CDAR2 Implementation Guide 2012JUL
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CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL
HL7 Implementation Guide for CDA® Release 2:
IHE Health Story Consolidation, DSTU Release 1.1
(US Realm)
Draft Standard for Trial Use
July 2012
Publication of this draft standard for trial use and comment has been approved by
Health Level Seven International (HL7). This draft standard is not an accredited
American National Standard. The comment period for use of this draft standard shall
end 24 months from the date of publication. Suggestions for revision should be
submitted at http://www.hl7.org/dstucomments/index.cfm.
Following this 24 month evaluation period, this draft standard, revised as necessary,
will be submitted to a normative ballot in preparation for approval by ANSI as an
American National Standard. Implementations of this draft standard shall be viable
throughout the normative ballot process and for up to six months after publication of
the relevant normative standard.
Copyright © 2012 Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction
of this material in any form is strictly forbidden without the written permission of the publisher.
HL7 International and Health Level Seven are registered trademarks of Health Level Seven
International. Reg. U.S. Pat & TM Off.
Page 2 HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1
© 2012 Health Level Seven, Inc. All rights reserved. July 2012
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Terminology
Owner/Contact
Current Procedures Terminology
(CPT) code set
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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
July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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
© 2012 Health Level Seven, Inc. All rights reserved. July 2012
Acknowledgments
This guide was produced and developed through the joint efforts of Health Level
Seven (HL7), Integrating the Healthcare Environment (IHE), the Health Story
Project, and the Office of the National Coordinator (ONC) within the US
Department of Health and Human Services (HSS).
The project was carried out within the ONC’s Standards and Interoperability
(S&I) Framework as the Clinical Document Architecture (CDA) Consolidation
Project with a number of goals, one of which is providing a set of harmonized
CDA templates for the US Realm.
The co-editors appreciate the support and sponsorship of the HL7 Structured
Documents Working Group (SDWG) and all the volunteers, staff and contractors
participating in the S&I Framework.
The conformance requirements included here for review were generated from two
model-driven tools: the Model-Driven Health Tools (MDHT)—developed as on
open source tool under the auspices of the Veterans Administration, IBM, and
the ONC—and the Trifolia Template Database (Tdb)—developed initially for the
Centers for Disease Control and Prevention (CDC) and released by Lantana
Consulting Group under an open source license.
This material contains content from SNOMED CT®
(http://www.ihtsdo.org/snomed-ct/). SNOMED CT is a registered trademark of
the International Health Terminology Standard Development Organisation
(IHTSDO).
This material contains content from LOINC® (http://loinc.org). The LOINC table,
LOINC codes, and LOINC panels and forms file are copyright © 1995-2012,
Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and
Codes (LOINC) Committee and available at no cost under the license at
http://loinc.org/terms-of-use.
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 5
July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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
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2.2.6 InformationRecipient ........................................................................................ 64
2.2.7 LegalAuthenticator ........................................................................................... 65
2.2.8 Authenticator ................................................................................................... 67
2.2.9 Participant (Support) ........................................................................................ 69
2.2.10 InFulfillmentOf ................................................................................................. 70
2.2.11 DocumentationOf/serviceEvent ........................................................................ 70
2.2.12 Authorization/consent ...................................................................................... 72
2.2.13 ComponentOf ................................................................................................... 73
2.3 US Realm Address (AD.US.FIELDED) .................................................................... 73
2.4 US Realm Date and Time (DT.US.FIELDED) .......................................................... 74
2.5 US Realm Date and Time (DTM.US.FIELDED) ....................................................... 75
2.6 US Realm Patient Name (PTN.US.FIELDED) .......................................................... 75
2.7 US Realm Person Name (PN.US.FIELDED) ............................................................. 77
2.8 Rendering Header Information for Human Presentation ......................................... 77
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
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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
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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
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5.5 Allergy Problem Act ............................................................................................. 306
5.6 Allergy Status Observation ................................................................................... 309
5.7 Assessment Scale Observation ............................................................................. 310
5.8 Assessment Scale Supporting Observation ........................................................... 314
5.9 Authorization Activity .......................................................................................... 315
5.10 Boundary Observation ......................................................................................... 317
5.11 Caregiver Characteristics ..................................................................................... 318
5.12 Code Observations ............................................................................................... 321
5.13 Cognitive Status Problem Observation.................................................................. 323
5.14 Cognitive Status Result Observation .................................................................... 328
5.15 Cognitive Status Result Organizer ........................................................................ 331
5.16 Comment Activity ................................................................................................ 333
5.17 Coverage Activity ................................................................................................. 336
5.18 Deceased Observation ......................................................................................... 337
5.19 Discharge Medication .......................................................................................... 339
5.20 Drug Vehicle ....................................................................................................... 341
5.21 Encounter Activities ............................................................................................ 343
5.22 Encounter Diagnosis ........................................................................................... 346
5.23 Estimated Date of Delivery ................................................................................... 348
5.24 Family History Death Observation ........................................................................ 349
5.25 Family History Observation .................................................................................. 351
5.26 Family History Organizer ..................................................................................... 356
5.27 Functional Status Problem Observation ............................................................... 360
5.28 Functional Status Result Observation .................................................................. 363
5.29 Functional Status Result Organizer ..................................................................... 366
5.30 Health Status Observation ................................................................................... 368
5.31 Highest Pressure Ulcer Stage ............................................................................... 371
5.32 Hospital Admission Diagnosis .............................................................................. 372
5.33 Hospital Discharge Diagnosis ............................................................................... 373
5.34 Immunization Activity .......................................................................................... 375
5.35 Immunization Medication Information .................................................................. 381
5.36 Immunization Refusal Reason .............................................................................. 384
5.37 Indication ............................................................................................................ 386
5.38 Instructions ........................................................................................................ 388
5.39 Medication Activity .............................................................................................. 390
5.40 Medication Dispense ............................................................................................ 399
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5.41 Medication Information ....................................................................................... 402
5.42 Medication Supply Order .................................................................................... 404
5.43 Medication Use – None Known (deprecated) ......................................................... 407
5.44 Non-Medicinal Supply Activity ............................................................................ 408
5.45 Number of Pressure Ulcers Observation .............................................................. 410
5.46 Plan of Care Activity Act ...................................................................................... 412
5.47 Plan of Care Activity Encounter ........................................................................... 413
5.48 Plan of Care Activity Observation ........................................................................ 414
5.49 Plan of Care Activity Procedure ........................................................................... 416
5.50 Plan of Care Activity Substance Administration ................................................... 417
5.51 Plan of Care Activity Supply ................................................................................ 418
5.52 Policy Activity ..................................................................................................... 419
5.53 Postprocedure Diagnosis ..................................................................................... 430
5.54 Precondition for Substance Administration .......................................................... 431
5.55 Pregnancy Observation ....................................................................................... 432
5.56 Preoperative Diagnosis ........................................................................................ 434
5.57 Pressure Ulcer Observation ................................................................................. 436
5.58 Problem Concern Act (Condition) ......................................................................... 444
5.59 Problem Observation .......................................................................................... 446
5.60 Problem Status ................................................................................................... 451
5.61 Procedure Activity Act ......................................................................................... 452
5.62 Procedure Activity Observation ........................................................................... 460
5.63 Procedure Activity Procedure .............................................................................. 466
5.64 Procedure Context .............................................................................................. 472
5.65 Product Instance ................................................................................................ 473
5.66 Purpose of Reference Observation ....................................................................... 475
5.67 Quantity Measurement Observation .................................................................... 476
5.68 Reaction Observation .......................................................................................... 480
5.69 Referenced Frames Observation .......................................................................... 483
5.70 Result Observation ............................................................................................. 484
5.71 Result Organizer ................................................................................................. 488
5.72 Series Act ........................................................................................................... 490
5.73 Service Delivery Location .................................................................................... 493
5.74 Severity Observation ........................................................................................... 495
5.75 Smoking Status Observation ............................................................................... 497
5.76 Social History Observation .................................................................................. 500
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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
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© 2012 Health Level Seven, Inc. All rights reserved. July 2012
CD Examples .................................................................................................................. 578
APPENDIX L — LARGE UML DIAGRAMS ......................................................................... 580
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July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
Table of Figures
Figure 1: Constraints format example ........................................................................ 35
Figure 2: Constraints format – only one allowed......................................................... 37
Figure 3: Constraints format – only one like this allowed ........................................... 37
Figure 4: Binding to a single code .............................................................................. 38
Figure 5: XML expression of a single-code binding ..................................................... 39
Figure 6: Translation code example ........................................................................... 39
Figure 7: nullFlavor example ..................................................................................... 40
Figure 8: Attribute required....................................................................................... 41
Figure 9: Allowed nullFlavors when element is required (with xml examples) .............. 41
Figure 10: nullFlavor explicitly disallowed ................................................................. 41
Figure 11: Unknown medication example .................................................................. 42
Figure 12: Unknown medication use of anticoagulant drug example .......................... 43
Figure 13: No known medications example ................................................................ 43
Figure 14: XML document example ........................................................................... 44
Figure 15: XPath expression example ........................................................................ 44
Figure 16: ClinicalDocument example ....................................................................... 44
Figure 17: US Realm header example ........................................................................ 48
Figure 18: effectiveTime with time zone example ........................................................ 48
Figure 19: recordTarget example ............................................................................... 56
Figure 20: Person author example ............................................................................. 60
Figure 21: Device author example ............................................................................. 60
Figure 22: dataEnterer example ................................................................................ 62
Figure 23: Informant with assignedEntity example .................................................... 63
Figure 24: Custodian example ................................................................................... 64
Figure 25: informationRecipient example ................................................................... 65
Figure 26: legalAuthenticator example ....................................................................... 67
Figure 27: Authenticator example.............................................................................. 68
Figure 28: Participant example for a supporting person ............................................. 70
Figure 29: DocumentationOf example ........................................................................ 72
Figure 30: Procedure note consent example ............................................................... 73
Figure 31: CCD ClinicalDocument/templateId example ............................................. 84
Figure 32: CCD code example ................................................................................... 85
Figure 33: Consultation note ClinicalDocument/templateId example ......................... 97
Figure 34: Consultation note ClinicalDocument/code example ................................. 100
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Figure 35: Consultation note translation of local code example ................................ 100
Figure 36: Consultation note uncoordinated document type codes example .............. 101
Figure 37: Consultation note inFulfillmentOf example ............................................. 101
Figure 38: Consultation note componentOf example ................................................ 103
Figure 39: DIR ClinicalDocument/templateId example ............................................. 113
Figure 40: DIR ClinicalDocument/code example ...................................................... 115
Figure 41: DIR use of the translation element to include local codes for document type
....................................................................................................................... 115
Figure 42: DIR participant example ......................................................................... 116
Figure 43: DIR inFulfillmentOf example ................................................................... 117
Figure 44: DIR procedure context (CDA Header) illustration (non-normative) ............ 117
Figure 45: DIR documentationOf example................................................................ 118
Figure 46: DIR relatedDocument example ................................................................ 119
Figure 47: DIR componentOf example...................................................................... 121
Figure 48: Physician reading study performer example ............................................ 122
Figure 49: Physician of record participant example .................................................. 123
Figure 50: WADO reference using linkHtml example ................................................ 127
Figure 51: Fetus subject context example ................................................................ 128
Figure 52: Observer context example ....................................................................... 129
Figure 53: Discharge summary ClinicalDocument/templateId example .................... 130
Figure 54: Discharge summary ClinicalDocument/code example ............................ 131
Figure 55: Discharge summary componentOf example ............................................. 133
Figure 56: H&P ClinicalDocument/templateId example ............................................ 147
Figure 57: H&P ClinicalDocument/code example ................................................... 148
Figure 58: H&P use of translation to include local equivalents for document type ..... 148
Figure 59: H&P componentOf example .................................................................... 150
Figure 60: Operative note ClinicalDocument/templateId example ............................. 160
Figure 61: Operative note ClinicalDocument/code example ..................................... 162
Figure 62: Operative note serviceEvent example....................................................... 164
Figure 63: Operative note performer example ........................................................... 165
Figure 64: Procedure note ClinicalDocument/templateId category I example ............ 170
Figure 65: Procedure note ClinicalDocument/code example ..................................... 171
Figure 66: Procedure note serviceEvent example ...................................................... 176
Figure 67: Procedure note serviceEvent example with null value in width element .... 176
Figure 68: Procedure note performer example .......................................................... 177
Figure 69: Progress note ClinicalDocument/templateId example .............................. 188
Figure 70: Progress note ClinicalDocument/code example ...................................... 190
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Figure 71: Progress note serviceEvent example ........................................................ 191
Figure 72: Progress note componentOf example ....................................................... 192
Figure 73: nonXMLBody example with embedded content ........................................ 200
Figure 74: nonXMLBody example with referenced content ....................................... 200
Figure 75: nonXMLBody example with compressed content ..................................... 200
Figure 76: Unique file reference example ................................................................. 202
Figure 77: Advance directives section UML diagram ................................................. 210
Figure 78: Advance directives section example ......................................................... 211
Figure 79: Allergies section UML diagram ................................................................ 212
Figure 80: Allergies section example ........................................................................ 213
Figure 81: Anesthesia section example .................................................................... 215
Figure 82: Assessment and plan section example .................................................... 216
Figure 83: Assessment section example ................................................................... 217
Figure 84: Chief complaint and reason for visit section example ............................... 218
Figure 85: Chief complaint section example ............................................................. 218
Figure 86: Complications section example ............................................................... 219
Figure 87: DICOM object catalog section example .................................................... 221
Figure 88: Discharge diet section example ............................................................... 222
Figure 89: Encounters section UML diagram ........................................................... 223
Figure 90: Encounters section example ................................................................... 224
Figure 91: Family history section UML diagram ....................................................... 225
Figure 92: Family history section example ............................................................... 225
Figure 93: Findings section example ........................................................................ 226
Figure 94: Functional status section UML diagram .................................................. 227
Figure 95: Functional status section example .......................................................... 230
Figure 96: General status section example .............................................................. 232
Figure 97: History of past illness section example .................................................... 233
Figure 98: History of present illness section example ............................................... 234
Figure 99: Hospital admission diagnosis section example......................................... 235
Figure 100: Hospital admission medications section example ................................... 236
Figure 101: Hospital consultations section example ................................................. 237
Figure 102: Hospital course section example ........................................................... 238
Figure 103: Hospital discharge diagnosis section example ........................................ 239
Figure 104: Hospital discharge instructions section example ................................... 240
Figure 105: Hospital discharge medications section example.................................... 242
Figure 106: Hospital discharge physical section example ......................................... 243
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Figure 107: Hospital discharge studies summary section example ............................ 244
Figure 108: Immunization section* UML diagram .................................................... 244
Figure 109: Immunization section example .............................................................. 246
Figure 110: Instructions section example ................................................................ 248
Figure 111: Interventions section example ............................................................... 249
Figure 112: Medical equipment section UML diagram .............................................. 249
Figure 113: Medical equipment section example ...................................................... 250
Figure 114: Medical (general) history section example .............................................. 251
Figure 115: Medications administered section example ............................................ 252
Figure 116: Medications section UML diagram ......................................................... 252
Figure 117: Medications section entries example ..................................................... 254
Figure 118: Objective section example ..................................................................... 255
Figure 119: Operative Note fluid section example ..................................................... 256
Figure 120: Operative Note surgical procedure section example ............................... 256
Figure 121: Payers section UML diagram ................................................................. 257
Figure 122: Payers section example ......................................................................... 258
Figure 123: Physical exam section example ............................................................. 260
Figure 124: Plan of care section UML diagram ......................................................... 260
Figure 125: Plan of care section example ................................................................. 261
Figure 126: Planned procedure section example ...................................................... 263
Figure 127: Postoperative diagnosis section example................................................ 264
Figure 128: Postprocedure diagnosis section example .............................................. 265
Figure 129: Preoperative diagnosis section example ................................................. 266
Figure 130: Problem section UML diagram............................................................... 266
Figure 131: Problem section example ...................................................................... 268
Figure 132: Pressure ulcer on a problem list example .............................................. 268
Figure 133: Procedure description section example .................................................. 269
Figure 134: Procedure disposition section example .................................................. 270
Figure 135: Procedure estimated blood loss section example .................................... 271
Figure 136: Procedure findings section example ....................................................... 272
Figure 137: Procedure implants section example ..................................................... 273
Figure 138: Procedure indications section example .................................................. 274
Figure 139: Procedure specimens taken section example ......................................... 275
Figure 140: Procedures section UML diagram .......................................................... 275
Figure 141: Procedures section example .................................................................. 277
Figure 142: Reason for referral section example ....................................................... 278
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Figure 143: Reason for visit section example ........................................................... 279
Figure 144: Results section UML diagram................................................................ 280
Figure 145: Results section example ....................................................................... 282
Figure 146: Review of systems section example........................................................ 283
Figure 147: Social history section UML diagram ...................................................... 283
Figure 148: Social history section example .............................................................. 284
Figure 149: Subjective section example ................................................................... 285
Figure 150: Surgical drains section example ............................................................ 286
Figure 151: Vital signs section UML diagram ........................................................... 287
Figure 152: Vital signs section example ................................................................... 288
Figure 153: Admission medication entry example .................................................... 291
Figure 154: Advance directive observation example .................................................. 295
Figure 155: Age observation example ....................................................................... 298
Figure 156: Allergy - intolerance observation example .............................................. 305
Figure 157: Allergy problem act example ................................................................. 308
Figure 158: Allergy status observation example ....................................................... 310
Figure 159: Assessment scale observation example .................................................. 313
Figure 160: Assessment scale supporting observation example ................................ 315
Figure 161: Authorization activity example .............................................................. 317
Figure 162: Boundary observation example ............................................................. 318
Figure 163: Caregiver characteristics example with assertion ................................... 320
Figure 164: Caregiver characteristics example without assertion .............................. 320
Figure 165: Code observation example .................................................................... 323
Figure 166:Cognitive status problem observation example ....................................... 327
Figure 167: Cognitive status result observation example .......................................... 331
Figure 168 Cognitive status result organizer example .............................................. 333
Figure 169: Comment act example .......................................................................... 335
Figure 170: Coverage activity example ..................................................................... 337
Figure 171: Deceased observation example .............................................................. 339
Figure 172: Discharge medication entry example ..................................................... 341
Figure 173: Drug vehicle entry example ................................................................... 342
Figure 174: Encounter activities example ................................................................ 346
Figure 175: Encounter diagnosis act example .......................................................... 348
Figure 176: Estimated date of delivery example ....................................................... 349
Figure 177: Family history death observation example ............................................. 350
Figure 178: Family history observation scenario ...................................................... 353
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Figure 179: Family history observation example ...................................................... 354
Figure 180: Family history organizer example .......................................................... 359
Figure 181: Functional status problem observation example .................................... 363
Figure 182: Functional status result observation example ........................................ 366
Figure 183: Functional status result organizer example ........................................... 368
Figure 184: Health status observation example ........................................................ 370
Figure 185: Hospital admission diagnosis example .................................................. 373
Figure 186: Hospital discharge diagnosis act example .............................................. 375
Figure 187: Immunization activity example .............................................................. 381
Figure 188: Immunization medication information example ..................................... 384
Figure 189: Immunization refusal reason ................................................................ 385
Figure 190: Indication entry example ...................................................................... 387
Figure 191: Instructions entry example ................................................................... 389
Figure 192: Medication activity example .................................................................. 397
Figure 193: Medication dispense example ................................................................ 402
Figure 194: Medication information example ........................................................... 404
Figure 195: Medication supply order example .......................................................... 407
Figure 196: Medication use – none known example .................................................. 408
Figure 197: Non-medicinal supply activity example .................................................. 410
Figure 198: Number of pressure ulcers example ...................................................... 412
Figure 199: Plan of care activity act example ........................................................... 413
Figure 200: Plan of care activity encounter example ................................................. 414
Figure 201: Plan of care activity observation example .............................................. 416
Figure 202: Plan of care activity procedure example ................................................. 417
Figure 203: Plan of care activity substance administration example ......................... 418
Figure 204: Plan of care activity supply example ...................................................... 419
Figure 205: Policy activity example .......................................................................... 427
Figure 206: Postprocedure diagnosis example .......................................................... 431
Figure 207: Precondition for substance administration example ............................... 432
Figure 208: Pregnancy observation example ............................................................ 434
Figure 209: Preoperative diagnosis example ............................................................. 436
Figure 210: Pressure ulcer observation example ...................................................... 443
Figure 211: Problem concern act (condition) example ............................................... 445
Figure 212: Problem observation example ................................................................ 449
Figure 213: Problem observation with specific problem not observed ........................ 450
Figure 214: Problem observation for no known problems ......................................... 450
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Figure 215: NullFlavor example ............................................................................... 450
Figure 216: Problem status example ........................................................................ 452
Figure 217: Procedure activity act example .............................................................. 459
Figure 218: Procedure activity observation example ................................................. 465
Figure 219: Procedure activity procedure example ................................................... 471
Figure 220: Procedure context template example ..................................................... 473
Figure 221: Product instance example ..................................................................... 474
Figure 222: Purpose of reference example ................................................................ 476
Figure 223: Quantity measurement observation example ......................................... 479
Figure 224: Reaction observation example ............................................................... 483
Figure 225: Referenced frames observation example ................................................ 484
Figure 226: Result observation example .................................................................. 487
Figure 227: No evaluation procedures (e.g., labs/x-rays) performed example ............ 488
Figure 228: Local code example ............................................................................... 488
Figure 229: Result organizer example ...................................................................... 490
Figure 230: Series act example ................................................................................ 492
Figure 231: Service delivery location example .......................................................... 494
Figure 232: Severity observation example ................................................................ 497
Figure 233: Smoking status observation example .................................................... 499
Figure 234: Unknown if ever smoked ....................................................................... 499
Figure 235: Social history observation template example ......................................... 502
Figure 236: SOP instance observation example ........................................................ 504
Figure 237: Study act example ................................................................................ 507
Figure 238: Text observation example...................................................................... 510
Figure 239: Tobacco use entry example ................................................................... 512
Figure 240: Vital sign observation example .............................................................. 515
Figure 241: Vital signs organizer example ................................................................ 517
Figure 242: Correct use of name example 1 ............................................................. 577
Figure 243: Incorrect use of name example 1 - whitespace ....................................... 577
Figure 244: Incorrect use of Patient name example 2 - no tags ................................. 577
Figure 245: Correct use telecom address example .................................................... 577
Figure 246: Correct use postal address example ...................................................... 577
Figure 247: Correct use of IVL_TS example .............................................................. 578
Figure 248: Correct use of TS with precision to minute example .............................. 578
Figure 249: Correct use of TS with time zone offset example .................................... 578
Figure 250: Incorrect use of IVL_TS example ........................................................... 578
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Figure 251: Incorrect use of TS - insufficient precision example ............................... 578
Figure 252: Incorrect use of TS when time zone offset required example ................... 578
Figure 253: Incorrect use of time zone offset - not enough precision example ........... 578
Figure 254: Correct use of CD with no code example................................................ 578
Figure 255: Incorrect use of CD with no code - missing nullFlavor attribute example 579
Figure 256: Immunizations section UML diagram (larger copy) ................................. 580
Figure 257: Functional Status section UML diagram (larger copy) ............................ 580
Figure 258: Medications section UML diagram (larger copy) ..................................... 580
Figure 259: Plan of care section UML diagram (larger copy) ...................................... 580
Table of Tables
Table 1: Content of the Package ................................................................................ 45
Table 2: Basic Confidentiality Kind Value Set............................................................. 47
Table 3: Language Value Set (excerpt) ........................................................................ 47
Table 4: Telecom Use (US Realm Header) Value Set .................................................... 52
Table 5: Administrative Gender (HL7) Value Set ......................................................... 52
Table 6: Marital Status Value Set .............................................................................. 53
Table 7: Religious Affiliation Value Set (excerpt) ......................................................... 53
Table 8: Race Value Set (excerpt) ............................................................................... 54
Table 9: Ethnicity Value Set ...................................................................................... 54
Table 10: Personal Relationship Role Type Value Set (excerpt) .................................... 54
Table 11: State Value Set (excerpt) ............................................................................ 55
Table 12: Postal Code Value Set (excerpt)................................................................... 55
Table 13: Country Value Set (excerpt) ........................................................................ 55
Table 14: Language Ability Value Set ......................................................................... 56
Table 15: Language Ability Proficiency Value Set........................................................ 56
Table 16: IND Role classCode Value Set ..................................................................... 69
Table 17: PostalAddressUse Value Set ....................................................................... 74
Table 18: EntityNameUse Value Set ........................................................................... 76
Table 19: EntityPersonNamePartQualifier Value Set ................................................... 77
Table 20: Document Types and Required/Optional Sections with Structured Body ..... 80
Table 21: Template Containment for a CCD ............................................................... 88
Table 22: Consultation Note LOINC Document Codes ................................................ 98
Table 23: Invalid Codes for Consultation Note .......................................................... 100
Table 24: Template Containment for a Consultation Note ......................................... 105
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Table 25: DIR LOINC Document Type Codes ............................................................ 114
Table 26: Template Containment for Constrained DIR Sections ................................ 124
Table 27: DIR Section Type Codes ........................................................................... 125
Table 28: Discharge summary LOINC Document Codes ........................................... 131
Table 29: HL7 Discharge Disposition Codes ............................................................. 133
Table 30: Template Containment for a Discharge Summary ..................................... 137
Table 31: H&P LOINC Document Type Codes ........................................................... 148
Table 32: Template Containment for an H&P Note ................................................... 152
Table 33: Surgical Operation Note LOINC Document Codes ..................................... 161
Table 34: Provider Type Value Set (excerpt) .............................................................. 164
Table 35: Procedure Codes from SNOMED CT ......................................................... 164
Table 36: Template Containment for an Operative Note ............................................ 167
Table 37: Procedure Note LOINC Document Type Codes ........................................... 171
Table 38: Participant Scenario ................................................................................. 172
Table 39: Healthcare Provider Taxonomy Value Set .................................................. 175
Table 40: Template Containment for a Procedure Note ............................................. 180
Table 41: Progress Note LOINC Document Codes ..................................................... 190
Table 42: Template Containment for a Progress Note ............................................... 194
Table 43: Supported File Formats Value Set (Unstructured Documents) ................... 200
Table 44: Sections and Required/Optional Document Types with Structured Body ... 204
Table 45: Advance Directives Section Contexts ........................................................ 210
Table 46: Allergies Section Contexts ........................................................................ 212
Table 47: Anesthesia Section Contexts .................................................................... 214
Table 48: Assessment and Plan Section Contexts ..................................................... 215
Table 49: Assessment Section Contexts ................................................................... 216
Table 50: Chief Complaint and Reason for Visit Section Contexts ............................. 217
Table 51: Chief Complaint Section Contexts ............................................................ 218
Table 52: Complications Section Contexts ............................................................... 219
Table 53: DICOM Object Catalog Section - DCM 121181 Contexts ........................... 220
Table 54: Discharge Diet Section Contexts ............................................................... 222
Table 55: Encounters Section Contexts ................................................................... 222
Table 56: Family History Section Contexts ............................................................... 224
Table 57: Findings Section Contexts ........................................................................ 226
Table 58: Functional Status Section Contexts .......................................................... 227
Table 59: Functional and Cognitive Status Problem Observation Examples .............. 228
Table 60: Functional and Cognitive Status Result Observation Examples ................. 229
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Table 61: General Status Section Contexts .............................................................. 232
Table 62: History of Past Illness Section Contexts .................................................... 233
Table 63: History of Present Illness Section Contexts ............................................... 234
Table 64: Hospital Admission Diagnosis Section Contexts ........................................ 235
Table 65: Hospital Admission Medications Section Contexts ..................................... 236
Table 66: Hospital Consultations Section Contexts .................................................. 237
Table 67: Hospital Course Section Contexts ............................................................. 237
Table 68: Hospital Discharge Diagnosis Section Contexts ......................................... 238
Table 69: Hospital Discharge Instructions Section Contexts ..................................... 239
Table 70: Hospital Discharge Medications Section Contexts ..................................... 240
Table 71: Hospital Discharge Physical Section Contexts ........................................... 242
Table 72: Hospital Discharge Studies Summary Section Contexts ............................ 243
Table 73: Immunizations Section Contexts .............................................................. 244
Table 74: Interventions Section Contexts ................................................................. 247
Table 75: Interventions Section Contexts ................................................................. 248
Table 76: Medical Equipment Section Contexts ........................................................ 249
Table 77: Medical (General) History Section Contexts ............................................... 250
Table 78: Medications Administered Section Contexts .............................................. 251
Table 79: Medications Section Contexts ................................................................... 252
Table 80: Objective Section Contexts ....................................................................... 254
Table 81: Operative Note Fluids Section Contexts .................................................... 255
Table 82: Operative Note Surgical Procedure Section Contexts ................................. 256
Table 83: Payers Section Contexts ........................................................................... 257
Table 84: Physical Exam Section Contexts ............................................................... 259
Table 86: Plan of Care Section Contexts................................................................... 260
Table 87: Planned Procedure Section Contexts......................................................... 262
Table 88: Postoperative Diagnosis Section Contexts ................................................. 263
Table 89: Postprocedure Diagnosis Section Contexts ................................................ 264
Table 90: Preoperative Diagnosis Section Contexts ................................................... 265
Table 91: Problem Section Contexts ......................................................................... 266
Table 92: Procedure Description Section Contexts ................................................... 269
Table 93: Procedure Disposition Section Contexts .................................................... 270
Table 94: Procedure Estimated Blood Loss Section Contexts .................................... 270
Table 95: Procedure Findings Section Contexts ........................................................ 271
Table 96: Procedure Implants Section Contexts ....................................................... 272
Table 97: Procedure Indications Section Contexts .................................................... 273
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Table 98: Procedure Specimens Taken Section Contexts .......................................... 274
Table 99: Procedures Section Contexts .................................................................... 275
Table 100: Reason for Referral Section Contexts ...................................................... 278
Table 101: Reason for Visit Section Contexts ........................................................... 279
Table 102: Results Section Contexts ........................................................................ 280
Table 103: Review of Systems Section Contexts ....................................................... 282
Table 104: Social History Section Contexts .............................................................. 283
Table 105: Subjective Section Contexts ................................................................... 285
Table 106: Surgical Drains Section Contexts ........................................................... 286
Table 107: Vital Signs Section Contexts ................................................................... 287
Table 108: Admission Medication Contexts .............................................................. 289
Table 109: Admission Medication Constraints Overview ........................................... 290
Table 110: Advance Directive Observation Contexts ................................................. 291
Table 111: Advance Directive Observation Constraints Overview .............................. 292
Table 112: Advance Directive Type Code Value Set .................................................. 295
Table 113: Age Observation Contexts ...................................................................... 296
Table 114: Age Observation Constraints Overview ................................................... 297
Table 115: AgePQ_UCUM Value Set ......................................................................... 298
Table 116: Allergy - Intolerance Observation Contexts ............................................. 298
Table 117: Allergy - Intolerance Observation Constraints Overview .......................... 299
Table 118: Allergy/Adverse Event Type Value Set .................................................... 303
Table 119: Medication Brand Name Value Set (excerpt) ............................................ 303
Table 120: Medication Clinical Drug Value Set (excerpt) ........................................... 304
Table 121: Medication Drug Class Value Set (excerpt) .............................................. 304
Table 122: Ingredient Name Value Set (excerpt) ....................................................... 305
Table 123: Allergy Problem Act Contexts .................................................................. 306
Table 124: Allergy Problem Act Constraints Overview ............................................... 307
Table 125: ProblemAct statusCode Value Set ........................................................... 308
Table 126: Allergy Status Observation Contexts ....................................................... 309
Table 127: Allergy Status Observation Constraints Overview .................................... 309
Table 128: HITSP Problem Status Value Set ............................................................ 310
Table 129: Assessment Scale Observation Contexts ................................................. 310
Table 130: Assessment Scale Observation Constraints Overview .............................. 311
Table 131: Assessment Scale Supporting Observation Contexts ............................... 314
Table 132: Assessment Scale Supporting Observation Constraints Overview ............ 314
Table 133: Authorization Activity Contexts .............................................................. 315
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Table 134: Authorization Activity Constraints Overview ........................................... 316
Table 135: Boundary Observation Contexts ............................................................. 317
Table 136: Boundary Observation Constraints Overview .......................................... 317
Table 137: Caregiver Characteristics Contexts ......................................................... 318
Table 138: Caregiver Characteristics Constraints Overview ...................................... 319
Table 139: Code Observations Contexts ................................................................... 321
Table 140: Code Observations Constraints Overview ................................................ 322
Table 141: Cognitive Status Problem Observation Contexts ...................................... 323
Table 142: Cognitive Status Problem Observation Constraints Overview ................... 324
Table 143: Problem type value set ........................................................................... 326
Table 144: Problem Value Set (excerpt) .................................................................... 326
Table 145: Cognitive Status Result Observation Contexts......................................... 328
Table 146: Cognitive Status Result Observation Constraints Overview ...................... 328
Table 147: Cognitive Status Result Organizer Contexts ............................................ 331
Table 148: Cognitive Status Result Organizer Constraints Overview ......................... 332
Table 149: Comment Activity Contexts .................................................................... 333
Table 150: Comment Activity Constraints Overview ................................................. 334
Table 151: Coverage Activity Contexts ..................................................................... 336
Table 152: Coverage Activity Constraints Overview .................................................. 336
Table 153: Deceased Observation Contexts .............................................................. 337
Table 154: Deceased Observation Constraints Overview ........................................... 338
Table 155: Discharge Medication Contexts ............................................................... 339
Table 156: Discharge Medication Constraints Overview ............................................ 340
Table 157: Drug Vehicle Contexts ............................................................................ 341
Table 158: Drug Vehicle Constraints Overview ......................................................... 342
Table 159: Encounter Activities Contexts ................................................................. 343
Table 160: Encounter Activities Constraints Overview .............................................. 343
Table 161: Encounter Type Value Set ...................................................................... 345
Table 162: Encounter Diagnosis Contexts................................................................ 346
Table 163: Encounter Diagnosis Constraints Overview ............................................. 347
Table 164: Estimated Date of Delivery Contexts ....................................................... 348
Table 165: Estimated Date of Delivery Constraints Overview .................................... 348
Table 166: Family History Death Observation Contexts ............................................ 349
Table 167: Family History Death Observation Constraints Overview ......................... 350
Table 168: Family History Observation Contexts ...................................................... 351
Table 169: Family History Observation Constraints Overview ................................... 351
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Table 170: Family History Organizer Contexts ......................................................... 356
Table 171: Family History Organizer Constraints Overview ...................................... 356
Table 172: Family History Related Subject Value Set (excerpt) ................................. 359
Table 173: Functional Status Problem Observation Contexts ................................... 360
Table 174: Functional Status Problem Observation Constraints Overview ................ 360
Table 175: Functional Status Result Observation Contexts ...................................... 363
Table 176: Functional Status Result Observation Constraints Overview ................... 364
Table 177: Functional Status Result Organizer Contexts .......................................... 366
Table 178: Functional Status Result Organizer Constraints Overview ....................... 367
Table 179: Health Status Observation Contexts ....................................................... 368
Table 180: Health Status Observation Constraints Overview .................................... 368
Table 181: HealthStatus Value Set .......................................................................... 369
Table 182: Highest Pressure Ulcer Stage Contexts ................................................... 371
Table 183: Highest Pressure Ulcer Stage Constraints Overview ................................ 371
Table 184: Hospital Admission Diagnosis Contexts .................................................. 372
Table 185: Hospital Admission Diagnosis Constraints Overview ............................... 372
Table 186: Hospital Discharge Diagnosis Contexts ................................................... 373
Table 187: Hospital Discharge Diagnosis Constraints Overview ................................ 374
Table 188: Immunization Activity Contexts .............................................................. 375
Table 189: Immunization Activity Constraints Overview ........................................... 376
Table 190: Immunization Medication Information Contexts ...................................... 381
Table 191: Immunization Medication Information Constraints Overview ................... 382
Table 192: Vaccine Administered (Hepatitis B) Value Set (excerpt) ............................ 383
Table 193: Immunization Refusal Reason Contexts .................................................. 384
Table 194: Immunization Refusal Reason Constraints Overview ............................... 384
Table 195: No Immunization Reason Value Set ........................................................ 385
Table 196: Indication Contexts ................................................................................ 386
Table 197: Indication Constraints Overview ............................................................. 386
Table 198: Instructions Contexts ............................................................................. 388
Table 199: Instructions Constraints Overview .......................................................... 388
Table 200: Patient Education Value Set ................................................................... 389
Table 201: Medication Activity Contexts .................................................................. 390
Table 202: Medication Activity Constraints Overview ............................................... 390
Table 203: MoodCodeEvnInt Value Set .................................................................... 395
Table 204: Medication Route FDA Value Set (excerpt) .............................................. 396
Table 205: Body Site Value Set (excerpt) .................................................................. 396
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Table 206: Medication Product Form Value Set (excerpt) .......................................... 397
Table 207: Unit of Measure Value Set (excerpt) ........................................................ 397
Table 208: Medication Dispense Contexts ................................................................ 399
Table 209: Medication Dispense Constraints Overview ............................................. 400
Table 210: Medication Fill Status Value Set ............................................................. 401
Table 211: Medication Information Contexts ............................................................ 402
Table 212: Medication Information Constraints Overview ......................................... 403
Table 213: Medication Supply Order Contexts ......................................................... 404
Table 214: Medication Supply Order Constraints Overview ...................................... 405
Table 215: Non-Medicinal Supply Activity Contexts .................................................. 408
Table 216: Non-Medicinal Supply Activity Constraints Overview ............................... 409
Table 217: Number of Pressure Ulcers Observation Contexts ................................... 410
Table 218: Number of Pressure Ulcers Observation Constraints Overview................. 410
Table 219: Plan of Care Activity Act Contexts ........................................................... 412
Table 220: Plan of Care Activity Act Constraints Overview ........................................ 412
Table 221: Plan of Care moodCode (Act/Encounter/Procedure) ................................ 413
Table 222: Plan of Care Activity Encounter Contexts ................................................ 413
Table 223: Plan of Care Activity Encounter Constraints Overview ............................. 414
Table 224: Plan of Care Activity Observation Contexts ............................................. 414
Table 225: Plan of Care Activity Observation Constraints Overview .......................... 415
Table 226: Plan of Care moodCode (Observation) Value Set ...................................... 415
Table 227: Plan of Care Activity Procedure Contexts ................................................ 416
Table 228: Plan of Care Activity Procedure Constraints Overview ............................. 416
Table 229: Plan of Care Activity Substance Administration Contexts ........................ 417
Table 230: Plan of Care Activity Substance Administration Constraints Overview ..... 417
Table 231: Plan of Care moodCode (SubstanceAdministration/Supply) Value Set ..... 418
Table 232: Plan of Care Activity Supply Contexts ..................................................... 418
Table 233: Plan of Care Activity Supply Constraints Overview .................................. 419
Table 234: Policy Activity Contexts .......................................................................... 419
Table 235: Policy Activity Constraints Overview ....................................................... 420
Table 236: Health Insurance Type Value Set (excerpt) .............................................. 426
Table 237: Coverage Type Value Set ........................................................................ 427
Table 238: Financially Responsible Party Value Set (excerpt) .................................... 427
Table 239: Postprocedure Diagnosis Contexts .......................................................... 430
Table 240: Postprocedure Diagnosis Constraints Overview ....................................... 430
Table 241: Precondition for Substance Administration Contexts ............................... 431
HL7 Implementation Guide for CDA R2: IHE Health Story Consolidation, DSTU R1.1 Page 27
July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
Table 242: Precondition for Substance Administration Constraints Overview ............ 431
Table 243: Pregnancy Observation Contexts ............................................................ 432
Table 244: Pregnancy Observation Constraints Overview ......................................... 432
Table 245: Preoperative Diagnosis Contexts ............................................................. 434
Table 246: Preoperative Diagnosis Constraints Overview .......................................... 435
Table 247: Pressure Ulcer Observation Contexts ...................................................... 436
Table 248: Pressure Ulcer Observation Constraints Overview ................................... 436
Table 249 Pressure Ulcer Stage Value Set ................................................................ 440
Table 250: Pressure Point Value Set ........................................................................ 441
Table 251: Target Site Qualifiers Value Set .............................................................. 442
Table 252: Problem Concern Act (Condition) Contexts .............................................. 444
Table 253: Problem Concern Act (Condition) Constraints Overview ........................... 444
Table 254: Problem Observation Contexts ............................................................... 446
Table 255: Problem Observation Constraints Overview............................................. 446
Table 256: Problem Status Contexts ........................................................................ 451
Table 257: Problem Status Constraints Overview ..................................................... 451
Table 258: Procedure Activity Act Contexts .............................................................. 452
Table 259: Procedure Activity Act Constraints Overview ........................................... 454
Table 260: Procedure Act Status Code Value Set ...................................................... 458
Table 261: Act Priority Value Set ............................................................................. 458
Table 262: Procedure Activity Observation Contexts ................................................ 460
Table 263: Procedure Activity Observation Constraints Overview.............................. 460
Table 264: Procedure Activity Procedure Contexts.................................................... 466
Table 265: Procedure Activity Procedure Constraints Overview ................................. 466
Table 266: Procedure Context Contexts ................................................................... 472
Table 267: Procedure Context Constraints Overview ................................................ 472
Table 268: Product Instance Contexts ..................................................................... 473
Table 269: Product Instance Constraints Overview .................................................. 474
Table 270: Purpose of Reference Observation Contexts ............................................ 475
Table 271: Purpose of Reference Observation Constraints Overview ......................... 475
Table 272: DICOM Purpose of Reference Value Set .................................................. 476
Table 273: Quantity Measurement Observation Contexts ......................................... 476
Table 274: Quantity Measurement Observation Constraints Overview ...................... 477
Table 275: DIR Quantity Measurement Type Value Set ............................................ 478
Table 276: DICOM Quantity Measurement Type Value Set ....................................... 479
Table 277: Reaction Observation Contexts ............................................................... 480
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© 2012 Health Level Seven, Inc. All rights reserved. July 2012
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
July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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
© 2012 Health Level Seven, Inc. All rights reserved. July 2012
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
July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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
© 2012 Health Level Seven, Inc. All rights reserved. July 2012
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
July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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
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language) format for the body of the document that contains the required
clinical content. Conformance, in this case, to the clinical content requirements
could not be validated without human review.
The section libraries for each document type list the required and optional
sections.
2.8 Conformance Conventions Used in This Guide
2.8.1 Templates and Conformance Statements
Conformance statements within this implementation guide are presented as
constraints from a Template Database (Tdb). An algorithm converts constraints
recorded in a Templates Database to a printable presentation. Each constraint is
uniquely identified by an identifier at or near the end of the constraint (e.g.,
CONF:7345). These identifiers are persistent but not sequential.
Bracketed information following each template title indicates the template type
(section, observation, act, procedure, etc.), the templateId, and whether the
template is open or closed.
Each section and entry template in the guide includes a context table. The "Used
By" column indicates which documents or sections use this template, and the
"Contains Entries" column indicates any entries that the template uses. Each
entry template also includes a constraint overview table to summarize the
constraints following the table.
The following figure shows a typical template explanation presented in this
guide. The next sections describe specific aspects of conformance statements—
open vs. closed statements, conformance verbs, cardinality, vocabulary
conformance, containment relationships, and null flavors.
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Figure 1: Constraints format example
Severity Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.8(open)]
Table xxx: Severity Observation Contexts
Used By:
Contains Entries:
Reaction Observation
Allergy - Intolerance Observation
This clinical statement represents the severity of the reaction to an agent. A
person may manifest many symptoms …
Table yyy: Severity Observation Contexts
Name
XPath
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
CE
7349
2.16.840.1.113883.5.4 (ActCode) =
SEV
severity
FreeText
text
0..1
SHOULD
ED
7350
reference
/@value
0..1
SHOULD
7351
statusCode
1..1
SHALL
CS
7352
2.16.840.1.113883.5.14 (ActStatus)
= completed
severity
Coded
value
1..1
SHALL
CD
7356
2.16.840.1.113883.3.88.12.3221.6.8
(Problem Severity)
interpretation
Code
0..*
SHOULD
CE
9117
code
0..1
SHOULD
CE
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).
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4. SHALL contain exactly one [1..1] code with @xsi:type="CE"="SEV" Severity
Observation (CodeSystem: ActCode 2.16.840.1.113883.5.4)
(CONF:7349).
5. SHOULD contain zero or one [0..1] text (CONF:7350).
a. The text, if present, SHOULD contain zero or one [0..1]
reference/@value (CONF:7351).
i. This reference/@value SHALL begin with a '#' and SHALL point
to its corresponding narrative (using the approach defined in
CDA Release 2, section 4.3.5.1) (CONF:7378).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed
(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7352).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code
SHALL be selected from ValueSet Problem Severity
2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC (CONF:7356).
8. SHOULD contain zero or more [0..*] interpretationCode (CONF:9117).
a. The interpretationCode, if present, SHOULD contain zero or one [0..1]
code with @xsi:type="CE", where the @code SHOULD be selected from
ValueSet Observation Interpretation (HL7)
2.16.840.1.113883.1.11.78 DYNAMIC (CONF:9118).
2.8.2 Open and Closed Templates
In open templates, all of the features of the CDA R2 base specification are
allowed except as constrained by the templates. By contrast, a closed template
specifies everything that is allowed and nothing further may be included.
Estimated Date of Delivery (templateId 2.16.840.1.113883.10.20.15.3.1) is
an example of a closed template in this guide.
Open templates allow HL7 implementers to develop additional structured
content not constrained within this guide. HL7 encourages implementers to
bring their use cases forward as candidate requirements to be formalized in a
subsequent version of the standard to maximize the use of shared semantics.
2.8.3 Conformance Verbs (Keywords)
The keywords SHALL, SHOULD, MAY, NEED NOT, SHOULD NOT, and SHALL NOT in this
document are to be interpreted as described in the HL7 Version 3 Publishing
Facilitator's Guide (http://www.hl7.org/v3ballot/html/help/pfg/pfg.htm):
SHALL: an absolute requirement
SHALL NOT: an absolute prohibition against inclusion
SHOULD/SHOULD NOT: best practice or recommendation. There may be
valid reasons to ignore an item, but the full implications must be
understood and carefully weighed before choosing a different course
MAY/NEED NOT: truly optional; can be included or omitted as the author
decides with no implications
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The keyword "SHALL" allows the use of nullFlavor unless the requirement is on
an attribute or the use of nullFlavor is explicitly precluded.
The Consolidated Conformance Verb Matrix table represents a matrix of the
conformance verbs used across the standards reviewed for the consolidation
guide.
The subject of a conformance verb (keyword) in a top-level constraint is the
template itself; for example, the subject of CONF:5249 is the ClinicalDocument
element. In nested constraints, the subject is the element in the containing
constraint. Top-level constraints are those that begin with a number and are not
indented.
2.8.4 Cardinality
The cardinality indicator (0..1, 1..1, 1..*, etc.) specifies the allowable occurrences
within a document instance. The cardinality indicators are interpreted with the
following format “m…n” where m represents the least and n the most:
0..1 zero or one
1..1 exactly one
1..* at least one
0..* zero or more
1..n at least one and not more than n
When a constraint has subordinate clauses, the scope of the cardinality of the
parent constraint must be clear. In the next figure, the constraint says exactly
one participant is to be present. The subordinate constraint specifies some
additional characteristics of that participant.
Figure 2: Constraints format – only one allowed
1. SHALL contain exactly one [1..1] participant (CONF:2777).
a. This participant SHALL contain exactly one [1..1] @typeCode="LOC"
(CodeSystem: 2.16.840.1.113883.5.90 HL7ParticipationType)
(CONF:2230).
In the next figure, the constraint says only one participant “like this” is to be
present. Other participant elements are not precluded by this constraint.
Figure 3: Constraints format – only one like this allowed
1. SHALL contain exactly one [1..1] participant (CONF:2777) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" (CodeSystem:
2.16.840.1.113883.5.90 HL7ParticipationType) (CONF:2230).
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2.8.5 Optional and Required with Cardinality
The terms optional and required describe the lower bound of cardinality as
follows:
Optional means that the number of allowable occurrences of an element may be
0; the cardinality will be expressed as [0..1] or [0..*] or similar. In these
cases, the element may not be present in the instance.
Required means that the number of allowable occurrences of an element must
be at least 1; the cardinality will be expressed as [m..n] where m >=1 and n
>=1 for example [1..1] or [1..*].. In these cases, the element must be
present in the instance. If an element is required, but is not known (and would
otherwise be omitted if it were optional), it must be represented by a nullFlavor.
2.8.6 Vocabulary Conformance
The templates in this document use terms from several code systems. These
vocabularies are defined in various supporting specifications and may be
maintained by other bodies, as is the case for the LOINC® and SNOMED CT®
vocabularies.
Note that value-set identifiers (e.g., ValueSet 2.16.840.1.113883.1.11.78
Observation Interpretation (HL7) DYNAMIC) do not appear in CDA
submissions; they tie the conformance requirements of an implementation guide
to the appropriate code system for validation.
Value-set bindings adhere to HL7 Vocabulary Working Group best practices,
and include both a conformance verb (SHALL, SHOULD, MAY, etc.) and an
indication of DYNAMIC vs. STATIC binding. Value-set constraints can be STATIC,
meaning that they are bound to a specified version of a value set, or DYNAMIC,
meaning that they are bound to the most current version of the value set. A
simplified constraint, used when the binding is to a single code, includes the
meaning of the code, as follows.
Figure 4: Binding to a single code
... 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.
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July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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"/>
<!-- or -->
<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
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All other containment relationships are direct, for example:
1. SHALL contain exactly one [1..1]
templateId/@root="2.16.840.1.113883.10.20.22.2.21" (CONF:7928).
The templateId must be a direct child of the section (i.e., section/templateId).
2.8.8 Null Flavor
Information technology solutions store and manage data, but sometimes data
are not available: an item may be unknown, not relevant, or not computable or
measureable. In HL7, a flavor of null, or nullFlavor, describes the reason for
missing data.
For example, if a patient arrives at an Emergency Department unconscious and
with no identification, we would use a null flavor to represent the lack of
information. The patient’s birth date would be represented with a null flavor of
“NAV”, which is the code for “temporarily unavailable”. When the patient regains
consciousness or a relative arrives, we expect to know the patient’s birth date.
Figure 7: nullFlavor example
<birthTime nullFlavor=”NAV”/> <!--coding an unknown birthdate-->
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
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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).
or
2. SHALL contain exactly one [1..1] effectiveTime/@value (CONF:5256).
Figure 9: Allowed nullFlavors when element is required (with xml examples)
1. SHALL contain at least one [1..*] id
2. SHALL contain exactly one [1..1] code
3. SHALL contain exactly one [1..1] effectiveTime
<entry>
<observation classCode="OBS" moodCode="EVN">
<id nullFlavor="NI"/>
<code nullFlavor="OTH">
<originalText>New Grading system</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime nullFlavor="UNK"/>
<value xsi:type="CD" nullFlavor="NAV">
<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).
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2.8.9 Unknown Information
If a sender wants to state that a piece of information is unknown, the following
principles apply:
1. If the sender doesn’t know an attribute of an act, that attribute can be
null.
Figure 11: Unknown medication example
<entry>
<text>patient was given a medication but I do not know what it
was</text>
<substanceAdministration moodCode="EVN" classCode="SBADM">
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<code nullFlavor="NI"/>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
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July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<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>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<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
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2.9 XML Conventions Used in This Guide
2.9.1 XPath Notation
Instead of the traditional dotted notation used by HL7 to represent Reference
Information Model (RIM) classes, this document uses XML Path Language
(XPath) notation9 in conformance statements and elsewhere to identify the
Extended Markup Language (XML) elements and attributes within the CDA
document instance to which various constraints are applied. The implicit
context of these expressions is the root of the document. This notation provides
a mechanism that will be familiar to developers for identifying parts of an XML
document.
XPath statements appear in this document in a monospace font.
XPath syntax selects nodes from an XML document using a path containing the
context of the node(s). The path is constructed from node names and attribute
names (prefixed by a ‘@’) and catenated with a ‘/’ symbol.
Figure 14: XML document example
<author>
<assignedAuthor>
...
<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 xmls="urn:h17-org:v3">
...
</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
July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
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
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3 GENERAL HEADER TEMPLATE
This template describes constraints that apply to the header for all documents
within the scope of this implementation guide. Header constraints specific to
each document type are described in the appropriate document-specific section
below.
3.1 Document Type Codes
CDA R2 states that LOINC is the preferred vocabulary for document type codes,
which specify the type of document being exchanged (e.g., History and Physical).
Each document type in this guide recommends a single preferred
clinicalDocument/code, with further specification provided by author or
performer, setting, or specialty.
3.2 US Realm Header
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.22.1.1(open)]
1. SHALL contain exactly one [1..1] realmCode="US" (CONF:16791).
2. SHALL contain exactly one [1..1] typeId (CONF:5361).
a. This typeId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.1.3" (CONF:5250).
b. This typeId SHALL contain exactly one [1..1]
@extension="POCD_HD000040" (CONF:5251).
3. SHALL contain exactly one [1..1] templateId (CONF:5252) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.1.1" (CONF:10036).
4. SHALL contain exactly one [1..1] id (CONF:5363).
a. This id SHALL be a globally unique identifier for the document
(CONF:9991).
5. SHALL contain exactly one [1..1] code (CONF:5253).
a. This code SHALL specify the particular kind of document (e.g. History
and Physical, Discharge Summary, Progress Note) (CONF:9992).
6. SHALL contain exactly one [1..1] title (CONF:5254).
a. Can either be a locally defined name or the display name
corresponding to clinicalDocument/code (CONF:5255).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:5256).
a. The content SHALL be a conformant US Realm Date and Time
(DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:16865).
8. SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be
selected from ValueSet HL7 BasicConfidentialityKind
2.16.840.1.113883.1.11.16926 STATIC 2010-04-21 (CONF:5259).
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July 2012 © 2012 Health Level Seven, Inc. All rights reserved.
9. SHALL contain exactly one [1..1] languageCode, which SHALL be selected from
ValueSet Language 2.16.840.1.113883.1.11.11526 DYNAMIC
(CONF:5372).
10. MAY contain zero or one [0..1] setId (CONF:5261).
a. If setId is present versionNumber SHALL be present (CONF:6380).11
11. MAY contain zero or one [0..1] versionNumber (CONF:5264).
a. If versionNumber is present setId SHALL be present (CONF:6387).12
Table 2: Basic Confidentiality Kind Value Set
Value Set: HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC 2010-04-21
Code System(s):
Confidentiality Code 2.16.840.1.113883.5.25
Code
Code System
Print Name
N
Confidentiality Code
Normal
R
Confidentiality Code
Restricted
V
Confidentiality Code
Very Restricted
Table 3: Language Value Set (excerpt)
Value Set: Language 2.16.840.1.113883.1.11.11526 DYNAMIC
Code System(s):
Internet Society Language 2.16.840.1.113883.1.11.11526
Description:
A value set of codes defined by Internet RFC 4646 (replacing RFC 3066).
Please see ISO 639 language code set maintained by Library of Congress for
enumeration of language codes
http://www.ietf.org/rfc/rfc4646.txt
Code
Code System
Print Name
en
Internet Society Language
english
fr
Internet Society Language
french
ar
Internet Society Language
arabic
en-US
Internet Society Language
English, US
es-US
Internet Society Language
Spanish, US
…
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
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© 2012 Health Level Seven, Inc. All rights reserved. July 2012
Figure 17: US Realm header example
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- US General Header Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- History and Physical Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.3"/>
<id extension="999021" root="2.16.840.1.113883.19"/>
<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>
<effectiveTime value="20050329171504+0500"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"
displayName="English, US"
codeSystem="2.16.840.1.113883.1.11.11526"
codeSystemName="Internet Society Language"/>
<setId extension="111199021" root="2.16.840.1.113883.19"/>
<versionNumber value="1"/>
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. -->
<effectiveTime value=”201107061227-08”/>
<!-- July 6, 2011, 12:27, 8 hours before UTC -->
3.2.1 RecordTarget
The recordTarget records the patient whose health information is described by
the clinical document; each recordTarget must contain at least one
patientRole element.
12. SHALL contain at least one [1..*] recordTarget (CONF:5266).
a. Such recordTargets SHALL contain exactly one [1..1] patientRole
(CONF:5267).
i. This patientRole SHALL contain at least one [1..*] id
(CONF:5268).
ii. This patientRole SHALL contain at least one [1..*] addr
(CONF:5271).
1. The content of addr SHALL be a conformant US Realm
Address (AD.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.2) (CONF:10412).
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iii. This patientRole SHALL contain at least one [1..*] telecom
(CONF:5280).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:5375).
3.2.1.1 Patient
iv. This patientRole SHALL contain exactly one [1..1] patient
(CONF:5283).
1. This patient SHALL contain exactly one [1..1] name
(CONF:5284).
a. The content of name SHALL be a conformant US
Realm Patient Name (PTN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1)
(CONF:10411).
2. This patient SHALL contain exactly one [1..1]
administrativeGenderCode, which SHALL be selected
from ValueSet Administrative Gender (HL7 V3)
2.16.840.1.113883.1.11.1 DYNAMIC (CONF:6394).
3. This patient SHALL contain exactly one [1..1]
birthTime (CONF:5298).
a. SHALL be precise to year (CONF:5299).
b. SHOULD be precise to day (CONF:5300).
4. This patient SHOULD contain zero or one [0..1]
maritalStatusCode, which SHALL be selected from
ValueSet HL7 MaritalStatus
2.16.840.1.113883.1.11.12212 DYNAMIC
(CONF:5303).
5. This patient MAY contain zero or one [0..1]
religiousAffiliationCode, which SHALL be selected
from ValueSet HL7 Religious Affiliation
2.16.840.1.113883.1.11.19185 DYNAMIC
(CONF:5317).
6. This patient MAY contain zero or one [0..1] raceCode,
which SHALL be selected from ValueSet Race
2.16.840.1.113883.1.11.14914 DYNAMIC
(CONF:5322).
7. This patient MAY contain zero or more [0..*]
sdwg:raceCode, where the @code SHALL be selected
from ValueSet Race 2.16.840.1.113883.1.11.14914
DYNAMIC (CONF:7263).
8. This patient MAY contain zero or one [0..1]
ethnicGroupCode, which SHALL be selected from
ValueSet Ethnicity Value
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2.16.840.1.114222.4.11.837 DYNAMIC
(CONF:5323).
3.2.1.2 Guardian
9. This patient MAY contain zero or more [0..*] guardian
(CONF:5325).
a. The guardian, if present, SHOULD contain zero
or one [0..1] code, which SHALL be selected
from ValueSet Personal Relationship Role
Type 2.16.840.1.113883.1.11.19563
DYNAMIC (CONF:5326).
b. The guardian, if present, SHOULD contain zero
or more [0..*] addr (CONF:5359).
i. The content of addr SHALL be a
conformant US Realm Address
(AD.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.2)
(CONF:10413).
c. The guardian, if present, MAY contain zero or
more [0..*] telecom (CONF:5382).
i. The telecom, if present, SHOULD contain
exactly one [1..1] @use, which SHALL be
selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20
DYNAMIC (CONF:7993).
d. The guardian, if present, SHALL contain exactly
one [1..1] guardianPerson (CONF:5385).
i. This guardianPerson SHALL contain at
least one [1..*] name (CONF:5386).
1. The content of name SHALL be a
conformant US Realm Person Name
(PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10414).
3.2.1.3 Birthplace
10. This patient MAY contain zero or one [0..1] birthplace
(CONF:5395).
a. The birthplace, if present, SHALL contain
exactly one [1..1] place (CONF:5396).
i. This place SHALL contain exactly one
[1..1] addr (CONF:5397).
1. This addr SHOULD contain zero or
one [0..1] country, where the @code
SHALL be selected from ValueSet
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CountryValueSet
2.16.840.1.113883.3.88.12.80.63
DYNAMIC (CONF:5404).
2. This addr MAY contain zero or
one [0..1] postalCode, where the @code
SHALL be selected from ValueSet
PostalCodeValueSet
2.16.840.1.113883.3.88.12.80.2
DYNAMIC (CONF:5403).
3. If country is US, this addr SHALL
contain exactly one [1..1] state, which
SHALL be selected from ValueSet
2.16.840.1.113883.3.88.12.80.1
StateValueSet DYNAMIC (CONF:5402).
3.2.1.4 LanguageCommunication
11. This patient SHOULD contain zero or more [0..*]
languageCommunication (CONF:5406).
a. The languageCommunication, if present, SHALL
contain exactly one [1..1] languageCode, which
SHALL be selected from ValueSet Language
2.16.840.1.113883.1.11.11526 DYNAMIC
(CONF:5407).
b. The languageCommunication, if present, MAY
contain zero or one [0..1] modeCode, which
SHALL be selected from ValueSet HL7
LanguageAbilityMode
2.16.840.1.113883.1.11.12249 DYNAMIC
(CONF:5409).
c. The languageCommunication, if present,
SHOULD contain zero or one [0..1]
proficiencyLevelCode, which SHALL be
selected from ValueSet
LanguageAbilityProficiency
2.16.840.1.113883.1.11.12199 DYNAMIC
(CONF:9965).
d. The languageCommunication, if present, MAY
contain zero or one [0..1] preferenceInd
(CONF:5414).
3.2.1.5 ProviderOrganization
v. This patientRole MAY contain zero or one [0..1]
providerOrganization (CONF:5416).
1. The providerOrganization, if present, SHALL contain at
least one [1..*] id (CONF:5417).
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a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National
Provider Identifier (CONF:16820).
2. The providerOrganization, if present, SHALL contain at
least one [1..*] name (CONF:5419).
3. The providerOrganization, if present, SHALL contain at
least one [1..*] telecom (CONF:5420).
a. Such telecoms SHOULD contain exactly one
[1..1] @use, which SHALL be selected from
ValueSet Telecom Use (US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7994).
4. The providerOrganization, if present, SHALL contain at
least one [1..*] addr (CONF:5422).
a. The content of addr SHALL be a conformant US
Realm Address (AD.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.2)
(CONF:10415).
3.2.1.6 RecordTarget Value Sets
Table 4: Telecom Use (US Realm Header) Value Set
Value Set: Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC
Code System(s):
AddressUse 2.16.840.1.113883.5.1119
Code
Code System
Print Name
HP
AddressUse
primary home
WP
AddressUse
work place
MC
AddressUse
mobile contact
HV
AddressUse
vacation home
Table 5: Administrative Gender (HL7) Value Set
Value Set: Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC
Code System(s): AdministrativeGender 2.16.840.1.113883.5.1
Code
Code System
Print Name
F
AdministrativeGender
Female
M
AdministrativeGender
Male
UN
AdministrativeGender
Undifferentiated
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Table 6: Marital Status Value Set
Value Set: HL7 Marital Status 2.16.840.1.113883.1.11.12212 DYNAMIC
Code System(s):
MaritalStatus 2.16.840.1.113883.5.2
Code
Code System
Print Name
A
MaritalStatus
Annulled
D
MaritalStatus
Divorced
I
MaritalStatus
Interlocutory
L
MaritalStatus
Legally Separated
M
MaritalStatus
Married
P
MaritalStatus
Polygamous
S
MaritalStatus
Never Married
T
MaritalStatus
Domestic partner
W
MaritalStatus
Widowed
Table 7: Religious Affiliation Value Set (excerpt)
Value Set: HL7 Religious Affiliation 2.16.840.1.113883.1.11.19185 DYNAMIC
Code System(s):
ReligiousAffiliation 2.16.840.1.113883.5.1076
Description:
A value set of codes that reflect spiritual faith affiliation
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008
Code
Code System
Print Name
1026
ReligiousAffiliation
Judaism
1020
ReligiousAffiliation
Hinduism
1041
ReligiousAffiliation
Roman Catholic Church
…
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Table 8: Race Value Set (excerpt)
Value Set: Race 2.16.840.1.113883.1.11.14914 DYNAMIC
Code System(s):
Race and Ethnicity - CDC 2.16.840.1.113883.6.238
Description:
A Value Set of codes for Classifying data based upon race.
Race is always reported at the discretion of the person for whom this attribute
is reported, and reporting must be completed according to Federal guidelines
for race reporting. Any code descending from the Race concept (1000-9) in
that terminology may be used in the exchange
http://phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.
1.113883.6.238&code=1000-9
Code
Code System
Print Name
1002-5
Race and Ethnicity- CDC
American Indian or Alaska Native
2028-9
Race and Ethnicity- CDC
Asian
2054-5
Race and Ethnicity- CDC
Black or African American
2076-8
Race and Ethnicity- CDC
Native Hawaiian or Other Pacific
Islander
2106-3
Race and Ethnicity- CDC
White
...
Table 9: Ethnicity Value Set
Value Set: Ethnicity Value Set 2.16.840.1.114222.4.11.837 DYNAMIC
Code System(s):
Race and Ethnicity - CDC 2.16.840.1.113883.6.238
Code
Code System
Print Name
2135-2
Race and Ethnicity Code Sets
Hispanic or Latino
2186-5
Race and Ethnicity Code Sets
Not Hispanic or Latino
Table 10: Personal Relationship Role Type Value Set (excerpt)
Value Set: Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC
Code System(s):
RoleCode 2.16.840.1.113883.5.111
Description:
A Personal Relationship records the role of a person in relation to another
person. This value set is to be used when recording the relationships between
different people who are not necessarily related by family ties, but also
includes family relationships.
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008
Code
Code System
Print Name
HUSB
RoleCode
husband
WIFE
RoleCode
wife
FRND
RoleCode
friend
SISINLAW
RoleCode
sister-in-law
…
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Table 11: State Value Set (excerpt)
Value Set: StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC
Code System(s):
FIPS 5-2 (State) 2.16.840.1.113883.6.92
Description:
Codes for the Identification of the States, the District of Columbia and the
Outlying Areas of the United States, and Associated Areas Publication # 5-2,
May, 1987
http://www.itl.nist.gov/fipspubs/fip5-2.htm
Code
Code System
Print Name
AL
FIPS 5-2 (State Alpha Codes)
Alabama
AK
FIPS 5-2 (State Alpha Codes)
Alaska
AZ
FIPS 5-2 (State Alpha Codes)
Arizona
AR
FIPS 5-2 (State Alpha Codes)
Arkansas
…
Table 12: Postal Code Value Set (excerpt)
Value Set: PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC
Code System(s):
US Postal Codes 2.16.840.1.113883.6.231
Description:
A value set of codes postal (ZIP) Code of an address in the United States.
http://zip4.usps.com/zip4/welcome.jsp
Code
Code System
Print Name
19009
US Postal Codes
Bryn Athyn, PA
92869-1736
US Postal Codes
Orange, CA
32830-8413
US Postal Codes
Lake Buena Vista, FL
…
Table 13: Country Value Set (excerpt)
Value Set: CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC
Code System(s):
ISO 3166-1 Country Codes: 1.0.3166.1
Description:
A value set of codes for the representation of names of countries, territories
and areas of geographical interest.
Note: This table provides the ISO 3166-1 code elements available in the 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
AW
ISO 3166-1 Country Codes
Aruba
IL
ISO 3166-1 Country Codes
Israel
KZ
ISO 3166-1 Country Codes
Kazakhstan
US
ISO 3166-1 Country Codes
United States
…
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Table 14: Language Ability Value Set
Value Set: HL7 LanguageAbilityMode 2.16.840.1.113883.1.11.12249 DYNAMIC
Code System(s):
LanguageAbilityMode 2.16.840.1.113883.5.60
Description:
A value representing the method of expression of the language.
Code
Code System
Print Name
ESGN
LanguageAbilityMode
Expressed signed
ESP
LanguageAbilityMode
Expressed spoken
EWR
LanguageAbilityMode
Expressed written
RSGN
LanguageAbilityMode
Received signed
RSP
LanguageAbilityMode
Received spoken
RWR
LanguageAbilityMode
Received written
Table 15: Language Ability Proficiency Value Set
Value Set: LanguageAbilityProficiency 2.16.840.1.113883.1.11.12199 DYNAMIC
Code System(s):
LanguageAbilityProficiency 2.16.840.1.113883.5.61
Description:
A value representing the level of proficiency in a language.
Code
Code System
Print Name
E
LanguageAbilityProficiency
Excellent
F
LanguageAbilityProficiency
Fair
G
LanguageAbilityProficiency
Good
P
LanguageAbilityProficiency
Poor
3.2.1.7 RecordTarget Example
Figure 19: recordTarget example
<recordTarget>
<patientRole>
<id extension="12345" root="2.16.840.1.113883.19"/>
<!-- Fake ID using HL7 example OID. -->
<id extension="111-00-1234" root="2.16.840.1.113883.4.1"/>
<!-- Fake Social Security Number using the actual SSN OID. -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 --
>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes:
1.0.3166.1 -->
</addr>
<telecom value="tel:(781)555-1212" use="HP"/>
<!-- HP is "primary home" from AddressUse 2.16.840.1.113883.5.1119 --
>
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<patient>
<name use="L">
<!-- L is "Legal" from EntityNameUse 2.16.840.1.113883.5.45 -->
<prefix>Mr.</prefix>
<given>Adam</given>
<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"/>
<birthTime value="19541125"/>
<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"/>
<guardian>
<code code="GRFTH" displayName="Grandfather"
codeSystem="2.16.840.1.113883.5.111"
codeSystemName="RoleCode"/>
<addr use="HP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(781)555-1212" use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Relative</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
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<languageCommunication>
<languageCode code="fr-CN"/>
<modeCode code="RWR" displayName="Receive Written"
codeSystem="2.16.840.1.113883.5.60"
codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.19"/>
<name>Good Health Clinic</name>
<telecom use="WP" value="tel:(781)555-1212"/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</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).
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1. The content SHALL be a conformant US Realm Address
(AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
(CONF:16871).
iv. This assignedAuthor SHALL contain at least one [1..*] telecom
(CONF:5428).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7995).
v. This assignedAuthor SHOULD contain zero or one [0..1]
assignedPerson (CONF:5430).
1. The assignedPerson, if present, SHALL contain at least
one [1..*] name (CONF:16789).
a. The content SHALL be a conformant US Realm
Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:16872).
vi. This assignedAuthor SHOULD contain zero or one [0..1]
assignedAuthoringDevice (CONF:16783).
1. The assignedAuthoringDevice, if present, SHALL
contain exactly one [1..1] manufacturerModelName
(CONF:16784).
2. The assignedAuthoringDevice, if present, SHALL
contain exactly one [1..1] softwareName
(CONF:16785).
vii. There SHALL be exactly one assignedAuthor/assignedPerson or
exactly one assignedAuthor/assignedAuthoringDevice
(CONF:16790).
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Figure 20: Person author example
<author>
<time value="20050329224411+0500"/>
<assignedAuthor>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
Figure 21: Device author example
<author>
<time value="20050329224411+0500"/>
<assignedAuthor>
<id extension="KP00017dev" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedAuthoringDevice>
<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
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transfers information from one source to another (e.g., transcription from paper
form to electronic system).
14. MAY contain zero or one [0..1] dataEnterer (CONF:5441).
a. The dataEnterer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:5442).
i. This assignedEntity SHALL contain at least one [1..*] id
(CONF:5443).
1. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:16821).
ii. This assignedEntity SHALL contain at least one [1..*] addr
(CONF:5460).
1. The content of addr SHALL be a conformant US Realm
Address (AD.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.2) (CONF:10417).
iii. This assignedEntity SHALL contain at least one [1..*] telecom
(CONF:5466).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7996).
iv. This assignedEntity SHALL contain exactly one [1..1]
assignedPerson (CONF:5469).
1. This assignedPerson SHALL contain at least one [1..*]
name (CONF:5470).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10418).
v. This assignedEntity MAY contain zero or one [0..1] code which
SHOULD be selected from coding system NUCC Health Care
Provider Taxonomy 2.16.840.1.113883.6.101 (CONF:9944).
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Figure 22: dataEnterer example
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.19.5" extension="43252"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<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).
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iii. Ii. This assignedEntity MAY contain zero or one [0..1] code
which SHOULD be selected from coding system NUCC Health
Care Provider Taxonomy 2.16.840.1.113883.6.101
(CONF:9947).
iv. SHOULD contain zero or more [0..*] id (CONF:9945).
1. If assignedEntity/id is a provider then this id, SHOULD
include zero or one [0..1] id where id/@root
="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:9946).
Figure 23: Informant with assignedEntity example
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<assignedPerson>
<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).
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a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National
Provider Identifier (CONF:16822).
2. This representedCustodianOrganization SHALL contain
exactly one [1..1] name (CONF:5524).
3. This representedCustodianOrganization SHALL contain
exactly one [1..1] telecom (CONF:5525).
a. This telecom SHOULD contain exactly one [1..1]
@use, which SHALL be selected from ValueSet
Telecom Use (US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7998).
4. This representedCustodianOrganization SHALL contain
at least one [1..*] addr (CONF:5559).
a. The content of addr SHALL be a conformant US
Realm Address (AD.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.2)
(CONF:10421).
Figure 24: Custodian example
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Clinic</name>
<telecom value="tel:(555)555-1212" use="WP"/>
<addr use="WP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</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).
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1. The informationRecipient, if present, SHALL contain at
least one [1..*] name (CONF:5568).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10427).
ii. This intendedRecipient MAY contain zero or one [0..1]
receivedOrganization (CONF:5577).
1. The receivedOrganization, if present, SHALL contain
exactly one [1..1] name (CONF:5578).
Figure 25: informationRecipient example
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<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).
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i. The content SHALL be a conformant US Realm Date and Time
(DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
(CONF:16873).
b. The legalAuthenticator, if present, SHALL contain exactly one [1..1]
signatureCode (CONF:5583).
i. This signatureCode SHALL contain exactly one [1..1]
@code="S" (CodeSystem: Participationsignature
2.16.840.1.113883.5.89) (CONF:5584).
c. The legalAuthenticator, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:5585).
i. This assignedEntity SHALL contain at least one [1..*] id
(CONF:5586).
1. Such ids MAY contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:16823).
ii. This assignedEntity MAY contain zero or one [0..1] code,
which SHOULD be selected from ValueSet Healthcare
Provider Taxonomy (NUCC - HIPAA)
2.16.840.1.114222.4.11.1066 (CONF:17000).
iii. This assignedEntity SHALL contain at least one [1..*] addr
(CONF:5589).
1. The content of addr SHALL be a conformant US Realm
Address (AD.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.2) (CONF:10429).
iv. This assignedEntity SHALL contain at least one [1..*] telecom
(CONF:5595).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:7999).
v. This assignedEntity SHALL contain exactly one [1..1]
assignedPerson (CONF:5597).
1. This assignedPerson SHALL contain at least one [1..*]
name (CONF:5598).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10430).
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Figure 26: legalAuthenticator example
<legalAuthenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<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
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Healthcare Provider Taxonomy (NUCC - HIPAA)
2.16.840.1.114222.4.11.1066 (CONF:16826).
iii. This assignedEntity SHALL contain at least one [1..*] addr
(CONF:5616).
1. The content of addr SHALL be a conformant US Realm
Address (AD.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.2) (CONF:10425).
iv. This assignedEntity SHALL contain at least one [1..*] telecom
(CONF:5622).
1. Such telecoms SHOULD contain exactly one [1..1] @use,
which SHALL be selected from ValueSet Telecom Use
(US Realm Header)
2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:8000).
v. This assignedEntity SHALL contain exactly one [1..1]
assignedPerson (CONF:5624).
1. This assignedPerson SHALL contain at least one [1..*]
name (CONF:5625).
a. The content of name SHALL be a conformant US
Realm Person Name (PN.US.FIELDED)
(2.16.840.1.113883.10.20.22.5.1.1)
(CONF:10424).
Figure 27: Authenticator example
<authenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
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3.2.9 Participant (Support)
The participant element identifies other supporting participants, including
parents, relatives, caregivers, insurance policyholders, guarantors, and other
participants related in some way to the patient.
A supporting person or organization is an individual or an organization with a
relationship to the patient. A supporting person who is playing multiple roles
would be recorded in multiple participants (e.g., emergency contact and next-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
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Figure 28: Participant example for a supporting person
<participant typeCode='IND'>
<time xsi:type="IVL_TS">
<low value="19590101"/>
<high value="20111025"/>
</time>
<associatedEntity classCode='NOK'>
<code code='MTH' codeSystem='2.16.840.1.113883.5.111'/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom value='tel:(555)555-2006' use='WP'/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Martha</given>
<family>Mum</family>
</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).
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1. This effectiveTime SHALL contain exactly one [1..1] low
(CONF:14838).
ii. This serviceEvent SHOULD contain zero or more [0..*]
performer (CONF:14839).
1. The performer, if present, SHALL contain exactly one
[1..1] @typeCode="PRF" Participation physical
performer (CodeSystem: HL7ParticipationType
2.16.840.1.113883.5.90) (CONF:14840).
a. The performer participant represents clinicians
who actually and principally carry out the
serviceEvent. In a transfer of care this
represents the healthcare providers involved in
the current or pertinent historical care of the
patient. Preferably, the patient’s key healthcare
care team members would be listed,
particularly their primary physician and any
active consulting physicians, therapists, and
counselors (CONF:16753).
2. The performer, if present, MAY contain zero or one
[0..1] functionCode (CONF:16818).
a. The functionCode, if present, SHOULD contain
zero or one [0..1] @codeSystem, which SHOULD
be selected from CodeSystem
participationFunction
(2.16.840.1.113883.5.88) (CONF:16819).
3. The performer, if present, SHALL contain exactly one
[1..1] assignedEntity (CONF:14841).
a. This assignedEntity SHALL contain at least one
[1..*] id (CONF:14846).
i. Such ids SHOULD contain zero or one
[0..1]
@root="2.16.840.1.113883.4.6"
National Provider Identifier
(CONF:14847).
b. This assignedEntity SHOULD contain zero or one
[0..1] code (CONF:14842).
i. The code, if present, SHALL contain
exactly one [1..1] @code, which SHOULD
be selected from CodeSystem
NUCCProviderTaxonomy
(2.16.840.1.113883.6.101)
(CONF:14843).
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Figure 29: DocumentationOf example
<documentationOf>
<serviceEvent classCode="ACT">
<id root="1.2.840.113619.2.62.994044785528.114289542805"/>
<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"/>
<effectiveTime value="20080813222400"/>
<performer typeCode="PRF">
<templateId root="2.16.840.1.113883.10.20.6.2.1"/>
<assignedEntity>
<id extension="121008" root="2.16.840.1.113883.19.5"/>
<code code="208D00000X "
codeSystem="2.16.840.1.113883.6.101"
codeSystemName="NUCC"
displayName="General Practice"/>
<addr nullFlavor="NI"/>
<telecom nullFlavor="NI"/>
<assignedPerson>
<name>
<given>Matthew</given>
<family>Care</family>
<suffix>MD</suffix>
</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).
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iii. This consent SHALL contain exactly one [1..1] statusCode
(CONF:16797).
1. This statusCode SHALL contain exactly one [1..1]
@code="completed" Completed (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6)
(CONF:16798).
Figure 30: Procedure note consent example
<authorization typeCode="AUTH">
<consent classCode="CONS" moodCode="EVN">
<id root="629deb70-5306-11df-9879-0800200c9a66" />
<code codeSystem=" 2.16.840.1.113883.6.1" codeSystemName="LOINC"
code="64293-4" displayName="Procedure consent"/>
<statusCode code="completed"/>
</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).
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3. SHOULD contain zero or one [0..1] state (ValueSet: StateValueSet
2.16.840.1.113883.3.88.12.80.1 DYNAMIC) (CONF:7293).
a. State is required if the country is US. If country is not specified, its
assumed to be US. If country is something other than US, the state
MAY be present but MAY be bound to different vocabularies
(CONF:10024).
4. SHALL contain exactly one [1..1] city (CONF:7292).
5. SHOULD contain zero or one [0..1] postalCode (ValueSet:
PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC)
(CONF:7294).
a. PostalCode is required if the country is US. If country is not specified,
its assumed to be US. If country is something other than US, the
postalCode MAY be present but MAY be bound to different
vocabularies (CONF:10025).
6. SHALL contain at least one and not more than 4 streetAddressLine
(CONF:7291).
7. SHALL NOT have mixed content except for white 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
H
AddressUse
home address
HP
AddressUse
primary home
HV
AddressUse
vacation home
PHYS
AddressUse
physical visit address
PST
AddressUse
postal address
PUB
AddressUse
public
TMP
AddressUse
temporary
WP
AddressUse
work place
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).
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1. SHALL be precise to the day (CONF:10078).
2. SHOULD be precise to the minute (CONF:10079).
3. MAY be precise to the second (CONF:10080).
4. If more precise than day, SHOULD include time-zone offset (CONF:10081).
3.5 US Realm Date and Time (DTM.US.FIELDED)
[time: 2.16.840.1.113883.10.20.22.5.4(open)]
The US Realm Clinical Document Date and Time datatype flavor records date
and time information. If no time zone offset is provided, you can make no
assumption about time, unless you have made a local exchange agreement.
This data type uses the same rules as US Realm Date and Time
(DT.US.FIELDED), but is used with the time element.
1. SHALL be precise to the day (CONF:10127).
2. SHOULD be precise to the minute (CONF:10128).
3. MAY be precise to the second (CONF:10129).
4. If more precise than day, SHOULD include time-zone offset (CONF:10130).
3.6 US Realm Patient Name (PTN.US.FIELDED)
[PN: templateId 2.16.840.1.113883.10.20.22.5.1 (open)]
The US Realm Patient Name datatype flavor is a set of reusable constraints that
can be used for the patient or any other person. It requires a first (given) and
last (family) name. If a patient or person has only one name part (e.g., patient
with first name only) place the name part in the field required by the
organization. Use the appropriate nullFlavor, "Not Applicable" (NA), in the
other field.
For information on mixed content see the Extensible Markup Language
reference (http://www.w3c.org/TR/2008/REC-xml-20081126/).
1. MAY contain zero or one [0..1] @use, which SHALL be selected from ValueSet
EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01
(CONF:7154).
2. SHALL contain exactly one [1..1] family (CONF:7159).
a. This family MAY contain zero or one [0..1] @qualifier, which SHALL
be selected from ValueSet EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7160).
3. SHALL contain at least one [1..*] given (CONF:7157).
a. Such givens MAY contain zero or one [0..1] @qualifier, which SHALL
be selected from ValueSet EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7158).
b. The second occurrence of given (given[2]) if provided, SHALL include
middle name or middle initial (CONF:7163).
4. MAY contain zero or more [0..*] prefix (CONF:7155).
a. The prefix, if present, MAY contain zero or one [0..1] @qualifier,
which SHALL be selected from ValueSet
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EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7156).
5. MAY contain zero or one [0..1] suffix (CONF:7161).
a. The suffix, if present, MAY contain zero or one [0..1] @qualifier,
which SHALL be selected from ValueSet
EntityPersonNamePartQualifier
2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7162).
6. SHALL NOT have mixed content except for white space (CONF:7278).
Table 18: EntityNameUse Value Set
Value Set: EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01
Code System(s):
EntityNameUse 2.16.840.1.113883.5.45
Code
Code System
Print Name
A
EntityNameUse
Artist/Stage
ABC
EntityNameUse
Alphabetic
ASGN
EntityNameUse
Assigned
C
EntityNameUse
License
I
EntityNameUse
Indigenous/Tribal
IDE
EntityNameUse
Ideographic
L
EntityNameUse
Legal
P
EntityNameUse
Pseudonym
PHON
EntityNameUse
Phonetic
R
EntityNameUse
Religious
SNDX
EntityNameUse
Soundex
SRCH
EntityNameUse
Search
SYL
EntityNameUse
Syllabic
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Table 19: EntityPersonNamePartQualifier Value Set
Value Set: EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC
2011-09-30
Code System(s):
EntityNamePartQualifier 2.16.840.1.113883.5.43
Code
Code System
Print Name
AC
EntityNamePartQualifier
academic
AD
EntityNamePartQualifier
adopted
BR
EntityNamePartQualifier
birth
CL
EntityNamePartQualifier
callme
IN
EntityNamePartQualifier
initial
NB
EntityNamePartQualifier
nobility
PR
EntityNamePartQualifier
professional
SP
EntityNamePartQualifier
spouse
TITLE
EntityNamePartQualifier
title
VV
EntityNamePartQualifier
voorvoegsel
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
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Names of selected organizations along with their roles, participations,
participation date ranges, identifiers, address, and telecommunications
information
Date of birth for recordTarget(s)
In Operative and Procedure Notes, the following information is typically
displayed in the electronic health record (EHR) and/or rendered directly in the
document:
The performers of the surgery or procedure, including any assistants
The surgery or procedure performed (serviceEvent)
The date of the surgery or procedure
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4 DOCUMENT-LEVEL TEMPLATES
Document-level templates describe the purpose and rules for constructing a
conforming CDA document. Document templates include constraints on the
CDA header and refer to section-level templates. The Document Types and
Required/Optional Sections table lists the sections used by each document type.
Each document-level template contains the following information:
Scope and intended use of the document type
Description and explanatory narrative.
Template metadata (e.g., templateId, etc.)
Header constraints: this includes a reference to the US Realm Clinical
Document Header template and additional constraints specific to each
document type
Required and optional section-level templates
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Table 20: Document Types and Required/Optional Sections with Structured Body
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.
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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)
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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
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© 2012 Health Level Seven, Inc. All rights reserved. July 2012
Document Type
Preferred LOINC
templateId
Required Sections
Optional Sections
History & Physical Note
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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)
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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