:8895).

6. SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem:
ActStatus 2.16.840.1.113883.5.14) (CONF:8553).
7. SHOULD contain zero or one [0..1] value with @xsi:type="ANY" (CONF:8559).
a. Observation/value can be any data type. Where Observation/value is
a physical quantity, the unit of measure SHALL be expressed using a
valid Unified Code for Units of Measure (UCUM) expression
(CONF:8555).
Table 297: Social History Type Set Definition Value Set
Value Set: Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60
STATIC 2008-12-18
Code System(s):
Code

SNOMED CT 2.16.840.1.113883.6.96
Code System

Print Name

229819007

SNOMED CT

Tobacco use and exposure

256235009

SNOMED CT

Exercise

160573003

SNOMED CT

Alcohol intake

364393001

SNOMED CT

Nutritional observable

364703007

SNOMED CT

Employment detail

425400000

SNOMED CT

Toxic exposure status

363908000

SNOMED CT

Details of drug misuse behavior

228272008

SNOMED CT

Health-related behavior

105421008

SNOMED CT

Educational Achievement

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Figure 235: Social history observation template example













None


6.77 SOP Instance Observation
[observation: templateId 2.16.840.1.113883.10.20.6.2.8(open)]
Table 298: SOP Instance Observation Contexts
Used By:

Contains Entries:

Series Act
Text Observation
Code Observations
Quantity Measurement Observation

Purpose of Reference Observation
Referenced Frames Observation
SOP Instance Observation

A SOP Instance Observation contains the DICOM Service Object Pair (SOP)
Instance information for referenced DICOM composite objects. The SOP Instance
act class is used to reference both image and non-image DICOM instances. The
text attribute contains the DICOM WADO reference.
Table 299: SOP Instance Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.6.2.8']
@classCode

1..1

SHALL

9240

2.16.840.1.113883.5.6
(HL7ActClass) = DGIMG

@moodCode

1..1

SHALL

9241

2.16.840.1.113883.5.1001
(ActMood) = EVN

id

1..*

SHALL

II

9242

code

1..1

SHALL

CD

9244

text

0..1

SHOULD

ED

9246

@mediaType

1..1

SHALL

9247

reference

1..1

SHALL

9248

application/dicom

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Name

XPath

Card.

Verb

Data
Type

CONF#

0..1

SHOULD

TS or
IVL

9250

@value

1..1

SHALL

low

0..0

SHALL
NOT

TS

9252

high

0..0

SHALL
NOT

TS

9253

0..*

MAY

9254

1..1

SHALL

9255

0..*

MAY

9257

@typeCode

1..1

SHALL

9258

observation

1..1

SHALL

15935

effectiveTime

entryRelationship
@typeCode

entryRelationship

entryRelationship

Fixed Value

9251

0..*

MAY

9260

@typeCode

1..1

SHALL

9261

observation

1..1

SHALL

15936

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SUBJ
2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
RSON

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
COMP

1. SHALL contain exactly one [1..1] @classCode="DGIMG" Diagnostic Image
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9240).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9241).
3. SHALL contain at least one [1..*] id (CONF:9242).
a. The @root contains an OID representing the DICOM SOP Instance
UID (CONF:9243).
4. SHALL contain exactly one [1..1] code (CONF:9244).
a. SHALL contain codeSystem 1.2.840.10008.2.6.1 DCMUID and code is
an OID for a valid SOP class name UID (CONF:9245).
5. SHOULD contain zero or one [0..1] text (CONF:9246).
a. The text, if present, SHALL contain exactly one [1..1]
@mediaType="application/dicom" (CONF:9247).
b. The text, if present, SHALL contain exactly one [1..1] reference
(CONF:9248).
i.

contain a @value that contains a WADO reference as a
URI (CONF:9249).
SHALL

6. SHOULD contain zero or one [0..1] effectiveTime (CONF:9250).
a. The effectiveTime, if present, SHALL contain exactly one [1..1] @value
(CONF:9251).
b. The effectiveTime, if present, SHALL NOT contain [0..0] low
(CONF:9252).
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c. The effectiveTime, if present, SHALL NOT contain [0..0] high
(CONF:9253).
7. MAY contain zero or more [0..*] entryRelationship (CONF:9254) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9255).
b. SHALL contain exactly one [1..1] SOP Instance Observation
(2.16.840.1.113883.10.20.6.2.8) (CONF:9256).
8. MAY contain zero or more [0..*] entryRelationship (CONF:9257) such that
it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9258).
b. SHALL contain exactly one [1..1] Purpose of Reference
Observation (2.16.840.1.113883.10.20.6.2.9) (CONF:15935).
9. MAY contain zero or more [0..*] entryRelationship (CONF:9260) such that
it
a. This entryRelationship SHALL be present if the referenced DICOM
object is a multiframe object and the reference does not apply to all
frames (CONF:9263).
b. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9261).
c. SHALL contain exactly one [1..1] Referenced Frames Observation
(2.16.840.1.113883.10.20.6.2.10) (CONF:15936).
Figure 236: SOP instance observation example












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6.78 Study Act
[act: templateId 2.16.840.1.113883.10.20.6.2.6 (open)]
Table 300: Study Act Contexts
Used By:

Contains Entries:

DICOM Object Catalog Section - DCM 121181 (required)

Series Act

A Study Act contains the DICOM study information that defines the
characteristics of a referenced medical study performed on a patient. A study is
a collection of one or more series of medical images, presentation states, SR
documents, overlays, and/or curves that are logically related for the purpose of
diagnosing a patient. Each study is associated with exactly one patient. A study
may include composite instances that are created by a single modality, multiple
modalities, or by multiple devices of the same modality. The study information is
modality-independent. Study Act clinical statements are only instantiated in the
DICOM Object Catalog section; in other sections, the SOP Instance Observation
is included directly.

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Table 301: Study Act Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

act[templateId/@root = '2.16.840.1.113883.10.20.6.2.6']
@classCode

1..1

SHALL

9207

2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

9208

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

10533

1..*

SHALL

9210

@root

1..1

SHALL

9213

@extension

0..0

SHALL
NOT

9211

code

1..1

SHALL

text

0..1

MAY

9215

reference

0..1

SHOULD

15995

@value

0..1

SHOULD

15996

effectiveTime

0..1

SHOULD

entryRelationship

1..*

SHALL

9219

@typeCode

1..1

SHALL

9220

act

1..1

SHALL

15937

@root
id

SET

CE

TS or
IVL

9209

9214

2.16.840.1.113883.10.20.6.2.6

1.2.840.10008.2.16.4 (DCM) =
113014

9216

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
COMP

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6) (CONF:9207).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
2.16.840.1.113883.5.1001) (CONF:9208).
3. SHALL contain exactly one [1..1] templateId (CONF:9209) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.6" (CONF:10533).
4. SHALL contain at least one [1..*] id (CONF:9210).
The @root contains the OID of the study instance UID since DICOM study ids
consist only of an OID
a. Such ids SHALL contain exactly one [1..1] @root (CONF:9213).
b. Such ids SHALL NOT contain [0..0] @extension (CONF:9211).
5. SHALL contain exactly one [1..1] code="113014" with @xsi:type="CE"
(CodeSystem: DCM 1.2.840.10008.2.16.4) (CONF:9214).
If present, the text element contains the description of the study.
6. MAY contain zero or one [0..1] text (CONF:9215).

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a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15995).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15996).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15997).

If present, the effectiveTime contains the time the study was started
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:9216).
8. SHALL contain at least one [1..*] entryRelationship (CONF:9219) such that
it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Component
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9220).
b. SHALL contain exactly one [1..1] Series Act
(templateId:2.16.840.1.113883.10.20.22.4.63) (CONF:15937).
Figure 237: Study act example







...




6.79 Text Observation
[observation: templateId 2.16.840.1.113883.10.20.6.2.12 (open)]
Table 302: Text Observation Contexts
Used By:

Contains Entries:
Quantity Measurement Observation
SOP Instance Observation

DICOM Template 2000 specifies that Imaging Report Elements of Value Type
Text are contained in sections. The Imaging Report Elements are inferred from
Basic Diagnostic Imaging Report Observations that consist of image references
and measurements (linear, area, volume, and numeric). Text DICOM Imaging
Report Elements in this context are mapped to CDA text observations that are
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section components and are related to the SOP Instance Observations
(templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement
Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT
(Support) act relationship.
A Text Observation is required if the findings in the section text are represented
as inferred from SOP Instance Observations.
Table 303: Text Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.6.2.12']
@classCode

1..1

SHALL

9288

2.16.840.1.113883.5.4 (ActCode)
= OBS

@moodCode

1..1

SHALL

9289

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

code

1..1

SHALL

text

0..1

MAY

9295

reference

0..1

SHOULD

15938

@value

0..1

SHOULD

15939

effectiveTime

0..1

SHOULD

TS or
IVL

9294

value

1..1

SHALL

ED

9292

entryRelationship

@root

SET

9290
10534

CE

9291

0..*

MAY

9298

@typeCode

1..1

SHALL

9299

observation

1..1

SHALL

15941

0..*

MAY

9301

@typeCode

1..1

SHALL

9302

observation

1..1

SHALL

15942

entryRelationship

2.16.840.1.113883.10.20.6.2.12

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SPRT

2.16.840.1.113883.5.1002
(HL7ActRelationshipType) =
SPRT

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:9288).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:9289).
3. SHALL contain exactly one [1..1] templateId (CONF:9290) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.6.2.12" (CONF:10534).
4. SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:9291).
5. MAY contain zero or one [0..1] text (CONF:9295).

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a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15938).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15939).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15940).

6. SHOULD contain zero or one [0..1] effectiveTime (CONF:9294).
7. SHALL contain exactly one [1..1] value with @xsi:type="ED" (CONF:9292).
8. MAY contain zero or more [0..*] entryRelationship (CONF:9298) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SPRT" Has Support
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9299).
b. SHALL contain exactly one [1..1] SOP Instance Observation
(templateId:2.16.840.1.113883.10.20.6.2.8) (CONF:15941).
9. MAY contain zero or more [0..*] entryRelationship (CONF:9301) such that
it
a. SHALL contain exactly one [1..1] @typeCode="SPRT" Has Support
(CodeSystem: HL7ActRelationshipType
2.16.840.1.113883.5.1002) (CONF:9302).
b. SHALL contain exactly one [1..1] Quantity Measurement
Observation (templateId:2.16.840.1.113883.10.20.6.2.14)
(CONF:15942).

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Figure 238: Text observation example


Finding
The cardiomediastinum is within normal limits.
The trachea is midline. The previously described opacity at the medial
right lung base has cleared. There are no new infiltrates. There is a new
round density at the left hilus, superiorly (diameter about 45mm). A CT
scan is recommended for further evaluation. The pleural spaces are clear.
The visualized musculoskeletal structures and the upper abdomen are
stable and unremarkable.

...







...




6.80 Tobacco Use
[observation: templateId 2.16.840.1.113883.10.20.22.4.85 (open)]
Table 304: Tobacco Use Observation Contexts
Used By:

Contains Entries:

Social History Section (optional)

This clinical statement represents a patient’s tobacco use. All types of tobacco
use are represented using the codes from the tobacco use and exposure - finding
hierarchy in SNOMED CT.

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Table 305: Tobacco Use Constraints Overview
Name

XPath

Card.

Verb

Data Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.85']
@classCode

1..1

SHALL

16558

2.16.840.1.113883.5.6 (HL7ActClass)
= OBS

@moodCode

1..1

SHALL

16559

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

16566

1..1

SHALL

16567

2.16.840.1.113883.10.22.4.78

code

1..1

SHALL

16560

2.16.840.1.113883.5.4 (ActCode) =
ASSERTION

statusCode

1..1

SHALL

16561

2.16.840.1.113883.5.14 (ActStatus) =
completed

effectiveTime

1..1

SHALL

low

1..1

SHALL

value

1..1

SHALL

1..1

SHALL

@root

@code

TS or
IVL

16564
16565

CD

16562
16563

2.16.840.1.113883.11.20.9.41
(Tobacco Use)

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:16558).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:16559).
3. SHALL contain exactly one [1..1] templateId (CONF:16566) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.22.4.78" (CONF:16567).
4. SHALL contain exactly one [1..1] code="ASSERTION" Assertion (CodeSystem:
ActCode 2.16.840.1.113883.5.4) (CONF:16560).
5. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:16561).
6. SHALL contain exactly one [1..1] effectiveTime (CONF:16564).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:16565).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:16562).
a. This value SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet Tobacco Use
2.16.840.1.113883.11.20.9.41 DYNAMIC (CONF:16563).

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Table 306: Tobacco Use Value Set
Value Set: Tobacco Use 2.16.840.1.113883.11.20.9.41 DYNAMIC
Code System(s): SNOMED CT 2.16.840.1.113883.6.96
Description:

Contains all values descending from the SNOMED CT® 365980008 tobacco
use and exposure - finding hierarchy

http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html
Code

Code System

Print Name

81703003

Chews tobacco

228494002

SNOMED-CT
SNOMED-CT

59978006

SNOMED-CT

Cigar smoker

43381005

SNOMED-CT

449868002

SNOMED CT

Current every day smoker

428041000124
106

SNOMED CT

Current some day smoker

8517006

SNOMED CT

Former smoker

266919005

SNOMED CT

Never smoker

77176002

SNOMED CT

Smoker, current status unknown

266927001

SNOMED CT

Unknown if ever smoked

Snuff user

Passive smoker

…

Figure 239: Tobacco use entry example










6.81 Vital Sign Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.27(open)]
Table 307: Vital Sign Observation Contexts
Used By:

Contains Entries:

Vital Signs Organizer

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Vital signs are represented as are other results, with additional vocabulary
constraints.
Table 308: Vital Sign Observation Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.27']
@classCode

1..1

SHALL

7297

2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

7298

2.16.840.1.113883.5.1001
(ActMood) = EVN

templateId

1..1

SHALL

1..1

SHALL

id

1..*

SHALL

code

1..1

SHALL

text

0..1

SHOULD

7302

reference

0..1

SHOULD

15943

@value

@root

SET

7299
10527

2.16.840.1.113883.10.20.22
.4.27

7300
CD

7301

0..1

SHOULD

15944

statusCode

1..1

SHALL

7303

effectiveTime

1..1

SHALL

TS or
IVL

7304

value

1..1

SHALL

PQ

7305

interpretationCode

0..1

MAY

methodCode

0..1

MAY

SET

7308

targetSiteCode

0..1

MAY

SET

7309

author

0..1

MAY

2.16.840.1.113883.3.88.12.
80.62 (HITSP Vital Sign
Result Type)

2.16.840.1.113883.5.14
(ActStatus) = completed

7307

7310

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7297).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7298).
3. SHALL contain exactly one [1..1] templateId (CONF:7299) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.27" (CONF:10527).
4. SHALL contain at least one [1..*] id (CONF:7300).
5. SHALL contain exactly one [1..1] code, where the @code SHOULD be selected
from ValueSet HITSP Vital Sign Result Type
2.16.840.1.113883.3.88.12.80.62 DYNAMIC (CONF:7301).
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6. SHOULD contain zero or one [0..1] text (CONF:7302).
a. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:15943).
i.

The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:15944).
1. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the
approach defined in CDA Release 2, section 4.3.5.1)
(CONF:15945).

7. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7303).
8. SHALL contain exactly one [1..1] effectiveTime (CONF:7304).
9. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7305).
10. MAY contain zero or one [0..1] interpretationCode (CONF:7307).
11. MAY contain zero or one [0..1] methodCode (CONF:7308).
12. MAY contain zero or one [0..1] targetSiteCode (CONF:7309).
13. MAY contain zero or one [0..1] author (CONF:7310).
Table 309: Vital Sign Result Type Value Set
Value Set: HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62 DYNAMIC
Code System(s): LOINC 2.16.840.1.113883.6.1
Description:

This identifies the vital sign result type

Code

Code System

Print Name

9279-1

LOINC

Respiratory Rate

8867-4

LOINC

Heart Rate

2710-2

LOINC

O2 % BldC Oximetry

8480-6

LOINC

BP Systolic

8462-4

LOINC

BP Diastolic

8310-5

LOINC

Body Temperature

8302-2

LOINC

Height

8306-3

LOINC

Height (Lying)

8287-5

LOINC

Head Circumference

3141-9

LOINC

Weight Measured

39156-5

LOINC

BMI (Body Mass Index)

3140-1

LOINC

BSA (Body Surface Area)

Page 514
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Figure 240: Vital sign observation example














6.82 Vital Signs Organizer
[organizer: templateId 2.16.840.1.113883.10.20.22.4.26(open)]
Table 310: Vital Signs Organizer Contexts
Used By:

Contains Entries:

Vital Signs Section (entries optional)
Vital Signs Section (entries required)

Vital Sign Observation

The Vital Signs Organizer groups vital signs, which is similar to the Result
Organizer, but with further constraints.
An appropriate nullFlavor can be used when the organizer/code or
organizer/id is unknown.

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Table 311: Vital Signs Organizer Constraints Overview
Name

XPath

Card.

Verb

Data
Type

CONF#

Fixed Value

organizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.26']
@classCode

1..1

SHALL

7279

2.16.840.1.113883.5.6 (HL7ActClass)
= CLUSTER

@moodCode

1..1

SHALL

7280

2.16.840.1.113883.5.1001 (ActMood)
= EVN

templateId

1..1

SHALL

1..1

SHALL

id

1..*

SHALL

II

7282

code

1..1

SHALL

CD

7283

2.16.840.1.113883.6.96 (SNOMEDCT)
= 46680005

statusCode

1..1

SHALL

CS

7284

2.16.840.1.113883.5.14 (ActStatus) =
completed

effectiveTime

1..1

SHALL

TS or
IVL

7288

component

1..*

SHALL

7285

1..1

SHALL

15946

@root

SET

7281
10528

2.16.840.1.113883.10.20.22.4.26

observation

1. SHALL contain exactly one [1..1] @classCode="CLUSTER" CLUSTER
(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7279).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem:
ActMood 2.16.840.1.113883.5.1001) (CONF:7280).
3. SHALL contain exactly one [1..1] templateId (CONF:7281) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.26" (CONF:10528).
4. SHALL contain at least one [1..*] id (CONF:7282).
5. SHALL contain exactly one [1..1] code="46680005" Vital Signs (CodeSystem:
SNOMED CT 2.16.840.1.113883.6.96) (CONF:7283).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7284).
The effectivetime represents clinically effective time of the measurement,
which is most likely when the measurement was performed (e.g., a BP
measurement).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:7288).
8. SHALL contain at least one [1..*] component (CONF:7285) such that it
a. SHALL contain exactly one [1..1] Vital Sign Observation
(2.16.840.1.113883.10.20.22.4.27) (CONF:15946).

Page 516
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Figure 241: Vital signs organizer example










...




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7

REFERENCES
American Recovery And Reinvestment Act of 2009,
http://www.gpo.gov/fdsys/pkg/PLAW-111publ5/content-detail.html
CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases (The
Pink Book), Appendix D: Vaccine Administration Guidelines.
http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/
D/vacc_admin.pdf
Cross Transaction Specifications and Content Specifications. IHE ITI
Technical Framework, Volume 3 (ITI TF-3) (see 5.2 Scanned Documents
Content Model).
http://www.ihe.net/Technical_Framework/upload/IHE_ITI_TF_60_Vol3_FT_2009-08-10.pdf
Extensible Markup Language (XML) 1.0 (Fifth Edition),
http://www.w3c.org/TR/2008/REC-xml-20081126/
Final Rules for Stage 1 Meaningful Use,
http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf
Health Information Technology: Initial Set of Standards, Implementation
Specifications, and Certification Criteria for Electronic Health Record
Technology; 45 CFR Part 170, Final Rule,
http://edocket.access.gpo.gov/2010/pdf/2010-17210.pdf
HITSP Summary Documents Using HL7 Continuity of Care Document
(CCD) Component; (HITSP/C32); Versions 2.1, 2.2, 2.3, 2.5; December
13, 2007 - July 8, 2009
HL7 Clinical Document Architecture (CDA Release 2).
http://www.hl7.org/implement/standards/cda.cfm
HL7 Implementation Guide for CDA Release 2: Consultation Notes, (U.S.
Realm), Draft Standard for Trial Use, Release 1, Levels 1, 2, and 3, DSTU
Updated: January 2010
HL7 Implementation Guide for CDA Release 2: History and Physical (H&P)
Notes (U.S. Realm) Draft Standard for Trial Use, Release 1, Levels 1, 2,
and 3 A CDA Implementation guide for History and Physical Notes, DSTU
Updated: January 2010
HL7 Implementation Guide for CDA Release 2: Procedure Note (Universal
Realm), Draft Standard for Trial Use, Release 1, Levels 1, 2, and 3, July
2010
HL7 Implementation Guide for CDA Release 2: Unstructured Documents,
Release 1, Level 1 (Universal Realm), Draft Standard for Trial Use,
September 2010
HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document
(CCD) A CDA implementation of ASTM E2369-05 Standard Specification
for Continuity of Care Record© (CCR), April 01, 2007

Page 518
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© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

HL7 Version 3 Interoperability Standards, Normative Edition 2010.
http://www.hl7.org/memonly/downloads/v3edition.cfm - V32010
HL7 Version 3 Publishing Facilitator's Guide.
http://www.hl7.org/v3ballot/html/help/pfg/pfg.htm
Implementation Guide for CDA Release 2.0 Operative Note, (U.S. Realm),
Draft Standard for Trial Use, Release 1, Levels 1, 2 and 3, Published,
March 2009
Implementation Guide for CDA Release 2.0, Care Record Summary Release
2
Discharge Summary, (U.S. Realm) Draft Standard for Trial Use, Levels 1,
2 and 3, December 2009
Implementation Guide for CDA Release 2.0, Progress Note (U.S. Realm),
Draft Standard for Trial Use, Levels 1, 2, and 3, January 2011
Implementation Guide for CDA Release 2: Imaging Integration, Levels 1, 2,
and 3, Basic Imaging Reports in CDA and DICOM Diagnostic Imaging
Reports (DIR) – Universal Realm, Based on HL7 CDA Release 2.0, Release
1.0, Informative Document, First Release, March 2009
Joint Commission Requirements for Discharge Summary (JCAHO
IM.6.10 EP7). See
http://www.jointcommission.org/NR/rdonlyres/C9298DD0-6726-4105A007-FE2C65F77075/0/CMS_New_Revised_HAP_FINAL_withScoring.pdf
(page 26).
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.
Pressure Ulcer Prevention Domain Analysis Model May 2011.
http://wiki.hl7.org/images/b/be/PressureUlcerPreventionDomainAnalys
isModel_May2011.pdf
Pressure Ulcer Prevention Domain Analysis Model, current, accessed
May 2, 2012.
http://pressureulcerpreventionmodel.com/DAM20110325/
Taber's Cyclopedic Medical Dictionary, 21st Edition, F.A. Davis
Company. http://www.tabers.com
Term Info. http://www.hl7.org/special/committees/terminfo/index.cfm
Trifolia Workbench (Consolidation Project Edition). Open source template
database. http://www.lantanagroup.com/newsroom/pressreleases/trifolia-workbench/
You must be logged in as a member of HL7.org to access this resource:
http://www.hl7.org/login/singlesignon.cfm?next=/documentcenter/priv
ate/standards/cda/Trifolia_HL7_Consolidation_20110712-dist.zip
XML Path Language (XPath), Version 1.0. http://www.w3.org/TR/xpath/

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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APPENDIX A — ACRONYMS AND ABBREVIATIONS
ADL

Activities of Daily Living

AMA

American Medical Association

CCD

Continuity of Care Document

CDA

Clinical Document Architecture

CDC

Centers for Disease Control and Prevention

DAM

Domain Analysis Model

DICOM

Digital Imaging and Communications in Medicine

DIR

Diagnostic Imaging Report

EHR

electronic health record

DSTU

Draft Standard for Trial Use

H&P

History and Physical

HIMSS

Healthcare Information and Management Systems Society

HIT

healthcare information technology

HITECH

Health Information Technology for Economic and Clinical Health

HITSP

Health Information Technology Standards Panel

HL7

Health Level Seven

HSS

U.S. Department of Health and Human Services

HTML

Hypertext Markup Language

IG

implementation guide

IHE

Integrating the Healthcare Enterprise

IHTSDO

International Health Terminology Standard Development
Organisation

LOINC

Logical Observation Identifiers Names and Codes

MDHT

Model-Driven Health Tools

MIME

Multipurpose Internet Mail Extensions

NPP

non-physician providers

NUCC

Healthcare Provider Taxonomy Code

ONC

Office of National Coordinator

PCP

primary care provider

PDF

portable document format

PHCR

Public Health case reports

PHQ

Patient Health Questionnaire

PHR

personal health record

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July 2012

PPRF

primary performers

RIM

Reference Information Model

RTF

rich text format

S&I

Standards and Interoperability

SCOORD

Spatial Coordinates

SDWG

Structured Documents Working Group

SDO

Standards Development Organization

SNOMED CT Systemized Nomenclature for Medicine – Clinical Terms
SOP

Service Object Pair

SR

Structured Report

Tdb

Template Database

TIFF

tagged-image file format

UCUM

Unified Code for Units of Measure

UD

Unstructured Document

UDI

Unique Device Identification

UML

Unified Modeling Language

URL

Uniform Resource Locator

VIS

Vaccine Information Statement

WADO

Web Access to Persistent DICOM Objects

XPath

XML Path Language

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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APPENDIX B —

CHANGES FROM PREVIOUS GUIDES

The first subsection below lists the changes in the May 2012 ballot. The
remainder of the sections in this appendix explain all changes in the
consolidation of the HL7 Health Story guides, HITSP C32, related components of
IHE PCC, and CCD.

New and Updated Templates
Table 312: Templates Added and Updated in May 2012 Ballot
Template

Type

TemplateID

The following templates were updated for this version.
US Realm Header
documentOf/serviceEvent

Header

Not applicable

DIR Header documentOf

Header

Not applicable

Assessment Section

Section

2.16.840.1.113883.10.20.22.2.8

Functional Status Section

Section

2.16.840.1.113883.10.20.22.2.14

Plan of Care Section

Section

2.16.840.1.113883.10.20.22.2.10

Social History Section

Section

2.16.840.1.113883.10.20.22.2.17

Instructions Section

Section

2.16.840.1.113883.10.20.22.2.45

Encounter Activities

Entry

2.16.840.1.113883.10.20.22.4.49

Result Observation

Entry

2.16.840.1.113883.10.20.22.4.2

Result Organizer

Entry

2.16.840.1.113883.10.20.22.4.1

The following templates were added for this version.
Assessment Scale Observation

Entry

2.16.840.1.113883.10.20.22.4.69

Deceased Observation

Entry

2.16.840.1.113883.10.20.22.4.79

Caregiver Characteristics

Entry

2.16.840.1.113883.10.20.22.4.72

Cognitive Status Problem
Observation

Entry

2.16.840.1.113883.10.20.22.4.73

Cognitive Status Result
Observation

Entry

2.16.840.1.113883.10.20.22.4.74

Cognitive Status Result Organizer

Entry

2.16.840.1.113883.10.20.22.4.75

Encounter Diagnosis

Entry

2.16.840.1.113883.10.20.22.4.80

Functional Status Problem
Observation

Entry

2.16.840.1.113883.10.20.22.4.68

Functional Status Result
Observation

Entry

2.16.840.1.113883.10.20.22.4.67

Functional Status Result
Organizer

Entry

2.16.840.1.113883.10.20.22.4.66

Health Status Observation

Entry

2.16.840.1.113883.10.20.22.4.5

Highest Pressure Ulcer Stage

Entry

2.16.840.1.113883.10.20.22.4.77

Number of Pressure Ulcers
Observation

Entry

2.16.840.1.113883.10.20.22.4.76

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July 2012

Template

Type

TemplateID

Pressure Ulcer Observation

Entry

2.16.840.1.113883.10.20.22.4.70

Smoking Status Observation

Entry

2.16.840.1.113883.10.22.4.78

Cardinality Changes
The next three tables show updates for H&P, Consultation Note, and Discharge
Summary cardinality.
Table 313: H&P Cardinality Updates
HITSP

HL7

Sections Names

(C84)

(H&P)

Current Cardinality

Problems

R

O

O

Resolved Problems

R

-

Vital Signs

-

R

R

Past Medical History

-

R

R

Table 314: Consultation Note Cardinality Updates
HITSP

HL7

Sections Names

(C84)

(H&P)

Current Cardinality

Active Problems

R

O

O – Problems

Resolved Problems

R2

-

Allergies

R

O

O

Current Meds

R

O

O

Past Medical History

-

O

O

Chief Complaint

-

O

O

Functional Status

R2

-

-

Advance Directives

R

-

-

Pertinent Insurance
Information (Payers)

R2

-

-

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Table 315: Discharge Summary Cardinality Updates
HITSP

HL7

Sections Names

(C48)

(H&P)

Current Cardinality

Problems

R

O

O

Hospital Admission
Diagnosis Section

R

-

O

Section Code Changes
The following table documents changes to section codes used in the current
Operative Note templates to conform to those in use for general procedures.
Table 316: Surgical Operative Codes Mapping to Generic Procedure Codes
Sections Names

Section Codes

Sections Names

Section Codes

Previous Operative Section Codes

Now Using

Surgical Operation Note
Anesthesia

10213-7

Anesthesia

59774-0

Surgical Operation Note
Description

8724-7

Procedure Description

29554-3

Surgical Operation Note
Disposition

55102-8

Procedure Disposition

59775-7

Surgical Operation Note
Estimated Blood Loss

55103-6

Procedure Estimated Blood
Loss

59770-8

Surgical Operation Note
Findings

10215-2

Procedure Findings

59776-5

Surgical Operation Note
Indications

10217-8

Procedure Indications

59768-2

Surgical Operation Note
Planned Procedure

55104-4

Planned Procedure

59772-4

Surgical Operation Note
Specimens Taken

10221-0

Procedure Specimens taken

59773-2

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Conformance Verbs
The next table represents a matrix of the conformance verbs used across the standards reviewed for the consolidation
guide. Cells with a dash (-) did not have an equivalent conformance convention.
Table 317: Consolidated Conformance Verb Matrix
RFC 2119

HL7

IHE

HITSP

Workgroup Consensus

SHALL

SHALL

Required/Mandatory

R (Required)
Data elements must
always be sent. A NULL
can be sent.

SHALL

Absolute requirement
of the specification

R (Required)
Element must be present
but can be NULL

Element must be present but can be
NULL
Where necessary to explicitly
preclude nullFlavor (e.g. where you
want to preclude nullFlavor on
observation/value), can include
something like "SHALL NOT include
nullFlavor".
Where SHALL is applied to an
attribute, it must be present and
cannot be a NULL

SHALL NOT

SHALL NOT

Absolute prohibition
of the specification

Not
Required/Mandatory

-

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

-

SHALL NOT

Absolute prohibition against
inclusion

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RFC 2119

HL7

IHE

HITSP

Workgroup Consensus

SHOULD

SHOULD

Best Practice or
Recommendation

R2 (Required if known)
The sending application
must be able to
demonstrate that it can
send all required if known
elements, unless it does
not in fact gather that
data. If the information
cannot be transmitted, the
data element shall contain
a value indicating the
reason for omission of the
data.

R2 (Required if known)
If the sending
application has data for
the data element, it is
REQUIRED to populate
the data element. If the
value is not known, the
data element need not be
sent

SHOULD

Recommended
There may exist valid
reasons in particular
circumstances to
ignore a particular
item, but the full
implications must be
understood and
carefully weighed
before choosing a
different course.
SHOULD NOT

SHOULD NOT

-

-

SHOULD NOT

Not Recommended

Not Recommended

MAY

MAY

Optional

Accepted/Permitted

-

-

Page 526
© 2012 Health Level Seven, Inc. All rights reserved.

Best Practice or Recommendation
There may exist valid reasons in
particular circumstances to ignore a
particular item, but the full
implications must be understood and
carefully weighed before choosing a
different course

Not Recommended
O (Optional)

O (Optional)

MAY

Optional
C (Conditional)
A conditional data element
is one that is required,
required if known or
optional depending upon
other conditions.

C (Conditional)
Required to be sent when
the conditions specified
in the HITSP additional
specifications column are
true

-

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Template ID Changes
The following table tracks changes in template IDs, for the most part representing a consolidation of separate templates
into a single template. In some cases, two new template IDs are assigned to distinguish sections where computable data
entries are required and those where entries are optional and only the human-readable narrative is required. To meet
future requirements, an Entry Required template may be added to a section that doesn’t currently contain one.
Table 318: Section Template Change Tracking
Section

LOINC
Code(s)

Consolidated Entry Optional
templateId

Consolidated Entry Required
templateId

Previous templateIds

Was

2.16.840.1.113883.10.20.1.8 (CCD)

HL7

2.16.840.1.113883.3.88.11.83.112

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.19

IHE

2.16.840.1.113883.10.20.16.2.2
(DS)

HL7

2.16.840.1.113883.3.88.11.83.114

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.22

IHE

Medications Category
Medications
Section

10160-0

Hospital
Discharge
Medications
Section

10183-2

2.16.840.1.113883.10.20.22.2
.1

2.16.840.1.113883.10.20.22.2.
1.1

2.16.840.1.113883.10.20.22.2
.11

2.16.840.1.113883.10.20.22.2.
11.1

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Section

LOINC
Code(s)

Consolidated Entry Optional
templateId

Consolidated Entry Required
templateId

Previous templateIds

Was

Medications
Administere
d Section37

29549-3
18610-6

2.16.840.1.113883.10.20.22.2
.38

Future assignment

2.16.840.1.113883.10.20.18.2.8
(Proc Note)

HL7

2.16.840.1.113883.3.88.11.83.115

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.21

IHE

2.16.840.1.113883.10.20.1.6 (CCD)

HL7

2.16.840.1.113883.3.88.11.83.117

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.23

IHE

2.16.840.1.113883.10.20.1.2 (CCD)

HL7

2.16.840.1.113883.3.88.11.83.102

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.13

IHE

2.16.840.1.113883.10.20.1.11

HL7

2.16.840.1.113883.3.88.11.83.103

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.6

IHE

2.16.840.1.113883.10.20.2.9 (H&P)

HL7

2.16.840.1.113883.3.88.11.83.104

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.8

IHE

2.16.840.1.113883.10.20.16.2.1
(DS)

HL7

2.16.840.1.113883.3.88.11.83.111

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.7

IHE

2.16.840.1.113883.10.20.7.1
(OpNote)

HL7

2.16.840.1.113883.3.88.11.83.129

HITSP

2.16.840.1.113883.10.20.7.2
(OpNote)

HL7

2.16.840.1.113883.3.88.11.83.130

HITSP

Immunizatio
ns Section

11369-6

2.16.840.1.113883.10.20.22.2
.2

Future assignment

Conditions/Concern Category
Allergies
Section
(2.2.1.2)

48765-2

Problem
Section

11450-4

History of
Past Illness
Section
(2.2.1.4)

11348-0

Hospital
Discharge
Diagnosis
Section

11535-2

Preoperative
Diagnosis
Section

10219-4

Postoperative
Diagnosis
Section

10218-6

37

2.16.840.1.113883.10.20.22.2
.6

2.16.840.1.113883.10.20.22.2
.5

2.16.840.1.113883.10.20.22.2
.20

2.16.840.1.113883.10.20.22.2
.24

2.16.840.1.113883.10.20.22.2
.34
2.16.840.1.113883.10.20.22.2
.35

2.16.840.1.113883.10.20.22.2.
6.1

2.16.840.1.113883.10.20.22.2.
5.1

Requires further discussion and resolution.

Page 528
© 2012 Health Level Seven, Inc. All rights reserved.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Section

LOINC
Code(s)

Consolidated Entry Optional
templateId

Consolidated Entry Required
templateId

Previous templateIds

Was

Chief
Complaint
Section /
Reason for
Visit

10154-3
29299-5
46239-0

Chief complaint
(1.3.6.1.4.1.19376.1.5.3.1.1.1
3.2.1)
Reason for Visit
(2.16.840.1.113883.10.20.22.
2.12)
Chief Complaint + Reason for
Visit
(2.16.840.1.113883.10.20.22.
2.13)

N/A (narrative-only)

2.16.840.1.113883.10.20.2.8 (H&P)
2.16.840.1.113883.10.20.18.2.16
(Proc Note)

HL7

2.16.840.1.113883.3.88.11.83.105

HITSP

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

IHE

Reason for
Referral
Section

42349-1

1.3.6.1.4.1.19376.1.5.3.1.3.1

N/A (narrative-only)

2.16.840.1.113883.10.20.4.8
(Consult Note)

HL7

2.16.840.1.113883.3.88.11.83.106

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.1
(narrative-only)
1.3.6.1.4.1.19376.1.5.3.1.3.2
(coded)

IHE

1.3.6.1.4.1.19376.1.5.3.1.3.4

HL7

2.16.840.1.113883.3.88.11.83.107

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.4

IHE

2.16.840.1.113883.10.20.18.2.5
(Proc Note)

HL7

2.16.840.1.113883.10.20.1.12
(CCD)
HL7:2.16.840.1.113883.10.20.18.2
.18 (Proc Note)

HL7

2.16.840.1.113883.3.88.11.83.108

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.12

IHE

2.16.840.1.113883.10.20.7.12
(OpNote)

HL7

History of
Present
Illness
Section

10164-2

Medical
(General)
History
Section

11329-0

N/A (use IHE
1.3.6.1.4.1.19376.1.5.3.1.3.4)

N/A (narrative-only)

2.16.840.1.113883.10.20.22.2
.39

Procedure and Surgery Category
Procedures
Section (List
of Surgeries)
(History of
Procedures)

Operative
Note Fluids
Section

47519-4

10216-0

2.16.840.1.113883.10.20.22.2
.7

N/A (narrative-only)

2.16.840.1.113883.10.20.7.12

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 529
© 2012 Health Level Seven, Inc. All rights reserved.

Section

LOINC
Code(s)

Consolidated Entry Optional
templateId

Operative
Note
Surgical
Procedure
Section

10223-6

Surgical
Drains
Section

Previous templateIds

Was

2.16.840.1.113883.10.20.7.14

2.16.840.1.113883.10.20.7.14
(OpNote)

HL7

11537-8

2.16.840.1.113883.10.20.7.13

2.16.840.1.113883.10.20.7.13
(OpNote)

HL7

Procedure
Indications
Section

59768-2

2.16.840.1.113883.10.20.22.2
.29

2.16.840.1.113883.10.20.18.2.1
(Proc Note)

HL7

Procedure
Description
Section

29554-3

2.16.840.1.113883.10.20.22.2
.27

2.16.840.1.113883.10.20.18.2.2
(Proc Note)

HL7

Postprocedure
Diagnosis
Section

59769-0

2.16.840.1.113883.10.20.22.2
.36

2.16.840.1.113883.10.20.18.2.3
(Proc Note)

HL7

Complications
Section

55109-3

2.16.840.1.113883.10.20.22.2
.37

2.16.840.1.113883.10.20.18.2.4
(Proc Note)
2.16.840.1.113883.10.20.7.10
(OpNote)

HL7

Anesthesia
Section

59774-0

2.16.840.1.113883.10.20.22.2
.25

2.16.840.1.113883.10.20.18.2.7
(Proc Note)
2.16.840.1.113883.10.20.7.5
(OpNote)

HL7

Procedure
Disposition
Section

59775-7

2.16.840.1.113883.10.20.18.2
.12

2.16.840.1.113883.10.20.18.2.12
(Proc Note)

HL7

Procedure
Estimated
Blood Loss
Section

59770-8

2.16.840.1.113883.10.20.18.2
.9

2.16.840.1.113883.10.20.18.2.9
(Proc Note)

HL7

Procedure
Findings

59776-5

2.16.840.1.113883.10.20.22.2
.28

2.16.840.1.113883.10.20.18.2.15
(Proc Note)

HL7

Page 530
© 2012 Health Level Seven, Inc. All rights reserved.

Consolidated Entry Required
templateId

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Section

LOINC
Code(s)

Consolidated Entry Optional
templateId

Procedure
Implants
Section

59771-6

Planned
Procedure
Section
Procedure
Specimens
Taken
Section

Consolidated Entry Required
templateId

Previous templateIds

Was

2.16.840.1.113883.10.20.22.2
.40

2.16.840.1.113883.10.20.18.2.11
(Proc Note)

HL7

59772-4

2.16.840.1.113883.10.20.22.2
.30

2.16.840.1.113883.10.20.18.2.6
(Proc Note)

HL7

59773-2

2.16.840.1.113883.10.20.22.2
.31

2.16.840.1.113883.10.20.18.2.10
(Proc Note)

HL7

2.16.840.1.113883.10.20.2.7 (H&P)
2.16.840.1.113883.10.20.18.2.13
(Proc Note)

HL7

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4

HITSP

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4

IHE

2.16.840.1.113883.10.20.2.7 (H&P)
2.16.840.1.113883.10.20.18.2.14
(Proc Note)

HL7

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5

IHE

2.16.840.1.113883.10.20.2.7 (H&P)
2.16.840.1.113883.10.20.1.10
(CCD)

HL7

2.16.840.1.113883.3.88.11.83.124

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.31

IHE

2.16.840.1.113883.10.20.1.5
(CCD)

HL7

2.16.840.1.113883.3.88.11.83.109

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.17

IHE

2.16.840.1.113883.10.20.1.14

HL7

Section

Care Planning/Assessment Category
Assessment
s Section

Assessment
and Plan
Section

51848-0

51847-2

Plan of Care
Section
(may be
used for
Discharge
Instructions)

18776-5

Functional
Status
Section

47420-5

2.16.840.1.113883.10.20.22.2
.8

2.16.840.1.113883.10.20.22.2
.9

2.16.840.1.113883.10.20.22.2
.10

2.16.840.1.113883.10.20.22.2
.14

-

-

-

-

Results Category
Results

30954-2

2.16.840.1.113883.10.20.22.2

2.16.840.1.113883.10.20.22.2.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 531
© 2012 Health Level Seven, Inc. All rights reserved.

Section

LOINC
Code(s)

Section
(Diagnostic
Results in
HITSP)
Vital Signs
Section

8716-3

Consolidated Entry Optional
templateId

Consolidated Entry Required
templateId

Previous templateIds

.3

3.1

(CCD)

2.16.840.1.113883.10.20.22.2
.4

DICOM
Object
Catalog
Section

121181

N/A

Findings
(DIR)
(Radiology
Comparison
Study Observation)
Section

18782-3

2.16.840.1.113883.10.20.6.1.
2

2.16.840.1.113883.10.20.22.2.
4.1

2.16.840.1.113883.10.20.6.1.1

Was

2.16.840.1.113883.3.88.11.83.122

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.28

IHE

2.16.840.1.113883.10.20.1.16
(CCD)
2.16.840.1.113883.10.20.2.4 (H&P)

HL7

2.16.840.1.113883.3.88.11.83.119

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.25

IHE

2.16.840.1.113883.10.20.6.1.1

HL7

2.16.840.1.113883.10.20.6.1.2

HL7

2.16.840.1.113883.10.20.1.9 (CCD)

HL7

2.16.840.1.113883.3.88.11.83.101.
1

HITSP

1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7

IHE

2.16.840.1.113883.10.20.1.1 (CCD)

HL7

2.16.840.1.113883.3.88.11.83.116

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.34
(narrative-only)
1.3.6.1.4.1.19376.1.5.3.1.3.35
(coded)

IHE

2.16.840.1.113883.10.20.2.10
(H&P)

HL7

Other Templates
Payers
Section

48768-6

Advance
Directives
Section

42348-3

Physical
Exam

29545-1

2.16.840.1.113883.10.20.22.2
.18

2.16.840.1.113883.10.20.22.2
.21

2.16.840.1.113883.10.20.2.10

Page 532
© 2012 Health Level Seven, Inc. All rights reserved.

-

-

-

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Section

LOINC
Code(s)

Consolidated Entry Optional
templateId

Consolidated Entry Required
templateId

Section

Review of
Systems
Section

10187-3

Hospital
Course
Section
(may be
used as part
of Discharge
Summary)

8648-8

Family
History
Section

10157-6

Social
History
Section(incl.
smoking)

29762-2

Encounters
Section

46240-8

Medical

46264-8

1.3.6.1.4.1.19376.1.5.3.1.3.18

1.3.6.1.4.1.19376.1.5.3.1.3.5

2.16.840.1.113883.10.20.22.2
.15

2.16.840.1.113883.10.20.22.2
.17

2.16.840.1.113883.10.20.22.2
.22

2.16.840.1.113883.10.20.22.2

N/A (narrative-only)

N/A (narrative-only)

-

N/A (no stds require entry)

-

-

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Previous templateIds

Was

2.16.840.1.113883.3.88.11.83.118

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.24
(narrative-only)
1.3.6.1.4.1.19376.1.5.3.1.1.9.15
(coded)

IHE

2.16.840.1.113883.10.20.4.10
(Consult)

HL7

2.16.840.1.113883.3.88.11.83.120

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.18

IHE

1.3.6.1.4.1.19376.1.5.3.1.3.5

HL7

2.16.840.1.113883.3.88.11.83.121

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.5

IHE

2.16.840.1.113883.10.20.1.4 (CCD)
2.16.840.1.113883.10.20.18.2.17
(Proc Note)

HL7

2.16.840.1.113883.3.88.11.83.125

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.14
(narrative-only)
1.3.6.1.4.1.19376.1.5.3.1.3.15
(coded)

IHE

2.16.840.1.113883.10.20.1.15
(CCD)

HL7

2.16.840.1.113883.3.88.11.83.126

HITSP

1.3.6.1.4.1.19376.1.5.3.1.3.16

IHE

2.16.840.1.113883.10.20.1.3 (CCD)

HL7

2.16.840.1.113883.3.88.11.83.127

HITSP

1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3

IHE

2.16.840.1.113883.10.20.1.7 (CCD)

HL7

Page 533
© 2012 Health Level Seven, Inc. All rights reserved.

Section

LOINC
Code(s)

Equipment
Section

Consolidated Entry Optional
templateId

Consolidated Entry Required
templateId

.23

Hospital
Discharge
Physical
Section

10184-0

General
Status
Section

Previous templateIds

Was

2.16.840.1.113883.3.88.11.83.128

HITSP

1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5

IHE

N/A – Used IHE

HL7

1.3.6.1.4.1.19376.1.5.3.1.3.26

IHE

N/A
(1.3.6.1.4.1.19376.1.5.3.1.3.2
6)

N/A (narrative-only)

10210-3

N/A
(2.16.840.1.113883.10.20.2.5)

N/A (narrative-only)

2.16.840.1.113883.10.20.2.5 (H&P)

HL7

Objective
Section

61149-1

N/A
(2.16.840.1.113883.10.20.21.
2.1)

N/A (narrative-only)

2.16.840.1.113883.10.20.22.2.1
(Prog Note)

HL7

Subjective
Section

61150-9

N/A
(2.16.840.1.113883.10.20.21.
2.2)

N/A (narrative-only)

2.16.840.1.113883.10.20.22.2.2
(Prog Note)

HL7

Discharge
Diet

42344-2

N/A
(1.3.6.1.4.1.19376.1.5.3.1.3.3
3)

N/A (narrative-only)

N/A – Used IHE

HL7

1.3.6.1.4.1.19376.1.5.3.1.3.33

IHE

Hospital
Discharge
Studies
Summary
Section

11493-4

2.16.840.1.113883.10.20.22.2
.16

N/A (no stds require entry)

2.16.840.1.113883.10.20.16.2.3
(DS)

HL7

Page 534
© 2012 Health Level Seven, Inc. All rights reserved.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Consolidated Entries
The following table tracks changes made to consolidate templates originating in HL7, IHE, and HITSP.
Table 319: Entry Change Tracking Table
Entry

New templateId

Previous Title

Previous templateId

Previous Template
Organization

Result Organizer

2.16.840.1.113883.10.20.22.4.1

Result Organizer

2.16.840.1.113883.10.20.1.32

CCD

Result Observation

2.16.840.1.113883.10.20.22.4.2

Result Observation
Result Entry Content
Module

2.16.840.1.113883.10.20.1.31
2.16.840.1.113883.3.88.11.83.15.1

CCD
HITSP C83

Problem Concern Act
(Condition)

2.16.840.1.113883.10.20.22.4.3

Problem Act
Concern Entry
Problem Concern
Entry
Condition Entry
Module

2.16.840.1.113883.10.20.1.27
1.3.6.1.4.1.19376.1.5.3.1.4.5.1
1.3.6.1.4.1.19376.1.5.3.1.4.5.2

CCD
IHE PCC R6-0 V2
IHE PCC R6-0 V2

2.16.840.1.113883.3.88.11.83.7

HITSP C83

Problem Observation

2.16.840.1.113883.10.20.22.4.4

Problem Observation
Problem Entry

2.16.840.1.113883.10.20.1.28
1.3.6.1.4.1.19376.1.5.3.1.4.5

CCD
IHE PCC R6-0 V2

Health Status
Observation

2.16.840.1.113883.10.20.22.4.5

Problem Healthstatus
observation
Health Status

2.16.840.1.113883.10.20.1.51

CCD
IHE PCC R6-0 V2

1.3.6.1.4.1.19376.1.5.3.1.4.1.2

Problem Status
Observation

2.16.840.1.113883.10.20.22.4.6

Problem status
observation
Problem Status
Observation

2.16.840.1.113883.10.20.1.50
1.3.6.1.4.1.19376.1.5.3.1.4.1.1

CCD
IHE PCC R6-0 V2

Allergy - Intolerance
Observation

2.16.840.1.113883.10.20.22.4.7

Allergy/Alert
Observation
Alert observation
Allergy and
Intolerance Concern
Allergy/Drug
Sensitivity Module

2.16.840.1.113883.10.20.22.4.7

Consolidated IG

2.16.840.1.113883.10.20.1.18
1.3.6.1.4.1.19376.1.5.3.1.4.5.3

CCD
IHE PCC R6-0 V2

2.16.840.1.113883.3.88.11.83.6

HITSP C83

Severity observation
Severity

2.16.840.1.113883.10.20.1.55
1.3.6.1.4.1.19376.1.5.3.1.4.1

CCD
IHE PCC R6-0 V2

Severity Observation

2.16.840.1.113883.10.20.22.4.8

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 535
© 2012 Health Level Seven, Inc. All rights reserved.

Entry

New templateId

Previous Title

Previous templateId

Previous Template
Organization

Reaction Observation

2.16.840.1.113883.10.20.22.4.9

Reaction Observation

2.16.840.1.113883.10.20.1.54

CCD

Procedure Activity

2.16.840.1.113883.10.20.22.4.12

Procedure activity

2.16.840.1.113883.10.20.1.29

CCD

Procedure Activity
Observation

2.16.840.1.113883.10.20.22.4.13

Procedure activity

2.16.840.1.113883.10.20.1.29

CCD

Procedure Activity
Procedure

2.16.840.1.113883.10.20.22.4.14

Procedure activity
Procedure Entry
Procedure

2.16.840.1.113883.10.20.1.29
1.3.6.1.4.1.19376.1.5.3.1.4.19
2.16.840.1.113883.3.88.11.83.17

CCD
IHE PCC R6-0 V2
HITSP C83

Immunization
SubstanceAdministra
tion

2.16.840.1.113883.10.20.22.4.52

Medication Activity
(for immunization)
Immunization
Immunization

2.16.840.1.113883.10.20.1.24
1.3.6.1.4.1.19376.1.5.3.1.4.12
2.16.840.1.113883.3.88.11.83.13

CCD
IHE PCC R6-0 V2
HITSP C83

Medication Activity

2.16.840.1.113883.10.20.22.4.16

Medication Activity
Medication
Medication

2.16.840.1.113883.10.20.1.24
1.3.6.1.4.1.19376.1.5.3.1.4.7
2.16.840.1.113883.3.88.11.83.8

CCD
IHE PCC R6-0 V2
HITSP C83

Medication Supply
Order

2.16.840.1.113883.10.20.22.4.17

Supply Activity
Supply entry
Order Information
Constraint

2.16.840.1.113883.10.20.1.34
1.3.6.1.4.1.19376.1.5.3.1.4.7.3
2.16.840.1.113883.3.88.11.83.8.3

CCD
IHE PCC R6-0 V2
HITSP C83

Medication Dispense

2.16.840.1.113883.10.20.22.4.18

Supply Activity
Supply entry

2.16.840.1.113883.10.20.1.34
1.3.6.1.4.1.19376.1.5.3.1.4.7.3

CCD
IHE PCC R6-0 V2

Indication

2.16.840.1.113883.10.20.22.4.19

Indications

2.16.840.1.113883.3.88.11.83.138

HITSP C83

Instructions

2.16.840.1.113883.10.20.22.4.20

Patient instruction
Patient Medication
Instructions

2.16.840.1.113883.10.20.1.49
1.3.6.1.4.1.19376.1.5.3.1.4.3

CCD
IHE PCC R6-0 V2

Sequence Number

2.16.840.1.113883.10.20.22.4.22

Medication
Information
(manufacturedMateri
al)

2.16.840.1.113883.10.20.22.4.23

Product
Product Entry
Medication
Information
Constraints

2.16.840.1.113883.10.20.1.53
1.3.6.1.4.1.19376.1.5.3.1.4.7.2
2.16.840.1.113883.3.88.11.83.8.2

CCD
IHE PCC R6-0 V2
HITSP C83

Page 536
© 2012 Health Level Seven, Inc. All rights reserved.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Entry

New templateId

Previous Title

Previous templateId

Previous Template
Organization

Drug Vehicle
(participant)

2.16.840.1.113883.10.20.22.4.24

Precondition
(criterion)

2.16.840.1.113883.10.20.22.4.25

Medication Use –
None known
(deprecated)

2.16.840.1.113883.10.20.22.4.29

Vital Signs Organizer

2.16.840.1.113883.10.20.22.4.26

Vital signs organizer
Vital Signs Organizer

2.16.840.1.113883.10.20.1.35
1.3.6.1.4.1.19376.1.5.3.1.4.13.1

CCD
IHE PCC R6-0 V2

Vital Signs
Observation

2.16.840.1.113883.10.20.22.4.27

Vital Signs
Observation

1.3.6.1.4.1.19376.1.5.3.1.4.13.2

IHE PCC R6-0 V2

Allergy Status
Observation

2.16.840.1.113883.10.20.22.4.28

Alert Status

2.16.840.1.113883.10.20.1.39

CCD

Allergy Problem Act

2.16.840.1.113883.10.20.22.4.30

Age Observation

2.16.840.1.113883.10.20.22.4.31

Age Observation

2.16.840.1.113883.10.20.22.4.38

CCD

Encounter Location

2.16.840.1.113883.10.20.22.4.32

Encounter Location

2.16.840.1.113883.10.20.1.45

CCD

Hospital Discharge
Diagnosis

2.16.840.1.113883.10.20.22.4.33

Discharge Diagnosis

Hospital Admission
Diagnosis

2.16.840.1.113883.10.20.22.4.34

Admission Diagnosis

Discharge medication

2.16.840.1.113883.10.20.22.4.35

Admission medication

2.16.840.1.113883.10.20.22.4.36

Product Instance

2.16.840.1.113883.10.20.22.4.37

Social History
Observation

2.16.840.1.113883.10.20.22.4.38

Social History
Observation
Social History
Social History
Observation

2.16.840.1.113883.10.20.1.33
2.16.840.1.113883.3.88.11.83.19
1.3.6.1.4.1.19376.1.5.3.1.4.13.4

CCD
HITSP C83
IHE PCC R6-0 V2

Family History
Organizer

2.16.840.1.113883.10.20.22.4.45

Family History
Organizer
Family Member
Information

2.16.840.1.113883.10.20.1.23
2.16.840.1.113883.3.88.11.83.18

CCD
HITSP C83

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 537
© 2012 Health Level Seven, Inc. All rights reserved.

Entry

New templateId

Previous Title

Previous templateId

Family History
Observation

2.16.840.1.113883.10.20.22.4.46

Family History
Observation

2.16.840.1.113883.10.20.1.22

Family History Death
Observation

2.16.840.1.113883.10.20.22.4.47

Family History Cause
of Death Observation

2.16.840.1.113883.10.20.1.42

Advance Directive
Observation

2.16.840.1.113883.10.20.22.4.48

Advance Directive
Observation

2.16.840.1.113883.10.20.1.17

CCD

Comment Template

2.16.840.1.113883.10.20.22.4.64

Comments
Comment Module
IHE Comment
Module

2.16.840.1.113883.10.20.1.40
2.16.840.1.113883.3.88.11.83.11
1.3.6.1.4.1.19376.1.5.3.1.4.2

CCD
HITSP C83
IHE PCC R6-0 V2

Page 538
© 2012 Health Level Seven, Inc. All rights reserved.

Previous Template
Organization
CCD
CCD

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Changes Within Sections
The next five tables show changes in the Results, Problems, Vital Signs, Procedures, and Medications sections.
Table 320: Result Section Changes
Title

Previous Templates

New Templates

Changes from HITSP C83

Changes from CCD

Results
Section

2.16.840.1.113883.10.20.1.14
(HL7)
2.16.840.1.113883.3.88.11.83.122
(HITSP)
1.3.6.1.4.1.19376.1.5.3.1.3.28 (IHE)

2.16.840.1.113883.10.20.22.2.3
(optional entries)
2.16.840.1.113883.10.20.22.2.3.
1 (requires entries)

1. IHE Coded Results template
(1.3.6.1.4.1.19376.1.5.3.1.3.28)
is not required
2. The C83 Procedure Module
(2.16.840.1.113883.3.88.11.83.
17 ) is not required
3. Result Organizer
(section/entry/organizer) is
required for all coded results

1. Result Organizer
(section/entry/organize
r) is required for all
coded results

Result
Organizer

2.16.840.1.113883.10.20.1.32
(CCD)

2.16.840.1.113883.10.20.22.4.1

1. Requires new Result
Observation
(2.16.840.1.113883.10.20.22.4.
2)

1. Requires new Result
Observation
(2.16.840.1.113883.10.
20.22.4.2)

Result
Observation

2.16.840.1.113883.10.20.1.31
(CCD)
2.16.840.1.113883.3.88.11.83.15.1
(HITSP)
1.3.6.1.4.1.19376.1.5.3.1.4.13 (IHE)

2.16.840.1.113883.10.20.22.4.2

1. Narrative-entry link is not
required.
2. observation “INT” and “PRP”
@moodCodes no longer included

1. Requires
observation/statusCode
2. Requires
observation/effectiveTi
me

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 539
© 2012 Health Level Seven, Inc. All rights reserved.

Table 321: Problems Section Changes
Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

Problems Section
(Entries Optional)
(2.16.840.1.11388
3.10.20.22.2.5)

2.16.840.1.113883.10.20.1.11
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.3.6 (IHE)
2.16.840.1.113883.3.88.11.83.103
(C83)

1. IHE templateId(s) no longer
required
2. title updated to SHALL
[1..1] be present
3. entry should be present
and contain Problem
Concern Act

1. C83 templateId(s) no
longer required
2. title updated to SHALL
[1..1] be present
3. entry should be present
and contain Problem
Concern Act

1. CCD templateId no
longer required
2. title updated to not
require inclusion of
"problems"
3. text updated to SHALL
[1..1] be present
4. entry should be
present and contain
Problem Concern Act

Problems Section
(Entries Required)
(2.16.840.1.11388
3.10.20.22.2.5.1)

2.16.840.1.113883.10.20.1.11
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.3.6 (IHE)
2.16.840.1.113883.3.88.11.83.103
(C83)

1. IHE templateId(s) no longer
required
2. title updated to SHALL
[1..1] be present
3. entry updated to SHALL
[1..*] contain Problem
Concern Act

1. C83 templateId(s) no
longer required
2. title updated to SHALL
[1..1] be present
3. entry updated to SHALL
[1..*] contain Problem
Concern Act

1. CCD templateId no
longer required
2. title updated to not
require inclusion of
"problems"
3. entry updated to SHALL
[1..*] contain Problem
Concern Act

Problem Concern
Act
(2.16.840.1.11388
3.10.20.22.4.3)

2.16.840.1.113883.10.20.1.27
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.5.1
(IHE)
1.3.6.1.4.1.19376.1.5.3.1.4.5.2
(IHE)
2.16.840.1.113883.3.88.11.83.7
(C83)

1. IHE templateId(s) no longer
required
2. id updated to SHALL [1..*]
3. code updated to SHALL
[1..1] 'CONC' from
2.16.840.1.113883.5.6
4. statusCode updated to
SHALL [1..1] be from
2.16.840.1.113883.11.20.9.
19
5. effectiveTime/high updated
to remove dependency on
status

1. C83 templateId(s) no
longer required
2. id updated to SHALL [1..*]
3. code updated to SHALL
[1..1] 'CONC' from
2.16.840.1.113883.5.6
4. statusCode updated to
SHALL [1..1] be from
2.16.840.1.113883.11.20.
9.19
5. effectiveTime updated to
SHALL [1..1]

1. CCD templateId no
longer required
2. id updated to SHALL
[1..*]
3. code updated to
SHALL [1..1] 'CONC'
from
2.16.840.1.113883.5.6
4. statusCode updated to
SHALL [1..1] be from
2.16.840.1.113883.11.
20.9.19
5. effectiveTime updated
to SHALL [1..1]

(templateId)

Page 540
© 2012 Health Level Seven, Inc. All rights reserved.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

Problem
Observation
(2.16.840.1.11388
3.10.20.22.4.4)

2.16.840.1.113883.10.20.1.28
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.5 (IHE)

1. IHE templateId(s) no longer
required
2. id updated to SHALL [1..*]
3. code updated to SHALL
[1..1] be from
2.16.840.1.113883.3.88.12.
3221.7.2
4. Text and
text/reference/@value
updated to SHOULD [0..1]
be present
5. effectiveTime must be
updated for semantic
differences
6. value updated to SHALL
[1..1] be CD from
2.16.840.1.113883.3.88.12.
3221.7.4
7. entryRelationships must be
updated for differences

New requirement, no
mappings required

1. CCD templateId no
longer required
2. id updated to SHALL
[1..*]
3. code updated to
SHALL [1..1] be from
2.16.840.1.113883.3.8
8.12.3221.7.2
4. Text and
text/reference/@value
SHOULD be present
5. effectiveTime and child
elements updated to
SHOULD [0..1] be
present
6. value updated to
SHALL [1..1] be CD
from
2.16.840.1.113883.3.8
8.12.3221.7.4
7. entryRelationships
must be updated for
differences
8. Sources of information
differences are allowed
under open template
rules.

Problem Status
Entry
(2.16.840.1.11388
3.10.20.22.4.6)

2.16.840.1.113883.10.20.1.50
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.1.1
(IHE)

1. IHE templateId(s) no longer
required
2. text updated to SHOULD
[0..1] (not SHALL)
3. value updated to SHALL be
[1..1] CD from
2.16.840.1.113883.3.88.12.
80.68

New requirement, no
mappings required

1. CCD templateId no
longer required
2. text updated to
SHOULD [0..1] be
present
3. value updated to
SHALL be [1..1] CD
from
2.16.840.1.113883.3.8
8.12.80.68

(templateId)

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 541
© 2012 Health Level Seven, Inc. All rights reserved.

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

2.16.840.1.113883.10.20.1.51
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.1.2
(IHE)

1. IHE templateId(s) no longer
required
2. text and
text/reference/@value
updated to SHOULD [0..1] be
present
3. value updated to SHALL be
[1..1] CD from
2.16.840.1.113883.3.88.12.8
0.68
4. entryRelationships must be
updated for differences

New requirement, no
mappings required

1. CCD templateId no
longer required
2. id updated to SHALL
[1..*]
3. text and text/@value
updated to SHOULD
[0..1] be present
4. effectiveTime and child
elements updated to
SHOULD [0..1] be
present
5. value updated to SHALL
be [1..1] CD from
2.16.840.1.113883.3.88
.12.80.68
6. entryRelationships
must be updated for
differences
7. Sources of information
differences are allowed
under open template
rules.

(templateId)
Health Status
Observation
(2.16.840.1.11388
3.10.20.22.4.5)

Page 542
© 2012 Health Level Seven, Inc. All rights reserved.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Table 322: Vital Signs Section Changes
Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

Vital Signs Section
(Entries Optional)
(2.16.840.1.11388
3.10.20.22.4)

2.16.840.1.113883.10.20.1.16
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.25
(IHE)
2.16.840.1.113883.3.88.11.83.119
(C83)

1. IHE templateId(s) no longer
required
2. title updated to not require
inclusion of "vital signs"

1. HITSP templateID(s) no
longer required
2. code/@code updated to
SHALL be [1..1] 8716-3
from
2.16.840.1.113883.6.1
3. title updated to SHALL
[1..1] occur

1. CCD templateId no
longer required
2. title updated to not
require inclusion of
"vital signs"

Vital Signs Section
(Entries Required)
(2.16.840.1.11388
3.10.20.22.4.1)

2.16.840.1.113883.10.20.1.16
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.25
(IHE)
2.16.840.1.113883.3.88.11.83.119
(C83)

1. IHE templateId(s) no longer
required
2. title updated to not require
inclusion of "vital signs"
3. Section updated to SHALL
contain [1..*] Vital Signs
Organizer

1. HITSP templateID(s) no
longer required
2. code/@code updated to
SHALL be [1..1] 8716-3
from
2.16.840.1.113883.6.1
3. title updated to SHALL
[1..1] occur
4. Section updated to SHALL
contain [1..*] Vital Signs
Organizer

1. CCD templateId no
longer required
2. title updated to not
require inclusion of
"vital signs"
3. Section updated to
SHALL contain [1..*]
Vital Signs Organizer

Vital Signs
Organizer
(2.16.840.1.11388
3.10.20.22.4.26)

1.3.6.1.4.1.19376.1.5.3.1.4.13.1
(IHE)
2.16.840.1.113883.10.20.1.35
(CCD)

1. IHE templateId(s) no longer
required
2. Requires [1..*] organizer/id
3. effectiveTime updated to
SHALL [1..1]

1. HITSP templateID(s) no
longer required
2. Requires [1..*]
organizer/id
3. effectiveTime updated to
SHALL [1..1]

1. CCD templateId no
longer required
2. @classCode updated to
CLUSTER
3. code updated to
46680005 from
2.16.840.1.113883.6.9
6
4. statusCode updated to
"completed"
5. effectiveTime updated
to SHALL [1..1]

(templateId)

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 543
© 2012 Health Level Seven, Inc. All rights reserved.

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

1.3.6.1.4.1.19376.1.5.3.1.4.13.2
(IHE)

1. IHE templateId(s) no longer
required
2. id updated to SHALL [1..*]
3. code replaced with value
from value set
2.16.840.1.113883.3.88.12.
80.62
4. text updated to SHOULD
[0..1]
5. text/reference/@value
updated to SHOULD [0..1]
6. statusCode updated to
SHALL [1..1] 'completed'
7. effectiveTime updated to
SHALL [1..1]

New requirement, no
mappings required

New requirement, no
mappings required

(templateId)
Vital Signs
Observation
(2.16.840.1.11388
3.10.20.22.4.27)

Page 544
© 2012 Health Level Seven, Inc. All rights reserved.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Table 323: Procedures Section Changes
Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

Procedures Section
(Entries Optional)
(2.16.840.1.11388
3.10.20.22.2.7)

2.16.840.1.113883.10.20.1.12
(CCD)

No equivalent template

No equivalent template

1. CCD templateId no longer
required
2. Remove title requirements
CONF-425 and CONF 426
3. Add SHALL requirement for text

Procedures Section
(Entries Required)
(2.16.840.1.11388
3.10.20.22.2.7.1)

2.16.840.1.113883.10.20.1.12
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.3.11
(IHE)
1.3.6.1.4.1.19376.1.5.3.1.3.12
(IHE)
2.16.840.1.113883.3.88.11.83.
145 (C83)

1. IHE templateId(s) no
longer required
2. Explicit that multiple
entries are allowed.
3. Remove constraint for
References Entry
4. Add text SHALL be [1..1]
present

1. C83 templateId(s) no
longer required
2. Add SHALL be [1..1]
present and
@code='45719-4' LOINC.
3. Add text SHALL be [1..1]
present

1. CCD templateId no longer
required
2. Remove title requirements
CONF-425 and CONF 426
3. Add text SHALL be [1..1]
present
4. Add requirement for at least one
Procedure Activity Act,
Procedure Activity Observation,
or Procedure Activity Procedure.

Procedure Activity
Procedure Entry
(2.16.840.1.11388
3.10.20.22.4.14)

2.16.840.1.113883.10.20.1.29
(CCD)
2.16.840.1.113883.11.83.17
(C83)
1.3.6.1.4.1.19376.1.5.3.1.4.19
(C83)

No template supplied in
guide.

1. C83 templateId(s) no
longer required.
2. Constrain @classCode to
PROC
3. Replace @moodCode with
value from
2.16.840.1.113883.11.20.
9.18
4. Relax code/originalText
to SHOULD contain
reference/@value
5. Add statusCode SHALL
be [1..1] present from
2.16.840.1.113883.11.20.
9.22
6. Add priorityCode MAY be
[0..1] present from
2.16.840.1.113883.1.11.1
6866

1. CCD templateId no longer
required
2. Constrain @classCode to PROC
3. Replace @moodCode with value
from
2.16.840.1.113883.11.20.9.18
4. Add code SHOULD contain
originalText
5. Add code/originalText SHOULD
contain reference/@value
6. Replace statusCode with value
from
2.16.840.1.113883.11.20.9.22
7. Add priorityCode MAY [0..1] be
present from
2.16.840.1.113883.1.11.16866
8. Constrain methodCode to MAY
[0..1]
9. Replace targetSiteCode with

(templateId)

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 545
© 2012 Health Level Seven, Inc. All rights reserved.

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

7. Add methodCode MAY be
[0..1] present
8. Add specimen and
children MAY be [0..*]
present.
9. Add required attributes
for
performer/assignedEntity
10.Add MAY [0..*]
participant/@typeCode='D
EV' and allow
corresponding Product
Instance
11.Add MAY [0..*]
participant/@typeCode='L
OC' and allow
corresponding Service
Delivery Location
12.Add MAY [0..1]
entryRelationship with
@typeCode='COMP'
@inversionInd='TRUE' to
encounter with required id.
13.Add MAY [0..1]
entryRelationship with
@typeCode='SUBJ'
@inversionInd='TRUE' to
Instructions with required
templateId.
14.Add MAY [0..1]
entryRelationship with
@typeCode='RSON' to
Indication with required
templateId.
15.Add MAY [0..1]
entryRelationship with
@typeCode='COMP' to
Medication Activity with

SHOULD [0..1] from
2.16.840.1.113883.3.88.12.322
1.8.9
10. Add required attributes for
performer/assignedEntity
11. Add MAY [0..*]
participant/@typeCode='DEV'
and allow corresponding
Product Instance
12. Add MAY [0..1]
entryRelationship with
@typeCode='COMP'
@inversionInd='TRUE' to
encounter with required
templateId.
13. Add required attributes for
entryRelationship/encounter
14. Replace templateId for
Encounter Location with that of
Service Delivery Location
15. Constrain entryRelationship to
instructions to [0..1]
16. Replace Instructions
templateId with
2.16.840.1.113883.10.20.22.4.
20
17. Add templateId
2.16.840.1.113883.10.20.22.4.
19 entryRelationship/Indication
(if required) and remove existing
templateId(s).
18. Replace
2.16.840.1.113883.10.20.1.24.
20 templateId with
2.16.840.1.113883.10.20.22.4.
16 Medication Activity and
constrain to MAY be [0..1]

(templateId)

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HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

(templateId)
required templateId.

present.

ProcedureActivity
Observation Entry
(2.16.840.1.11388
3.10.20.22.4.13)

2.16.840.1.113883.10.20.1.29
(CCD)
2.16.840.1.113883.11.83.17
(C83)
1.3.6.1.4.1.19376.1.5.3.1.4.19
(C83)

No template supplied in
guide.

Same as
2.16.840.1.113883.11.83.17
changes EXCEPT:
1. Constrain @classCode to
OBS
2. specimen and children
MAY be [0..*] present
constraint is not
applicable
3. participant/@typeCode='
DEV' and corresponding
Product Instance template
are not applicable.

Same as
2.16.840.1.113883.10.20.1.29
changes EXCEPT:
1. Constrain @classCode to OBS
2. specimen and children MAY be
[0..*] present constraint is not
applicable
3. participant/@typeCode='DEV'
and corresponding Product
Instance template are not
applicable.

ProcedureActivity
Act Entry
(2.16.840.1.11388
3.10.20.22.4.12)

2.16.840.1.113883.10.20.1.29
(CCD)
2.16.840.1.113883.11.83.17
(C83)
1.3.6.1.4.1.19376.1.5.3.1.4.19
(C83)

No template supplied in
guide.

Same as
2.16.840.1.113883.11.83.17
changes EXCEPT:
1. Constrain @classCode to
ACT
2. specimen and children
MAY be [0..*] present
constraint is not
applicable
3. participant/@typeCode='
DEV' and corresponding
Product Instance template
are not applicable.
4. methodCode constraint is
not applicable
5. targetSiteCode constraint
is not applicable

Same as
2.16.840.1.113883.10.20.1.29
changes EXCEPT:
1. Constrain @classCode to ACT
2. specimen and children MAY be
[0..*] present constraint is not
applicable
3. participant/@typeCode='DEV'
and corresponding Product
Instance template are not
applicable.
4. methodCode constraint is not
applicable
5. targetSiteCode constraint is not
applicable

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 547
© 2012 Health Level Seven, Inc. All rights reserved.

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

Service Delivery
Location Entry
(2.16.840.1.11388
3.10.20.22.4.32)

2.16.840.1.113883.10.20.1.45
(CCD)

No equivalent template.

No equivalent template.

1. CCD templateId no longer
required.
2. Constrain code to SHALL be
[1..1] from
2.16.840.1.113883.1.11.20275
3. Update addr to SHOULD be
[0..1] present
4. Update telecom to SHOULD be
[0..1] present
5. Add playingEntity/name MAY
be [0..1] present.

Product Instance
Entry
(2.16.840.1.11388
3.10.20.22.4.37)

2.16.840.1.113883.10.20.1.53
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.7.
2 (IHE)

1. IHE templateId(s) no
longer required.
2. Replace entire IHE
template with
Consolidated template
and templateId.
(differences in classes
in templates – IHE
product entry cannot be
attached to procedures
in CDA)

1. C83 templateId(s) no
longer required.
2. Replace entire C83
template with
Consolidated template
and templateId.
(differences in classes in
templates – C83 product
form cannot be attached
to procedures in CDA)

1. CCD templateId no longer
required.
2. Replace entire CCD template
with Consolidated template
and templateId. (differences in
classes in templates – CCD
product instance cannot be
attached to procedures in
CDA)

(templateId)

Table 324: Medications Section Changes
Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

2.16.840.1.113883.10.20.1.8
(CCD)

No equivalent template

No equivalent template

1. CCD templateId no longer
required
2. title updated to not require
inclusion of "medication"
3. text updated to SHALL [1..1] be
present

(templateId)
Medications
Section (Entries
Optional)
(2.16.840.1.113
883.10.20.22.2.
1)

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HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
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Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

(templateId)
4. entry should be present and
contain Medication Activity
5. entry should be present and
contain Medication Use – None
Known. This is in place of the
simple statement that absence
of known medications SHALL
be explicitly asserted
Medications
Section (Entries
Required)
(2.16.840.1.113
883.10.20.22.2.
1.1)

1.3.6.1.4.1.19376.1.5.3.1.3.19
(IHE)
2.16.840.1.113883.3.88.11.83.
112 (C83)

1. IHE templateId(s) no
longer required
2. title updated to SHALL
[1..1] be present
3. text updated to SHALL
[1..1] be present
4. entry SHALL be present
and contain Medication
Activity or and contain
Medication Use – None
Known

1. C83 templateId(s) no
longer required
2. title updated to SHALL
[1..1] be present
3. text updated to SHALL
[1..1] be present
4. entry SHALL be present
and contain Medication
Activity or and contain
Medication Use – None
Known

Medication
Activity
(2.16.840.1.113
883.10.20.22.4.
16)

2.16.840.1.113883.10.20.1.24
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.7
(IHE)
1.3.6.1.4.1.19376.1.5.3.1.4.7.1
(IHE)
1.3.6.1.4.1.19376.1.5.3.1.4.8
(IHE)
1.3.6.1.4.1.19376.1.5.3.1.4.9
(IHE)
1.3.6.1.4.1.19376.1.5.3.1.4.10
(IHE)
1.3.6.1.4.1.19376.1.5.3.1.4.11
(IHE)
2.16.840.1.113883.3.88.11.83.
8 (C83)

1. IHE templateId(s) no
longer required
2. @moodCode changed to
require value from
2.16.840.1.113883.11.2
0.9.18 (effect is same).
3. id SHALL [1..*] be
present
4. relax code to MAY BE
[0..1] present, and use
template Medication Use
– None Known to assert
no meds.
5. Relax
text/reference/@value to
SHOULD [0..1] be
present.
6. Relax statusCode to

1. C83 templateId(s) no
longer required
2. @moodCode changed to
require value from
2.16.840.1.113883.11.20.
9.18 (effect is same).
3. id SHALL [1..*] be present
4. relax entry SHALL to
SHOULD be present and
contain Medication Activity
5. Relax
text/reference/@value to
SHOULD [0..1] be present.
6. Add statusCode SHALL
be [1..1] present
7. effectiveTime updated to
SHALL be [1..1] present

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

No equivalent template

1. CCD templateId no longer
required
2. @classsCode updated to
SHALL [1..1] be 'SBADM'
3. @moodCode changed to
require value from
2.16.840.1.113883.11.20.9.18
(effect is same).
4. code may be present
5. add text SHOULD [0..1] be
present.
6. Replace statusCode SHOULD
with SHALL be [1..1] present.
7. effectiveTime updated to
SHALL be [1..1] present and
SHOULD [0..*]. See guides for
usage.

Page 549
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Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

SHALL be [1..1] present
7. effectiveTime updated to
SHALL be [1..1] present
and SHOULD [0..*]. See
guides for usage.
8. Add repeatNumber MAY
[0..1] be present
9. Constrain routeCode to
values from
2.16.840.1.113883.3.88.
12.3221.8.7
10.Constrain
approachSiteCode to
values from
2.16.840.1.113883.3.88.
12.3221.8.9
11.Simplify doseQuantity to
single element. See
guides for usage.
12.Update rateQuantity to
MAY be [0..1] present.
See guides for usage.
13.Update rateQuantity to
contain @unit from
2.16.840.1.113883.1.11.
12839
14.add constraint that
exactly one doseQuantity
or rateQuantity SHOULD
be present
15.add maxDoseQuantity
MAY be [0..1] present
16.add
administrationUnitCode
MAY be [0..1] present
17.update consumable to
include Medication

and SHOULD [0..*]. See
guides for usage.
8. Add repeatNumber MAY
[0..1] be present
9. Update routeCode
constraint to MAY be [0..1]
10.update doseQuantity to
SHOULD be [0..1] present
11.add rateQuantity MAY be
[0..1] present and contain
@unit from
2.16.840.1.113883.1.11.1
2839
12.add constraint that
exactly one doseQuantity
or rateQuantity SHOULD
be present
13.update maxDoseQuantity
to MAY be [0..1] present
14.update consumable to
include Medication
Information template. C83
templateId is no longer
required.
15.Add performer MAY be
[0..1] be present.
16.Update participant to
Drug Vehicle template,
replacing inline
constraints.
17.Replace
entryRelationship/[RSON]
distal Observation with
Indication template. C83
templateId no longer
required.
18.Replace

8. Add repeatNumber MAY [0..1]
be present
9. Relax routeCode to MAY be
[0..1] present and update to
values from
2.16.840.1.113883.3.88.12.32
21.8.7
10.approachSiteCode MAY be
[0..1] present with values from
2.16.840.1.113883.3.88.12.32
21.8.9
11.add doseQuantity SHOULD
[0..1] contain @unit and be
from
2.16.840.1.113883.1.11.12839
12.update rateQuantity to MAY
be [0..1] present and contain
@unit from
2.16.840.1.113883.1.11.12839
13.add administrationUnitCode
MAY be [0..1] present
14.add consumable SHALL [1..1]
to include Medication
Information
15.update performer MAY be
[0..1] be present.
16.Add participant MAY be [0..*]
present to Drug Vehicle
17.Replace
entryRelationship/[RSON]
distal end with Indication
template. CCD templateId no
longer required.
18.Replace
entryRelationship/[SUBJ]
distal end with Instructions
template. CCD templateId(s) no

(templateId)

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HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

Information template.
IHE templateId is no
longer required.
18.Add performer MAY be
[0..1] be present.
19.Add participant MAY be
[0..*] present to Drug
Vehicle
20.Replace
entryRelationship/[RSO
N] distal Act with
Indication template. IHE
templateId no longer
required.
21.Replace
entryRelationship/[SUBJ
] distal end with
Instructions template.
IHE templateId no longer
required.
22.Replace
entryRelationship/[REFR
] distal end with
Medication Supply Order
template. IHE
templateId(s) no longer
required.
23.Add
entryRelationship/[REFR
] to Medication Dispense
template MAY be [0..1]
present.
24.Add entryRelationship/
[CAUS] to Reaction
Observation template
MAY be [0..1] present.
25.Update precondition to
use Precondition for

entryRelationship/[SUBJ]
distal end with
Instructions template. C83
templateId(s) no longer
required.
19.Replace
entryRelationship/[REFR]
distal end with Medication
Supply Order template.
C83 templateId(s) no
longer required.
20.Replace
entryRelationship/[REFR]
with Medication Dispense
template. C83
templateId(s) no longer
required.
21.Replace
entryRelationship/[CAUS]
with Reaction Observation
template. C83
templateId(s) no longer
required.
22.Add precondition to
Precondition for Substance
Administration template.

longer required.
19.Replace
entryRelationship/[REFR]
distal end with Medication
Supply Order template. CCD
templateId(s) no longer
required.
20.Add entryRelationship/[REFR]
to Medication Dispense
template MAY be [0..1] present.
21.Add entryRelationship/[CAUS]
to Reaction Observation
template MAY be [0..1] present.
22.Add precondition to
Precondition for Substance
Administration template.

(templateId)

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 551
© 2012 Health Level Seven, Inc. All rights reserved.

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

No equivalent template.

No equivalent template.

No equivalent template.

1. IHE templateId(s) no
longer required
2. consumable/manufactur
edProduct/manufacture
dMaterial/code SHALL
be selected from
2.16.1.113883.3.88.12.8
0.17. Remove any
conflicting code
constraints.

1. C83 templateId(s) no
longer required.
2. consumable/manufacture
dProduct/manufacturedM
aterial/code SHALL be
selected from
2.16.1.113883.3.88.12.80
.17. Remove any
conflicting code
constraints.

1. CCD templateId no longer
required
2. consumable/manufacturedPro
duct/manufacturedMaterial/c
ode SHALL be selected from
2.16.1.113883.3.88.12.80.17.
Remove any conflicting code
constraints.

No equivalent template.

1. relax name element to
MAY be [0..1] present (in
playingEntity)
2. update code element to
SHALL be [1..1] present
(in playingEntity).

No equivalent template.

1. IHE templateId(s) no
longer required.
2. Replace IHE template
with Indication template.

1. C83 templateId(s) no
longer required
2. Remove observation/text
constraint

1. CCD templateId(s) no longer
required.
2. Replace CCD template with
Indication.

(templateId)
Substance
Administration template.
Remove existing
precondition elements.
26.Remove
entryRelationship/
[COMP] constraint.
Medication Use –
None Known
(2.16.840.1.113
883.10.20.22.4.
29)
Medication
Information
(2.16.840.1.113
883.10.20.22.4.
23)

2.16.840.1.113883.10.20.1.53
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.7.2
(IHE)
2.16.840.1.113883.3.88.11.83.
8.2 (C83)

Drug Vehicle
(2.16.840.1.113
883.10.20.22.4.
24)

Indication
(2.16.840.1.113
883.10.20.22.4.
19)

2.16.840.1.113883.10.20.1.27
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.4.1
(IHE)
2.16.840.1.113883.10.20.1.28
(C83)

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HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

2.16.840.1.113883.10.20.1.49
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.3
(IHE)

1. IHE templateId(s) no
longer required.
2. Remove code SHOULD
be 'PINSTRUCT'
codeSystem
1.3.6.1.4.1.19376.1.5.3.
2

1. C83 templateId(s) no
longer required
2. Remove code SHOULD be
'PINSTRUCT' codeSystem
1.3.6.1.4.1.19376.1.5.3.2

1. CCD templateId(s) no longer
required.
2. Add text SHOULD be [0..1]
present and add dependent
constraints
3. Add statusCode SHALL be
[1..1] present with value
'completed'.

No equivalent template.

No equivalent template.

No equivalent template.

1. IHE templateId(s) no
longer required.
2. Add id SHALL be [1..1]
present
3. Add code SHALL be [1..1]
present
4. Add text SHOULD be
[0..1] present, and child
constraints
5. Add effectiveTime
SHOULD be [0..1]
present and child
constraints
6. Add value SHALL be
[1..1] present with type
of 'CD' and value from
2.16.3.88.12.3221.7.4
7. Replace
entryRelationship/[SUBJ
] templateId with
Severity Observation
2.16.840.1.113883.10.2

No existing template.

1. CCD templateId(s) no longer
required.
2. Add id SHALL be [1..1] present
3. Add code SHALL be [1..1]
present
4. Add text SHOULD be [0..1]
present, and child constraints
5. Add effectiveTime SHOULD be
[0..1] present and child
constraints
6. Add value SHALL be [1..1]
present with type of 'CD' and
value from
2.16.3.88.12.3221.7.4
7. Add entryRelationship/[RSON]
to template Procedure Activity
Procedure MAY be [0..1]
present
8. Add entryRelationship/[RSON]
to template Medication Activity
MAY be [0..1] present.

(templateId)
Instructions
(2.16.840.1.113
883.10.20.22.4.
20)

Precondition for
Substance
Administration
(2.16.840.1.113
883.10.20.22.4.
25)
Reaction
Observation
(2.16.840.1.113
883.10.20.22.4.
9)

2.16.840.1.113883.10.20.1.54
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.5
(IHE)

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 553
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Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

(templateId)
0.22.4.8
8. Add
entryRelationship/[RSO
N] to template Procedure
Activity Procedure MAY
be [0..1] present
9. Add
entryRelationship/[RSO
N] to template
Medication Activity MAY
be [0..1] present.
10. Remove
entryRelationship/[REFR
] constraint
11. Remove
entryRelationship/[SUBJ
] to comments template
constraint.
Severity
Observation
(2.16.840.1.113
883.10.20.22.4.
8)

2.16.840.1.113883.10.20.1.55
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.1
(IHE)

1. IHE templateId(s) no
longer required.
2. Relax text to SHOULD be
[0..1] present
3. Update value to be from
2.16.840.1.113883.3.88.
12.3221.6.8

No existing template.

1. CCD templateId(s) no longer
required.
2. Add text SHOULD be [0..1]
present and child constraints.
3. Update value to be from
2.16.840.1.113883.3.88.12.32
21.6.8

Medication
Supply Order
Entry
(2.16.840.1.113
883.10.20.22.4.
17)

2.16.840.1.113883.10.20.1.34
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.7.3
(IHE)
2.16.840.1.113883.3.88.11.83.
8.3 (C83)

1. IHE templateId(s) no
longer required.
2. Constrain @moodCode to
INT
3. Update id to SHALL [1..*]
4. Add statusCode SHALL
be [1..1] present
5. Add effectiveTime/high
SHOULD be [0..1]
present
6. Add constraint that at

1. C83 templateId(s) no
longer required.
2. Constrain @moodCode to
INT
3. Update id to SHALL [1..*];
remove additional
constraints
4. Add statusCode SHALL be
[1..1] present
5. Add effectiveTime/high
SHOULD be [0..1] present

1. CCD templateId(s) no longer
required.
2. Constrain @moodCode to INT
3. Update statusCode to SHALL
be [1..1] present
4. Add effectiveTime/high
SHOULD be [0..1] present
5. Update repeatNumber to
SHOULD be [0..1] present
6. Update quantity to SHOULD be
[0..1] present

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HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

least 1 of
product/Medication
Information or
product/Immunization
Medication Information
SHALL be [1..1] present
7. Add
entryRelationship/[SUBJ
] to Instructions MAY be
[0..1] present along with
child constraints
8. Remove all other
differing constraints

6. Update repeatNumber to
SHOULD be [0..1] present
7. Update quantity to
SHOULD be [0..1] present
8. Add constraint that at
least 1 of
product/Medication
Information or
product/Immunization
Medication Information
SHALL be [1..1] present
9. Add
entryRelationship/[SUBJ]
to Instructions MAY be
[0..1] present along with
child constraints
10.Remove all other differing
constraints

7. Add constraint that at least 1
of product/Medication
Information or
product/Immunization
Medication Information SHALL
be [1..1] present
8. Add entryRelationship/[SUBJ]
to Instructions MAY be [0..1]
present along with child
constraints
9. Remove all other differing
constraints

1. IHE templateId(s) no
longer required.
2. Constrain @moodCode to
EVN
3. Update id to SHALL [1..*]
4. Add statusCode SHALL
be [1..1] present and
from
2.16.840.1.113883.3.88.
12.80.64
5. Add effectiveTime
SHOULD be [0..1]
present
6. Add constraint that at
least 1 of
product/Medication
Information or
product/Immunization
Medication Information

1. C83 templateId(s) no
longer required.
2. Constrain @moodCode to
EVN
3. Update id to SHALL [1..*];
remove additional
constraints
4. Add statusCode SHALL be
[1..1] present and from
2.16.840.1.113883.3.88.1
2.80.64
5. Add effectiveTime
SHOULD be [0..1] present
6. update repeatNumber
SHOULD be [0..1] present
7. Update quantity to
SHOULD be [0..1] present
8. Add constraint that at
least 1 of

1. CCD templateId(s) no longer
required.
2. Constrain @moodCode to EVN
3. Update statusCode to SHALL
be [1..1] present
4. Update repeatNumber to
SHOULD be [0..1] present
5. Update quantity to SHOULD be
[0..1] present
6. Add constraint that at least 1
of product/Medication
Information or
product/Immunization
Medication Information SHALL
be [1..1] present
7. Add entryRelationship/[REFR]
to Medication Supply Order
MAY be [0..1] present along
with child constraints

(templateId)

Medication
Dispense Entry
(2.16.840.1.113
883.10.20.22.4.
18)

2.16.840.1.113883.10.20.1.34
(CCD)
1.3.6.1.4.1.19376.1.5.3.1.4.7.3
(IHE)
2.16.840.1.113883.3.88.11.83.
8.3 (C83)

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

Page 555
© 2012 Health Level Seven, Inc. All rights reserved.

Title

Previous templateId

Changes from IHE

Changes from HITSP C83

Changes from CCD

SHALL be [1..1] present
7. Add
entryRelationship/[REFR
] to Medication Supply
Order MAY be [0..1]
present along with child
constraints
8. Add
assignedEntity/Consolid
ated US Realm Header
Address template
SHOULD be [0..1]
present
9. Remove all other
differing constraints

product/Medication
Information or
product/Immunization
Medication Information
SHALL be [1..1] present
9. Add performer MAY be
[0..1] present
10.Add
entryRelationship/[REFR]
to Medication Supply
Order MAY be [0..1]
present along with child
constraints
11.Add
assignedEntity/Consolida
ted US Realm Header
Address template
SHOULD be [0..1] present
12.Remove all other differing
constraints

8. Add
assignedEntity/Consolidated
US Realm Header Address
template SHOULD be [0..1]
present
9. Remove all other differing
constraints

(templateId)

Page 556
© 2012 Health Level Seven, Inc. All rights reserved.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
July 2012

APPENDIX C — TEMPLATE IDS IN THIS GUIDE
The following table lists all templateIds in this guide. The sections for document types
include tables showing the template containment within each document type:
CCD
Consultation Note
Diagnostic Imaging Report
Discharge Summary
History and Physical
Operative Note
Procedure Note
Progress Note
Table 325: Template Ids Alphabetically by Template Type
Template Title

Template
Type

templateId

US Realm Address (AD.US.FIELDED)

header

2.16.840.1.113883.10.20.22.5.2

US Realm Date and Time
(DT.US.FIELDED)

2.16.840.1.113883.10.20.22.5.3

US Realm Date and Time
(DTM.US.FIELDED)

2.16.840.1.113883.10.20.22.5.4

US Realm Patient Name
(PTN.US.FIELDED)

2.16.840.1.113883.10.20.22.5.1

US Realm Person Name
(PN.US.FIELDED)

2.16.840.1.113883.10.20.22.5.1.1

Consultation Note

document

2.16.840.1.113883.10.20.22.1.4

Continuity of Care Document (CCD)

document

2.16.840.1.113883.10.20.22.1.2

Diagnostic Imaging Report

document

2.16.840.1.113883.10.20.22.1.5

Discharge Summary

document

2.16.840.1.113883.10.20.22.1.8

History and Physical

document

2.16.840.1.113883.10.20.22.1.3

Operative Note

document

2.16.840.1.113883.10.20.22.1.7

Procedure Note

document

2.16.840.1.113883.10.20.22.1.6

Progress Note

document

2.16.840.1.113883.10.20.22.1.9

Unstructured Document

document

2.16.840.1.113883.10.20.22.1.10

US Realm Header

document

2.16.840.1.113883.10.20.22.1.1

Advance Directives Section (entries
optional)

section

2.16.840.1.113883.10.20.22.2.21

Advance Directives Section (entries
required)

section

2.16.840.1.113883.10.20.22.2.21.1

Allergies Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.6

Allergies Section (entries required)

section

2.16.840.1.113883.10.20.22.2.6.1

Page 557
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© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Template Title

Template
Type

templateId

Anesthesia Section

section

2.16.840.1.113883.10.20.22.2.25

Assessment and Plan Section

section

2.16.840.1.113883.10.20.22.2.9

Assessment Section

section

2.16.840.1.113883.10.20.22.2.8

Chief Complaint and Reason for Visit
Section

section

2.16.840.1.113883.10.20.22.2.13

Chief Complaint Section

section

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

Complications Section

section

2.16.840.1.113883.10.20.22.2.37

DICOM Object Catalog Section - DCM
121181

section

2.16.840.1.113883.10.20.6.1.1

Discharge Diet Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.33

Encounters Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.22

Encounters Section (entries required)

section

2.16.840.1.113883.10.20.22.2.22.1

Family History Section

section

2.16.840.1.113883.10.20.22.2.15

Fetus Subject Context

section

2.16.840.1.113883.10.20.6.2.3

Findings Section (DIR)

section

2.16.840.1.113883.10.20.6.1.2

Functional Status Section

section

2.16.840.1.113883.10.20.22.2.14

General Status Section

section

2.16.840.1.113883.10.20.2.5

History of Past Illness Section

section

2.16.840.1.113883.10.20.22.2.20

History of Present Illness Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.4

Hospital Admission Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.43

Hospital Admission Medications Section
(entries optional)

section

2.16.840.1.113883.10.20.22.2.44

Hospital Consultations Section

section

2.16.840.1.113883.10.20.22.2.42

Hospital Course Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.5

Hospital Discharge Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.24

Hospital Discharge Instructions Section

section

2.16.840.1.113883.10.20.22.2.41

Hospital Discharge Medications Section
(entries optional)

section

2.16.840.1.113883.10.20.22.2.11

Hospital Discharge Medications Section
(entries required)

section

2.16.840.1.113883.10.20.22.2.11.1

Hospital Discharge Physical Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.26

Hospital Discharge Studies Summary
Section

section

2.16.840.1.113883.10.20.22.2.16

Immunizations Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.2

Immunizations Section (entries required)

section

2.16.840.1.113883.10.20.22.2.2.1

Implants Section

section

2.16.840.1.113883.10.20.22.2.33

Instructions Section

section

2.16.840.1.113883.10.20.22.2.45

Interventions Section

section

2.16.840.1.113883.10.20.21.2.3

Medical (General) History Section

section

2.16.840.1.113883.10.20.22.2.39

Medical Equipment Section

section

2.16.840.1.113883.10.20.22.2.23

Page 558
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July 2012

Template Title

Template
Type

templateId

Medications Administered Section

section

2.16.840.1.113883.10.20.22.2.38

Medications Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.1

Medications Section (entries required)

section

2.16.840.1.113883.10.20.22.2.1.1

Objective Section

section

2.16.840.1.113883.10.20.21.2.1

Observer Context

section

2.16.840.1.113883.10.20.6.2.4

Operative Note Fluids Section

section

2.16.840.1.113883.10.20.7.12

Operative Note Surgical Procedure
Section

section

2.16.840.1.113883.10.20.7.14

Payers Section

section

2.16.840.1.113883.10.20.22.2.18

Physical Exam Section

section

2.16.840.1.113883.10.20.2.10

Plan of Care Section

section

2.16.840.1.113883.10.20.22.2.10

Planned Procedure Section

section

2.16.840.1.113883.10.20.22.2.30

Postoperative Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.35

Postprocedure Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.36

Preoperative Diagnosis Section

section

2.16.840.1.113883.10.20.22.2.34

Problem Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.5

Problem Section (entries required)

section

2.16.840.1.113883.10.20.22.2.5.1

Procedure Description Section

section

2.16.840.1.113883.10.20.22.2.27

Procedure Disposition Section

section

2.16.840.1.113883.10.20.18.2.12

Procedure Estimated Blood Loss Section

section

2.16.840.1.113883.10.20.18.2.9

Procedure Findings Section

section

2.16.840.1.113883.10.20.22.2.28

Procedure Implants Section

section

2.16.840.1.113883.10.20.22.2.40

Procedure Indications Section

section

2.16.840.1.113883.10.20.22.2.29

Procedure Specimens Taken Section

section

2.16.840.1.113883.10.20.22.2.31

Procedures Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.7

Procedures Section (entries required)

section

2.16.840.1.113883.10.20.22.2.7.1

Reason for Referral Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.1

Reason for Visit Section

section

2.16.840.1.113883.10.20.22.2.12

Results Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.3

Results Section (entries required)

section

2.16.840.1.113883.10.20.22.2.3.1

Review of Systems Section

section

1.3.6.1.4.1.19376.1.5.3.1.3.18

Social History Section

section

2.16.840.1.113883.10.20.22.2.17

Subjective Section

section

2.16.840.1.113883.10.20.21.2.2

Surgery Description Section

section

2.16.840.1.113883.10.20.22.2.26

Surgical Drains Section

section

2.16.840.1.113883.10.20.7.13

Vital Signs Section (entries optional)

section

2.16.840.1.113883.10.20.22.2.4

Vital Signs Section (entries required)

section

2.16.840.1.113883.10.20.22.2.4.1

Admission Medication

entry

2.16.840.1.113883.10.20.22.4.36

Advance Directive Observation

entry

2.16.840.1.113883.10.20.22.4.48

Page 559
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© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

Template Title

Template
Type

templateId

Age Observation

entry

2.16.840.1.113883.10.20.22.4.31

Allergy - Intolerance Observation

entry

2.16.840.1.113883.10.20.22.4.7

Allergy Problem Act

entry

2.16.840.1.113883.10.20.22.4.30

Allergy Status Observation

entry

2.16.840.1.113883.10.20.22.4.28

Assessment Scale Observation

entry

2.16.840.1.113883.10.20.22.4.69

Authorization Activity

entry

2.16.840.1.113883.10.20.1.19

Boundary Observation

entry

2.16.840.1.113883.10.20.6.2.11

Caregiver Characteristics

entry

2.16.840.1.113883.10.20.22.4.72

Code Observations

entry

2.16.840.1.113883.10.20.6.2.13

Cognitive Status Problem Observation

entry

2.16.840.1.113883.10.20.22.4.73

Cognitive Status Result Observation

entry

2.16.840.1.113883.10.20.22.4.74

Cognitive Status Result Organizer

entry

2.16.840.1.113883.10.20.22.4.75

Comment Activity

entry

2.16.840.1.113883.10.20.22.4.64

Coverage Activity

entry

2.16.840.1.113883.10.20.22.4.60

Deceased Observation

entry

2.16.840.1.113883.10.20.22.4.79

Discharge Medication

entry

2.16.840.1.113883.10.20.22.4.35

Drug Vehicle

entry

2.16.840.1.113883.10.20.22.4.24

Encounter Activities

entry

2.16.840.1.113883.10.20.22.4.49

Encounter Diagnosis

entry

2.16.840.1.113883.10.20.22.4.80

Estimated Date of Delivery

entry

2.16.840.1.113883.10.20.15.3.1

Family History Death Observation

entry

2.16.840.1.113883.10.20.22.4.47

Family History Observation

entry

2.16.840.1.113883.10.20.22.4.46

Family History Organizer

entry

2.16.840.1.113883.10.20.22.4.45

Functional Status Problem Observation

entry

2.16.840.1.113883.10.20.22.4.68

Functional Status Result Observation

entry

2.16.840.1.113883.10.20.22.4.67

Functional Status Result Organizer

entry

2.16.840.1.113883.10.20.22.4.66

5.19
Observation

entry

2.16.840.1.113883.10.20.22.4.5

Highest Pressure Ulcer Stage

entry

2.16.840.1.113883.10.20.22.4.77

Hospital Admission Diagnosis

entry

2.16.840.1.113883.10.20.22.4.34

Hospital Discharge Diagnosis

entry

2.16.840.1.113883.10.20.22.4.33

Immunization Activity

entry

2.16.840.1.113883.10.20.22.4.52

Immunization Medication Information

entry

2.16.840.1.113883.10.20.22.4.54

Immunization Refusal Reason

entry

2.16.840.1.113883.10.20.22.4.53

Indication

entry

2.16.840.1.113883.10.20.22.4.19

Instructions

entry

2.16.840.1.113883.10.20.22.4.20

Medication Activity

entry

2.16.840.1.113883.10.20.22.4.16

Medication Dispense

entry

2.16.840.1.113883.10.20.22.4.18

Medication Information

entry

2.16.840.1.113883.10.20.22.4.23

Page 560
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July 2012

Template Title

Template
Type

templateId

Medication Supply Order

entry

2.16.840.1.113883.10.20.22.4.17

Medication Use - None Known
(deprecated)

entry

2.16.840.1.113883.10.20.22.4.29

Non-Medicinal Supply Activity

entry

2.16.840.1.113883.10.20.22.4.50

Number of Pressure Ulcers Observation

entry

2.16.840.1.113883.10.20.22.4.76

Plan of Care Activity Act

entry

2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter

entry

2.16.840.1.113883.10.20.22.4.40

Plan of Care Activity Observation

entry

2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply

entry

2.16.840.1.113883.10.20.22.4.43

Policy Activity

entry

2.16.840.1.113883.10.20.22.4.61

Postprocedure Diagnosis

entry

2.16.840.1.113883.10.20.22.4.51

Precondition for Substance
Administration

entry

2.16.840.1.113883.10.20.22.4.25

Pregnancy Observation

entry

2.16.840.1.113883.10.20.15.3.8

Preoperative Diagnosis

entry

2.16.840.1.113883.10.20.22.4.65

Pressure Ulcer Observation

entry

2.16.840.1.113883.10.20.22.4.70

Problem Concern Act (Condition)

entry

2.16.840.1.113883.10.20.22.4.3

Problem Observation

entry

2.16.840.1.113883.10.20.22.4.4

Problem Status

entry

2.16.840.1.113883.10.20.22.4.6

Procedure Activity Act

entry

2.16.840.1.113883.10.20.22.4.12

Procedure Activity Observation

entry

2.16.840.1.113883.10.20.22.4.13

Procedure Activity Procedure

entry

2.16.840.1.113883.10.20.22.4.14

Procedure Context

entry

2.16.840.1.113883.10.20.6.2.5

Product Instance

entry

2.16.840.1.113883.10.20.22.4.37

Purpose of Reference Observation

entry

2.16.840.1.113883.10.20.6.2.9

Quantity Measurement Observation

entry

2.16.840.1.113883.10.20.6.2.14

Reaction Observation

entry

2.16.840.1.113883.10.20.22.4.9

Referenced Frames Observation

entry

2.16.840.1.113883.10.20.6.2.10

Result Observation

entry

2.16.840.1.113883.10.20.22.4.2

Result Organizer

entry

2.16.840.1.113883.10.20.22.4.1

Series Act

entry

2.16.840.1.113883.10.20.22.4.63

Service Delivery Location

entry

2.16.840.1.113883.10.20.22.4.32

Severity Observation

entry

2.16.840.1.113883.10.20.22.4.8

Smoking Status Observation

entry

2.16.840.1.113883.10.22.4.78

Social History Observation

entry

2.16.840.1.113883.10.20.22.4.38

SOP Instance Observation

entry

2.16.840.1.113883.10.20.6.2.8

Page 561
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July 2012

Template Title

Template
Type

templateId

Study Act

entry

2.16.840.1.113883.10.20.6.2.6

Text Observation

entry

2.16.840.1.113883.10.20.6.2.12

Tobacco Use

entry

2.16.840.1.113883.10.20.22.4.85

Vital Sign Observation

entry

2.16.840.1.113883.10.20.22.4.27

Vital Signs Organizer

entry

2.16.840.1.113883.10.20.22.4.26

Physician of Record Participant

unspecified

2.16.840.1.113883.10.20.6.2.2

Physician Reading Study Performer

unspecified

2.16.840.1.113883.10.20.6.2.1

Page 562
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© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

APPENDIX D —

CODE SYSTEMS IN THIS GUIDE

The following table lists all the code systems in this guide. The next two appendices list
all value sets (vocabularies) and single-value bindings.
Table 326: Code Systems in This Guide
Code System OID

Code System Name

1.0.3166.1

ISO 3166-1 Country Codes

1.2.840.10008.2.16.4

DCM

2.16.840.1.113883.1.11.11526

Internet Society Language

2.16.840.1.113883.12.292

Vaccines administered (CVX)

2.16.840.1.113883.5.1

Administrative Gender

2.16.840.1.113883.5.1001

ActMood

2.16.840.1.113883.5.1076

Religious Affiliation

2.16.840.1.113883.5.110

RoleClass

2.16.840.1.113883.5.111

RoleCode

2.16.840.1.113883.5.1119

AddressUse

2.16.840.1.113883.5.14

ActStatus

2.16.840.1.113883.5.2

MaritalStatus

2.16.840.1.113883.6.1

LOINC

2.16.840.1.113883.6.101

NUCC Health Care Provider Taxonomy

2.16.840.1.113883.6.104

ICD9 CM Procedures

2.16.840.1.113883.6.12

CPT-4

2.16.840.1.113883.5.25

Confidentiality Code

2.16.840.1.113883.3.26.1.1

National Cancer Institute (NCI) Thesaurus

2.16.840.1.113883.6.231

US Postal Codes

2.16.840.1.113883.6.238

Race and Ethnicity - CDC

2.16.840.1.113883.6.259

HealthcareServiceLocation

2.16.840.1.113883.5.4

ActCode

2.16.840.1.113883.5.43

EntityNamePartQualifier

2.16.840.1.113883.5.45

EntityNameUse

2.16.840.1.113883.6.255.1336

ASC X12

2.16.840.1.113883.5.6

HL7ActClass

2.16.840.1.113883.5.60

LanguageAbilityMode

2.16.840.1.113883.5.61

LanguageAbilityProficiency

2.16.840.1.113883.3.26.1.5

NDF-RT

2.16.840.1.113883.5.7

ActPriority

2.16.840.1.113883.4.9

Unique Ingredient Identifier (UNII)

2.16.840.1.113883.5.8

ActReason

2.16.840.1.113883.5.83

ObservationInterpretation

2.16.840.1.113883.5.88

ParticipationFunction

Page 563
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July 2012

Code System OID

Code System Name

2.16.840.1.113883.5.89

Participationsignature

2.16.840.1.113883.6.8

Unified Code for Units of Measure (UCUM)

2.16.840.1.113883.6.88

RXNorm

2.16.840.1.113883.6.92

FIPS 5-2 (State)

2.16.840.1.113883.6.96

SNOMED CT

2.16.840.1.113883.4.6

National Provider ID (NPI)

Page 564
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
© 2012 Health Level Seven, Inc. All rights reserved.
July 2012

APPENDIX E —

VALUE SETS IN THIS GUIDE

The following table lists all the value sets (vocabularies) in this guide.
2.16.840.1.113883.11.20.9.41
Table 327: Value Sets in This Guide
ValueSet OID

ValueSet Name

Binding

2.16.840.1.113883.1.11.16866

ActPriority

DYNAMIC

2.16.840.1.113883.1.11.1

Administrative Gender (HL7 V3)

DYNAMIC

2.16.840.1.113883.1.11.20.2

AdvanceDirectiveTypeCode

STATIC

2.16.840.1.113883.11.20.9.21

AgePQ_UCUM

DYNAMIC

2.16.840.1.113883.3.88.12.3221.6.2

Allergy/Adverse Event Type

DYNAMIC

2.16.840.1.113883.3.88.12.3221.8.9

Body Site Value Set

DYNAMIC

2.16.840.1.113883.11.20.9.31

ConsultDocumentType

DYNAMIC

2.16.840.1.113883.3.88.12.80.63

CountryValueSet

DYNAMIC

2.16.840.1.113883.1.11.18877

Coverage Role Type Value Set

DYNAMIC

2.16.840.1.113883.11.20.9.28

DICOMPurposeOfReference

DYNAMIC

2.16.840.1.113883.11.20.9.30

DICOMQuantityMeasurementType
Codes

DYNAMIC

2.16.840.1.113883.11.20.9.32

DIRDocumentTypeCodes

DYNAMIC

2.16.840.1.113883.11.20.9.29

DIRQuantityMeasurementTypeCodes

DYNAMIC

2.16.840.1.113883.11.20.4.1

DischargeSummary
DocumentTypeCode

DYNAMIC

2.16.840.1.113883.3.88.12.80.32

EncounterTypeCode

DYNAMIC

2.16.840.1.113883.1.11.15913

EntityNameUse

STATIC

2.16.840.1.113883.11.20.9.26

EntityPersonNamePartQualifier

STATIC

2.16.840.1.113883.1.11.19579

FamilyHistoryRelatedSubjectCode

DYNAMIC

2.16.840.1.113883.1.11.10416

FinanciallyResponsiblePartyType

DYNAMIC

2.16.840.1.113883.3.88.12.3221.5.2

Health Insurance Type Value Set

DYNAMIC

2.16.840.1.114222.4.11.1066

Healthcare Provider Taxonomy (NUCC
– HIPAA)

DYNAMIC

2.16.840.1.113883.1.11.20275

HealthcareServiceLocation

DYNAMIC

2.16.840.1.113883.1.11.20.12

HealthStatus

DYNAMIC

2.16.840.1.113883.1.11.15836

HITSP Ethnicity Value Set

DYNAMIC

2.16.840.1.113883.3.88.12.80.62

HITSP Vital Sign Result Type

DYNAMIC

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ValueSet OID

ValueSet Name

Binding

2.16.840.1.113883.3.88.12.80.68

HITSPProblemStatus

DYNAMIC

2.16.840.1.113883.1.11.16926

HL7 BasicConfidentialityKind

STATIC

2.16.840.1.113883.1.11.12249

HL7 LanguageAbilityMode

DYNAMIC

2.16.840.1.113883.1.11.12212

HL7 Marital Status

DYNAMIC

2.16.840.1.113883.1.11.19185

HL7 Religious Affiliation

DYNAMIC

2.16.840.1.113883.1.11.20.22

HPDocumentType

DYNAMIC

2.16.840.1.113883.11.20.9.33

INDRoleclassCodes

STATIC

2.16.840.1.113883.3.88.12.80.20

Ingredient Name

DYNAMIC

2.16.840.1.113883.1.11.11526

Language

DYNAMIC

2.16.840.1.113883.1.11.12199

LanguageAbilityProficiency

DYNAMIC

2.16.840.1.113883.3.88.12.80.16

Medication Brand Name

DYNAMIC

2.16.840.1.113883.3.88.12.80.17

Medication Clinical Drug

DYNAMIC

2.16.840.1.113883.3.88.12.80.18

Medication Drug Class

DYNAMIC

2.16.840.1.113883.3.88.12.80.64

Medication Fill Status

DYNAMIC

2.16.840.1.113883.3.88.12.3221.8.11

Medication Product Form

DYNAMIC

2.16.840.1.113883.3.88.12.3221.8.7

Medication Route FDA Value Set

DYNAMIC

2.16.840.1.113883.11.20.9.18

MoodCodeEvnInt

STATIC

2.16.840.1.113883.1.11.19717

No Immunization Reason Value Set

DYNAMIC

2.16.840.1.113883.3.88.12.80.33

NUBC UB-04 FL17-Patient Status

DYNAMIC

2.16.840.1.113883.11.20.9.34

Patient Education

DYNAMIC

2.16.840.1.113883.1.11.19563

Personal Relationship Role Type

DYNAMIC

2.16.840.1.113883.11.20.9.23

Plan of Care moodCode
(Act/Encounter/Procedure)

STATIC

2.16.840.1.113883.11.20.9.25

Plan of Care moodCode (Observation)

STATIC

2.16.840.1.113883.11.20.9.24

Plan of Care moodCode
(SubstanceAdministration/Supply)

STATIC

2.16.840.1.113883.1.11.10637

PostalAddressUse

STATIC

2.16.840.1.113883.3.88.12.80.2

PostalCodeValueSet

DYNAMIC

2.16.840.1.113883.11.20.9.36

Pressure Point

DYNAMIC

2.16.840.1.113883.11.20.9.35

Pressure Ulcer Stage

DYNAMIC

2.16.840.1.113883.3.88.12.3221.7.4

Problem

STATIC

2.16.840.1.113883.3.88.12.3221.6.8

Problem Severity

DYNAMIC

2.16.840.1.113883.3.88.12.3221.7.2

Problem Type

STATIC

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ValueSet OID

ValueSet Name

Binding

2.16.840.1.113883.11.20.9.19

ProblemAct statusCode

STATIC

2.16.840.1.113883.3.88.12.80.28

Procedure

DYNAMIC

2.16.840.1.113883.11.20.9.22

ProcedureAct statusCode

DYNAMIC

2.16.840.1.113883.11.20.6.1

ProcedureNoteDocument
TypeCodes

DYNAMIC

2.16.840.1.113883.11.20.8.1

ProgressNoteDocumentTypeCode

DYNAMIC

2.16.840.1.113883.3.88.12.3221.4

Provider Type

DYNAMIC

2.16.840.1.113883.1.11.14914

Race

DYNAMIC

2.16.840.1.113883.11.20.9.39

Result Status

STATIC

2.16.840.1.113883.11.20.9.38

Smoking Status

STATIC

2.16.840.1.113883.3.88.12.80.60

Social History Type Set Definition

STATIC

2.16.840.1.113883.3.88.12.80.1

StateValueSet

DYNAMIC

2.16.840.1.113883.11.20.7.1

SupportedFileFormats

STATIC

2.16.840.1.113883.11.20.1.1

SurgicalOperationNote
DocumentTypeCode

DYNAMIC

2.16.840.1.113883.11.20.9.37

TargetSite Qualifiers

DYNAMIC

2.16.840.1.113883.11.20.9.20

Telecom Use (US Realm Header)

DYNAMIC

2.16.840.1.113883.11.20.9.41

Tobacco Use

DYNAMIC

2.16.840.1.113883.1.11.12839

UCUM Units of Measure (case
sensitive)

DYNAMIC

2.16.840.1. 113883.3.88.12.80.22

Vaccine Administered Value Set

DYNAMIC

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APPENDIX F —

SINGLE-VALUE BINDINGS IN THIS GUIDE
Table 328: Single-Value Bindings in This Guide

Code

Display Name

Code System OID

121181

Dicom Object Catalog

1.2.840.10008.2.16.4

182904002

Drug treatment unknown

2.16.840.1.113883.6.96

397659008

Age at Onset

2.16.840.1.113883.6.96

412307009

Drug vehicle

2.16.840.1.113883.6.96

419099009

Dead

2.16.840.1.113883.6.96

46680005

Vital Signs

2.16.840.1.113883.6.96

77386006

Pregnant

2.16.840.1.113883.6.96

ASSERTION

Assertion

2.16.840.1.113883.5.4

SEV

Severity Observation

2.16.840.1.113883.5.4

S

2.16.840.1.113883.5.89

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APPENDIX G — EXTENSIONS TO CDA R2
Where there is a need to communicate information for which there is no suitable
representation in CDA R2, extensions to CDA R2 have been developed. These
extensions are described above in the context of the section where they are used. This
section serves to summarize the extensions and provide implementation guidance.
Extensions created for this guide include:
sdtc:raceCode - The raceCode extension allows for multiple races to be reported
for a patient.
sdtc:id - The id extension in the family history organizer on the related subject
allows for unique identification of the family member(s).
sdtc:deceasedInd - The deceasedIndextension (= “true” or “false”) in the family
history organizer on the related subject is used inside to indicate if a family
member is deceased.
sdtc:deceasedTime - The deceasedTime extension in the family history organizer
on the related subject allows for reporting the date and time a family member
died.
sdtc:birthTime - The  element allows for the birth date of
any person to be recorded. The purpose of this extension is to allow the
recording of the subscriber or member of a health plan in cases where the health
plan eligibility system has different information on file than the provider does for
the patient.
sdtc:dischargeDispositionCode - The sdtc:dischargeDispositionCode element
allows the provider to record a discharge disposition in an encounter activity.
To resolve issues that need to be addressed by extension, the developers of this guide
chose to approach extensions as follows:
An extension is a collection of element or attribute declarations and rules for
their application to the CDA Release 2.0.
All extensions are optional. An extension may be used, but need not be under
this guide.
A single namespace for all extension elements or attributes that may be used by
this guide will be defined.
The namespace for extensions created by the HL7 Structured Documents
Working Group (formerly Structured Documents Technical Committee) shall be
urn:hl7-org:sdtc.
This namespace shall be used as the namespace for any extension elements or
attributes that are defined by this implementation guide.
Each extension element shall use the same HL7 vocabularies and data types
used by CDA Release 2.0.

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Each extension element shall use the same conventions for order and naming as
is used by the current HL7 tooling.
An extension element shall appear in the XML where the expected RIM element
of the same name would have appeared had that element not been otherwise
constrained from appearing in the CDA XML schema.

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APPENDIX H — XDS-SD AND US REALM CLINICAL
DOCUMENT HEADER COMPARISON
The following table can help the implementer familiar with XDS-SD decide whether to
assert conformance to Unstructured Documents and the US Realm Clinical Document
Header constraints specified in this guide. [See References for a link to XDS-SD (CrossTransaction Specifications and Content Specifications, Scanned Documents Module).]
Areas where this Unstructured Document specification and the Clinical Document
Header constraints are more restrictive than XDS-SD have been highlighted in yellow.
Table 329: Comparison of XDS-SD and Clinical Document Header
CDA

XDS-SD

Clinical Document Header

ClinicalDocument

SHALL

SHALL

ClinicalDocument/ realmcode

SHALL

SHALL

ClinicalDocument/ typeId

SHALL

SHALL

ClinicalDocument/ templateId

SHALL

SHALL

ClinicalDocument/ id

SHALL

SHALL

ClinicalDocument/ code

SHALL

SHALL

ClinicalDocument/ title

SHOULD

SHALL

ClinicalDocument/ effectiveTime

SHALL

SHALL

ClinicalDocument/
confidentialityCode

SHALL

SHALL

ClinicalDocument/ languageCode

SHALL

SHALL

ClinicalDocument/
documentationOf/ serviceEvent/
effectiveTime

SHALL

Not required

ClinicalDocument/ recordTarget

SHALL

SHALL

ClinicalDocument/ recordTarget/
patientRole

SHALL

SHALL

ClinicalDocument/ recordTarget/
patientRole/ addr

SHALL

SHALL

ClinicalDocument/ recordTarget/
patientRole/ telecom

Not required

SHALL

ClinicalDocument/ recordTarget/
patientRole/ patient/ name

SHALL

SHALL

ClinicalDocument/ recordTarget/
patientRole/ patient/
administrativeGenderCode

SHALL

SHALL

ClinicalDocument/ recordTarget/
patientRole/ patient/ birthTime

SHALL

SHALL

ClinicalDocument/ author/ time

Not required

SHALL

ClinicalDocument/ author/
assignedAuthor

SHALL

SHALL

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CDA

XDS-SD

Clinical Document Header

ClinicalDocument/ author/
assignedAuthor/ id

assignedPerson:
SHOULD
assignedAuthoringDevice:
SHALL

SHALL

ClinicalDocument/ author/
assignedAuthor/ addr

Not required

SHALL

ClinicalDocument/ author/
assignedAuthor/ telecom

Not required

SHALL

ClinicalDocument/ custodian

SHALL

SHALL

ClinicalDocument/ custodian/
assignedCustodian/
representedCustodianOrganization/
name

SHALL

SHALL

ClinicalDocument/ custodian/
assignedCustodian/
representedCustodianOrganization/
addr

SHALL

SHALL

ClinicalDocument/ custodian/
assignedCustodian/
representedCustodianOrganization/
telecom

Not required

SHALL

ClinicalDocument/ author
(scanner)

SHALL

ClinicalDocument/ author/
assignedAuthor/ authoringDevice
(scanner)

SHALL

ClinicalDocument/ dataEnterer

SHALL

ClinicalDocument/
legalAuthenticator

SHOULD

ClinicalDocument/ component/
nonXMLBody

SHALL

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APPENDIX I —

MIME MULTIPART/RELATED MESSAGES

The following text is taken from the Claims Attachments Implementation Guide
(AIS00000) in Section 2.4
http://www.hl7.org/documentcenter/public/wg/ca/CDAR2AIS0000R030_Implementat
ionGuideDraft.pdf. For up-to-date guidance, refer to the latest edition of that
specification.

MIME Multipart/Related Messages
An attachment is comprised of the CDA document, including any supporting files
necessary to render the attested content of the document. Two Internet request for
comments (RFCs) are needed to properly construct the mime multipart message. When
supporting files are needed, the collection of information shall be organized using a
MIME multipart/related package constructed according to RFC 2557. Within the MIME
package, supporting files must be encoded using Base-64. RFC-4648 should be used
when encoding the contents of the MIME package using Base-64. Finally, RFC-2392
may be used to reference other content that appears in the same X12 transaction to use
the same content to answer multiple questions for a single claim. Internet RFCs can be
downloaded from the RFC editor page at http://www.rfc-editor.org.

RFC-2557 MIME Encapsulation of Aggregate Documents, Such as HTML (MHTML)
This RFC describes how to construct a MIME multipart/related package, and how URLs
are resolved within content items of that package. RFC-2557 can be obtained at:
http://www.rfc-editor.org/rfc/rfc2557.txt
A MIME multipart/related package is made up of individual content items. Each
content item has a MIME header identifying the item. Each content item is delimited
from other content items using a string of application specified text. In addition, there
must be an ending boundary. The actual content is recorded between these delimiter
strings using a BASE-64 encoding of the content item. There is also a MIME header for
the entire package.
The first content item of a multipart/related message supporting attachments is the
CDA document, containing the header and structured or non-structured body.
Subsequent content items included in this package will contain additional content that
appears within the body of the document. The CDA document will reference these
additional content items by their URLs.

Referencing Supporting Files in Multipart/Related Messages
Because the CDA document and its supporting files may have already existed in a
clinical information system, references may already exist within the CDA document to
URLs that are not accessible outside of the clinical information system that created the
document. When the CDA document is sent via attachments, these URLs may no
longer be accessible by the receiving information system. Therefore, each content item
that is referenced by a URL within the CDA document must be included as a content
item in the MIME package. Each content item may specify the URL by which it is

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known using the Content-Location header. The receiver of this MIME package shall
translate URL references according the RFC-2557. This will ensure resolution of the
original URL to the correct content item within the MIME package. Thus, URL
references contained within an original document need not be rewritten when the CDA
package is transmitted. Instead, these URLs are simply supplied as the value of the
Content-Location header in the MIME package.
This capability allows for the same content item to be referred to more than once in a
MIME multipart/related package without requiring the content item to be supplied
twice. However, it does not allow a separate MIME multipart/related package to
contain references to information sent in a previously recorded package.

Referencing Documents from Other Multiparts within the Same X12 Transactions
RFC-2392 is used when referencing content across MIME package boundaries, but still
contained within the same X12 transaction (ST to SE). This can occur when the same
document answers multiple questions for a single claim. Each component of a MIME
package may be assigned a content identifier using the Content-ID header for the
content item. For example, this header would appear as:
Content-ID: <07EE4DAC-76C4-4a98-967E-F6EF9667DED1>
This content identifier is a unique identifier for the content item, which means it must
never be used to refer to any other content item. RFC-2392 defines the cid: URL
scheme (http: and ftp: are two other URL schemes). This URL scheme allows for
references by the Content-ID header to be resolved. The URL for the content item
identified above would be:
cid:07EE4DAC-76C4-4a98-967E-F6EF9667DED1
Receivers of the MIME multipart message must be able to resolve a cid: URL to the
content item that it identifies. Senders must ensure that they only refer to items that
have already been transmitted to the receiver by their cid: URL. Thus, this
implementation guide prohibits forward URL references using the cid: URL scheme.
Content items shall not be referenced across X12 transactions using the cid: URL
scheme. For example, if the payer previously requested information using a 277, and
the provider returned that information in a MIME multipart/related package in a 275,
and then the payer requested additional information in another 277, the provider may
not refer to the content item previously returned in the prior 275 transaction.

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APPENDIX J — ADDITIONAL PHYSICAL EXAMINATION
SUBSECTIONS
Below is the list of additional optional subsections that may be used under the Physical
Examination section. Most of the codes for these subsections are included in the HL7
document titled “CDAR2AIS0004R030, Additional Information Specification 0004:
Clinical Reports Attachment,” which also lists General Status (10210-3) and Vital Signs
(8716-3)—defined in this guide.
10190-7

MENTAL STATUS

11451-2

PSYCHIATRIC FINDINGS

10199-8

HEAD, PHYSICAL FINDINGS

10197-2

EYE, PHYSICAL FINDINGS

10195-6

EAR, PHYSICAL FINDINGS

10203-8

NOSE, PHYSICAL FINDINGS

11393-6

EARS & NOSE & MOUTH & THROAT, PHYSICAL FINDINGS

10201-2

MOUTH & THROAT & TEETH, PHYSICAL FINDINGS

51850-6

HEAD & EARS & EYES & NOSE & THROAT, PHYSICAL FINDINGS

11411-6

NECK, PHYSICAL FINDINGS

10207-9

THORAX & LUNGS, PHYSICAL FINDINGS

11391-0

CHEST, PHYSICAL FINDINGS

11392-8

CHEST WALL, PHYSICAL FINDINGS

10200-4

HEART, PHYSICAL FINDINGS

10193-1

BREASTS, PHYSICAL FINDINGS

10192-3

BACK, PHYSICAL FINDINGS

10191-5

ABDOMEN, PHYSICAL FINDINGS

10204-6

PELVIS, PHYSICAL FINDINGS

11403-3

GROIN, PHYSICAL FINDINGS

10198-0

GENITOURINARY TRACT, PHYSICAL FINDINGS

11400-9

GENITALIA, PHYSICAL FINDINGS

11401-7

GENITALIA FEMALE, PHYSICAL FINDINGS

11402-5

GENITALIA MALE, PHYSICAL FINDINGS

11388-6

BUTTOCKS, PHYSICAL FINDINGS

10205-3

RECTUM, PHYSICAL FINDINGS

10196-4

EXTREMITIES, PHYSICAL FINDINGS

11413-2

SHOULDER, PHYSICAL FINDINGS

11387-8

AXILLA, PHYSICAL FINDINGS

11386-0

UPPER ARM, PHYSICAL FINDINGS

11394-4

ELBOW, PHYSICAL FINDINGS

11398-5

FOREARM, PHYSICAL FINDINGS

11415-7

WRIST, PHYSICAL FINDINGS

11404-1

HAND, PHYSICAL FINDINGS

11406-6

HIP, PHYSICAL FINDINGS

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11414-0

THIGH, PHYSICAL FINDINGS

11407-4

KNEE, PHYSICAL FINDINGS

11389-4

CALF, PHYSICAL FINDINGS

11385-2

ANKLE, PHYSICAL FINDINGS

11397-7

FOOT, PHYSICAL FINDINGS

10209-5

BALANCE+COORDINATION, PHYSICAL FINDINGS

10212-9

STRENGTH PHYSICAL FINDINGS

10211-1

SENSATION, PHYSICAL FINDINGS

10206-1

SKIN, PHYSICAL FINDINGS

10194-9

DEEP TENDON REFLEXES, PHYSICAL FINDINGS

10208-7

VESSELS, PHYSICAL FINDINGS

11384-5

PHYSICAL EXAMINATION BY ORGAN SYSTEMS

11447-0

HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC PHYSICAL FINDINGS

11390-2

CARDIOVASCULAR SYSTEM, PHYSICAL FINDINGS

11399-3

GASTROINTESTINAL SYSTEM, PHYSICAL FINDINGS

10202-0

NEUROLOGIC SYSTEM, PHYSICAL FINDINGS

11410-8

MUSCULOSKELETAL SYSTEM, PHYSICAL FINDINGS

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APPENDIX K —

ADDITIONAL EXAMPLES

This appendix contains various examples of use from this guide.

Names Examples
Figure 242: Correct use of name example 1
JohnQ.Doe

The name element in CDA contains mixed content. In XML, this means that name can
contain a mix of character data and element markup in any order. The consequence of
this is that all whitespace is significant, thus tab characters, carriage returns, space
characters, etc. all become “part” of the person’s name.
Figure 243: Incorrect use of name example 1 - whitespace

John
Q.
Doe


Figure 244: Incorrect use of Patient name example 2 - no tags
John Q. Doe

Addresses Examples
Figure 245: Correct use telecom address example


Figure 246: Correct use postal address example
17 Daws Rd.Blue
BellMA02368US


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Time Examples
Figure 247: Correct use of IVL_TS example





Figure 248: Correct use of TS with precision to minute example


Figure 249: Correct use of TS with time zone offset example


Figure 250: Incorrect use of IVL_TS example


Figure 251: Incorrect use of TS - insufficient precision example
 (must be precise to the minute)

Figure 252: Incorrect use of TS when time zone offset required example


Use of effectiveTime with time zone where not relevant (precise only to the day)
Figure 253: Incorrect use of time zone offset - not enough precision example
EXIF.tools