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.

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.

Page 2 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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Following is a non-exhaustive list of third-party terminologies that may require a separate license:

Terminology

Owner/Contact

Current Procedures Terminology

(CPT) code set

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resources/solutions-managing-your-practice/coding-billing-

insurance/cpt/cpt-products-services/licensing.page?

SNOMED CT

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Organization (IHTSDO) http://www.ihtsdo.org/snomed-

ct/get-snomed-ct or info@ihtsdo.org

Logical Observation Identifiers

Names & Codes (LOINC)

Regenstrief Institute

International Classification of

Diseases (ICD) codes

World Health Organization (WHO)

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 3

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

Page 4 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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,

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.

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

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 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

2 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

Page 6 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

3 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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 7

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

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

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

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

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

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

4 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

Page 8 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

5 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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 9

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

Page 10 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 11

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

6 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

Page 12 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

CD Examples .................................................................................................................. 578

APPENDIX L — LARGE UML DIAGRAMS ......................................................................... 580

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 13

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

Page 14 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 15

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

Page 16 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 17

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

Page 18 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 19

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

Page 20 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 21

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

Page 22 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 23

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

Page 24 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 25

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

Page 26 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 27

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

Page 28 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 29

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

Page 30 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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)

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.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 31

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

2 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

Page 32 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

Healthcare Safety Network3. The Tdb is the source for generation of platform-

independent validation rules as Schematron4 (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 section-

level 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,

3 http://www.lantanagroup.com/resources/tools/

4 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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 33

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 entry-

level 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

Page 34 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 35

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

Card.

Verb

Data

Type

CONF#

Fixed Value

Green

Severity

Observation

observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.8']

@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

SET<II>

7347

@root

1..1

SHALL

10525

2.16.840.1.113883.10.20.22.4.8

code

1..1

SHALL

7349

2.16.840.1.113883.5.4 (ActCode) =

SEV

severity

FreeText

text

0..1

SHOULD

7350

reference

/@value

0..1

SHOULD

7351

statusCode

1..1

SHALL

7352

2.16.840.1.113883.5.14 (ActStatus)

= completed

severity

Coded

value

1..1

SHALL

7356

2.16.840.1.113883.3.88.12.3221.6.8

(Problem Severity)

interpretation

Code

0..*

SHOULD

9117

code

0..1

SHOULD

9118

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).

Page 36 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 37

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).

Page 38 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

... 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).

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.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 39

The above example would be properly expressed as follows.

Figure 5: XML expression of a single-code binding

<code code="11450-4" codeSystem="2.16.840.1.113883.6.1"

displayName="Problem List"

codeSystemName=”LOINC”/>

A full discussion of the representation of vocabulary is outside the scope of this

document; for more information, see the HL7 V3 Normative Edition 20106

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

<code code='206525008’

displayName='neonatal necrotizing enterocolitis'

codeSystem='2.16.840.1.113883.6.96'

codeSystemName='SNOMED CT'>

<translation code='NEC-1'

displayName='necrotizing enterocolitis'

codeSystem='2.16.840.1.113883.19'/>

</code>

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.

6 HL7 Version 3 Interoperability Standards, Normative Edition 2010.

http://www.hl7.org/memonly/downloads/v3edition.cfm - V32010

Page 40 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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.

7 HL7 Clinical Document Architecture (CDA Release 2)

http://www.hl7.org/implement/standards/cda.cfm

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 41

Figure 8: Attribute required

1. 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).

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

<entry>

<originalText>New Grading system</originalText>

</code>

<originalText>Spiculated mass grade 5</originalText>

</value>

</observation>

</entry>

Figure 10: nullFlavor explicitly disallowed

1. SHALL contain exactly one [1..1] effectiveTime (CONF:5256).

a. SHALL NOT contain [0..0] nullFlavor (CONF:52580).

Page 42 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

<entry>

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

was</text>

</manufacturedLabeledDrug>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 43

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

<entry>

<substanceAdministration moodCode="EVN" classCode="SBADM"

nullFlavor="NI">

<text>I do not know whether or not patient received an anticoagulant

drug</text>

<code code="81839001" displayName="anticoagulant drug"

codeSystem="2.16.840.1.113883.6.96"

codeSystemName="SNOMED CT"/>

</manufacturedLabeledDrug>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

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

<entry>

<substanceAdministration moodCode="EVN" classCode="SBADM"

negationInd=”true”>

<text>No known medications</text>

<code code="410942007" displayName="drug or medication"

codeSystem="2.16.840.1.113883.6.96"

codeSystemName="SNOMED CT"/>

</manufacturedLabeledDrug>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

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.

8 HL7 Clinical Document Architecture (CDA Release 2).

http://www.hl7.org/implement/standards/cda.cfm

Page 44 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

...

<code codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'

code='17561000' displayName='Cardiologist' />

...

</assignedAuthor>

</author>

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

...

</ClinicalDocument>

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/

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 45

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

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

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

Page 46 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 47

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

Confidentiality Code

Normal

Confidentiality Code

Restricted

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

Internet Society Language

english

Internet Society Language

french

Internet Society Language

arabic

en-US

Internet Society Language

English, US

es-US

Internet Society Language

Spanish, US

…

11 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

Page 48 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

Figure 17: US Realm header example

<code codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" code="34117-2"

displayName="History and Physical Note"/>

<title>Good Health History & Physical</title>

<languageCode code="en-US"

displayName="English, US"

codeSystem="2.16.840.1.113883.1.11.11526"

codeSystemName="Internet Society Language"/>

Figure 18: effectiveTime with time zone example

<!-- the syntax is "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]" where digits can be

omitted

the right side to express less precision. -->

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 49

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

Page 50 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 51

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).

Page 52 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

AddressUse

primary home

AddressUse

work place

AddressUse

mobile contact

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

AdministrativeGender

Female

AdministrativeGender

Male

AdministrativeGender

Undifferentiated

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 53

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

MaritalStatus

Annulled

MaritalStatus

Divorced

MaritalStatus

Interlocutory

MaritalStatus

Legally Separated

MaritalStatus

Married

MaritalStatus

Polygamous

MaritalStatus

Never Married

MaritalStatus

Domestic partner

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

…

Page 54 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

…

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 55

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

FIPS 5-2 (State Alpha Codes)

Alabama

FIPS 5-2 (State Alpha Codes)

Alaska

FIPS 5-2 (State Alpha Codes)

Arizona

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 alpha-

2 code of ISO's country code standard

http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm

Code

Code System

Print Name

ISO 3166-1 Country Codes

Aruba

ISO 3166-1 Country Codes

Israel

ISO 3166-1 Country Codes

Kazakhstan

ISO 3166-1 Country Codes

United States

…

Page 56 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

LanguageAbilityProficiency

Excellent

LanguageAbilityProficiency

Fair

LanguageAbilityProficiency

Good

LanguageAbilityProficiency

Poor

3.2.1.7 RecordTarget Example

Figure 19: recordTarget example

<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 --

<!-- US is "United States" from ISO 3166-1 Country Codes:

1.0.3166.1 -->

</addr>

<!-- HP is "primary home" from AddressUse 2.16.840.1.113883.5.1119 --

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 57

<given qualifier="CL">Frankie</given>

<!-- CL is "Call me" from EntityNamePartQualifier

2.16.840.1.113883.5.43 -->

<family>Everyman</family>

</name>

<administrativeGenderCode code="M"

codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>

<maritalStatusCode code="M" displayName="Married"

codeSystem="2.16.840.1.113883.5.2"

codeSystemName="MaritalStatusCode"/>

<religiousAffiliationCode code="1013"

displayName="Christian (non-Catholic, non-specific)"

codeSystemName="Religious Affiliation "

codeSystem="2.16.840.1.113883.5.1076"/>

<raceCode code="2106-3" displayName="White"

codeSystem="2.16.840.1.113883.6.238"

codeSystemName="Race & Ethnicity - CDC"/>

<ethnicGroupCode code="2186-5"

displayName="Not Hispanic or Latino"

codeSystem="2.16.840.1.113883.6.238"

codeSystemName="Race & Ethnicity - CDC"/>

<code code="GRFTH" displayName="Grandfather"

codeSystem="2.16.840.1.113883.5.111"

codeSystemName="RoleCode"/>

</addr>

<name>

<given>Ralph</given>

<family>Relative</family>

</name>

</guardianPerson>

</guardian>

<place>

<addr>

</addr>

</place>

</birthplace>

Page 58 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

<modeCode code="RWR" displayName="Receive Written"

codeSystem="2.16.840.1.113883.5.60"

codeSystemName="LanguageAbilityMode"/>

</languageCommunication>

</patient>

<name>Good Health Clinic</name>

<addr>

<streetAddressLine>21 North Ave</streetAddressLine>

<city>Burlington</city>

</addr>

</providerOrganization>

</patientRole>

</recordTarget>

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 59

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).

Page 60 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

Figure 20: Person author example

<addr>

<streetAddressLine>21 North Ave.</streetAddressLine>

<city>Burlington</city>

</addr>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedAuthor>

</author>

Figure 21: Device author example

<addr>

<streetAddressLine>21 North Ave.</streetAddressLine>

<city>Burlington</city>

</addr>

<manufacturerModelName>Good Health Medical

Device</manufacturerModelName >

<softwareName>Good Health Report Generator</softwareName >

</ assignedAuthoringDevice >

</assignedAuthor>

</author>

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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 61

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).

Page 62 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

Figure 22: dataEnterer example

<addr>

<streetAddressLine>21 North Ave.</streetAddressLine>

<city>Burlington</city>

</addr>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedEntity>

</dataEnterer>

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 63

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

<addr>

<streetAddressLine>21 North Ave.</streetAddressLine>

<city>Burlington</city>

</addr>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedEntity>

</informant>

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).

Page 64 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

<name>Good Health Clinic</name>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 65

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

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</informationRecipient>

<name>Good Health Clinic</name>

</receivedOrganization>

</intendedRecipient>

</informationRecipient>

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).

Page 66 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 67

Figure 26: legalAuthenticator example

<addr>

<streetAddressLine>21 North Ave.</streetAddressLine>

<city>Burlington</city>

</addr>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedEntity>

</legalAuthenticator>

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

Page 68 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

<addr>

<streetAddressLine>21 North Ave.</streetAddressLine>

<city>Burlington</city>

</addr>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedEntity>

</authenticator>

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 69

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-of-

kin)

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):

RoleClass 2.16.840.1.113883.5.110

Code

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

Page 70 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

Figure 28: Participant example for a supporting person

</time>

<addr>

</addr>

<name>

<given>Martha</given>

</name>

</associatedPerson>

</associatedEntity>

</participant>

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 71

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).

Page 72 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

Figure 29: DocumentationOf example

<id extension="123453"

root="1.2.840.113619.2.62.994044785528.26"/>

<code code="93041"

displayName="Rhythm ECG, one to three leads; tracing

only without interpretation and report"

codeSystem="2.16.840.1.113883.6.12"

codeSystemName="CPT4"/>

<code code="208D00000X "

codeSystem="2.16.840.1.113883.6.101"

codeSystemName="NUCC"

displayName="General Practice"/>

<name>

<given>Matthew</given>

</name>

</assignedPerson>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

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).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 73

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

<code codeSystem=" 2.16.840.1.113883.6.1" codeSystemName="LOINC"

code="64293-4" displayName="Procedure consent"/>

</consent>

</authorization>

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).

Page 74 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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 space13 (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):

AddressUse 2.16.840.1.113883.5.1119

Code

Code System

Print Name

BAD

AddressUse

bad address

DIR

AddressUse

direct

AddressUse

home address

AddressUse

primary home

AddressUse

vacation home

PHYS

AddressUse

physical visit address

PST

AddressUse

postal address

PUB

AddressUse

public

TMP

AddressUse

temporary

AddressUse

work place

3.4 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.

13 For information on mixed content see Extensible Markup Language (XML)

(http://www.w3.org/TR/2008/REC-xml-20081126/#sec-mixed-content).

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 75

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

Page 76 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

EntityNameUse

Artist/Stage

ABC

EntityNameUse

Alphabetic

ASGN

EntityNameUse

Assigned

EntityNameUse

License

EntityNameUse

Indigenous/Tribal

IDE

EntityNameUse

Ideographic

EntityNameUse

Legal

EntityNameUse

Pseudonym

PHON

EntityNameUse

Phonetic

EntityNameUse

Religious

SNDX

EntityNameUse

Soundex

SRCH

EntityNameUse

SYL

EntityNameUse

Syllabic

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 77

Table 19: EntityPersonNamePartQualifier Value Set

Value Set: EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC

2011-09-30

Code System(s):

EntityNamePartQualifier 2.16.840.1.113883.5.43

Code

Code System

Print Name

EntityNamePartQualifier

academic

EntityNamePartQualifier

adopted

EntityNamePartQualifier

birth

EntityNamePartQualifier

callme

EntityNamePartQualifier

initial

EntityNamePartQualifier

nobility

EntityNamePartQualifier

professional

EntityNamePartQualifier

spouse

TITLE

EntityNamePartQualifier

title

EntityNamePartQualifier

voorvoegsel

3.7 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

Page 78 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

 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

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 79

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

Page 80 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

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

Document Type

Preferred LOINC

templateId

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*

History of Present Illness

Physical Exam

Reason for Referral/Reason for

Visit16 **

Allergies

Chief Complaint **

Chief Complaint and Reason

for Visit **

Family History

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 CCD is the only document with a fixed clinicalDocument/code

15 Required only for inpatient settings

16 Either Reason for Referral or Reason for Visit must be present.

HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 81

Document Type

Preferred LOINC

templateId

Required Sections

Optional Sections

Diagnostic Imaging Report

18748-4

2.16.840.1.113883.10.20.22.1.5

DICOM Object Catalog

Findings (Radiology Study

Observation)

Addendum

Clinical Presentation

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

Hospital Course

Hospital Discharge Diagnosis

Hospital Discharge Medications

Plan of Care

Chief Complaint **

Chief Complaint and Reason

for Visit **

Discharge Diet

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

Page 82 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1

Document Type

Preferred LOINC

templateId

Required Sections

Optional Sections

History & Physical Note

34117-2

2.16.840.1.113883.10.20.22.1.3

Allergies

Assessment and

Plan/Assessment/Plan of

Care*

Chief Complaint **

Chief Complaint and Reason

for Visit **

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

History of Present Illness

Immunizations

Instructions

Problem List

Procedures (List of Surgeries)

(History of Procedures)

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