Template 2.16.840.1.113883.10.20.22.1.1 US Realm Header

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.1 - USRealmHeader
Id 2.16.840.1.113883.10.20.22.1.1
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑599
Version valid from 2012‑01‑12 status draft
Description This section 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.
Item DT Card Conf Desc Label
cda:ClinicalDocument
When consent is recorded, it SHALL be represented as ClinicalDocument/authorization/consent conf-599
treetree cda:realmCode/@code
CD 1..1 M conf‑5249
treeblank treetree @code
1..1 F US
treetree cda:typeId
II 1..1 M conf‑5361
treeblank treetree @root
1..1 F 2.16.840.1.113883.1.3
treeblank treetree @extension
1..1
treeblank treetree @value
1..1 F POCD_HD000040
treetree cda:templateId
II 1..1 M conf‑5252
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:id
II 1..1 M This id SHALL be a globally unique identifier for the document conf‑5363
treetree cda:code
CE 1..1 M This code SHALL specify the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note) conf‑5253
treetree cda:title
ST 1..1 M can either be a locally defined name or the display name corresponding to clinicalDocument/code conf‑5254
treetree cda:effectiveTime
IVL_TS 1..1 M conf‑5256
Contains inherited template rules 2.16.840.1.113883.10.20.22.5.3 with overridden cardinality 1 .. 1 mandatory
treeblank treetree cda:low
1.. conf‑5256
treetree cda:confidentialityCode
1..1 M conf‑5259
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 flexibility 2010-04-21T00:00:00
alert Error: Cannot find value set "2.16.840.1.113883.1.11.16926"
treetree cda:languageCode
CS 1..1 M conf‑5372
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.11526"
treetree cda:setId
II 0..1 O conf‑5261
Schematron assert Role red error
Test count(../cda:versionNumber |../cda:setId)=2 or count(../cda:versionNumber | ../cda:setId)=0
Message
If setId is present versionNumber SHALL be present
treetree cda:versionNumber
INT 0..1 O conf‑5264
Schematron assert Role red error
Test count(//cda:versionNumber | //cda:setId)=2 or count(//cda:versionNumber | //cda:setId)=0
Message
If versionNumber is present setId SHALL be present
treetree cda:recordTarget
1..* M conf‑5266
treeblank treetree cda:patientRole
1..1 M conf‑5267
treeblank treeblank treetree cda:id
II 1..* M conf‑5268
treeblank treeblank treetree cda:addr
AD 1..* M conf‑5271
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treeblank treeblank treetree cda:telecom
TEL 1..* M conf‑5280
treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treetree cda:patient
1..1 M conf‑5283
treeblank treeblank treeblank treetree cda:name
PN 1..1 M conf‑5284
Schematron assert Role red error
Test cda:given and cda:family
Message
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)
treeblank treeblank treeblank treetree cda:administrativeGenderCode
CE 1..1 M conf‑6394
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.1"
treeblank treeblank treeblank treetree cda:birthTime
TS 1..1 M SHOULD be precise to day conf‑5298
Schematron assert Role red error
Test string-length(@value) >=4
Message
SHALL be precise to year
treeblank treeblank treeblank treetree cda:maritalStatusCode
CE 0..1 R conf‑5303
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12212 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.12212"
treeblank treeblank treeblank treetree cda:religiousAffiliationCode
CE 0..1 O conf‑5317
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19185 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.19185"
treeblank treeblank treeblank treetree cda:raceCode
CE 0..1 O conf‑5322
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14914 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.14914"
treeblank treeblank treeblank treetree sdwg:raceCode
CE 0..* O conf‑7263
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14914 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.14914"
treeblank treeblank treeblank treetree cda:ethnicGroupCode
CE 0..1 O conf‑5323
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15836 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.15836"
treeblank treeblank treeblank treetree cda:guardian
0..* O conf‑5325
treeblank treeblank treeblank treeblank treetree cda:code
CE 0..1 R conf‑5326
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.19563"
treeblank treeblank treeblank treeblank treetree cda:addr
AD 0..* R conf‑5359
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treeblank treeblank treeblank treeblank treetree cda:telecom
TEL 0..* O conf‑5382
treeblank treeblank treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treeblank treeblank treetree cda:guardianPerson
1..1 M conf‑5385
treeblank treeblank treeblank treeblank treeblank treetree cda:name
PN 1..* M conf‑5386
Schematron assert Role red error
Test (cda:given and cda:family) or (count(../cda:name[*])=0 and string-length(../cda:name)!=0)
Message
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)
treeblank treeblank treeblank treetree cda:birthplace
0..1 O conf‑5395
treeblank treeblank treeblank treeblank treetree cda:place
1..1 M conf‑5396
treeblank treeblank treeblank treeblank treeblank treetree cda:addr
AD 1..1 M conf‑5397
Schematron assert Role red error
Test (cda:country='US' or cda:country='USA') and cda:state
Message
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
treeblank treeblank treeblank treeblank treeblank treeblank treetree cda:postalCode
ST 0..1 O conf‑5403
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.2 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.80.2"
treeblank treeblank treeblank treeblank treeblank treeblank treetree cda:country
ST 0..1 R conf‑5404
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.63 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.80.63"
treeblank treeblank treeblank treetree cda:languageCommunication
0..* R conf‑5406
treeblank treeblank treeblank treeblank treetree cda:languageCode
CS 1..1 M conf‑5407
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.11526"
treeblank treeblank treeblank treeblank treetree cda:modeCode
CE 0..1 O conf‑5409
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.12249"
treeblank treeblank treeblank treeblank treetree cda:proficiencyLevelCode
CE 0..1 R conf‑9965
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.12199"
treeblank treeblank treeblank treeblank treetree cda:preferenceInd
BL 0..1 O conf‑5414
treeblank treeblank treetree cda:providerOrganization
0..1 O conf‑5416
treeblank treeblank treeblank treetree cda:id
II 1..* M conf‑5417
Schematron assert Role red error
Test @root='2.16.840.1.113883.4.6'
Message
The id SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier
treeblank treeblank treeblank treetree cda:name
PN 1..* M conf‑5419
treeblank treeblank treeblank treetree cda:telecom
TEL 1..* M conf‑5420
treeblank treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treeblank treetree cda:addr
AD 1..* M conf‑5422
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treetree cda:author
1..* M conf‑5444
treeblank treetree cda:time
IVL_TS 1..1 M conf‑5445
Schematron assert Role red error
Test string-length(@value) >=8
Message
The content of time SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
treeblank treetree cda:assignedAuthor
1..1 M conf‑5448
treeblank treeblank treetree cda:id
II 1..* M conf‑5449
treeblank treeblank treetree cda:id/@root
..1 conf‑9941
treeblank treeblank treeblank treetree @code
1..1 F 2.16.840.1.113883.4.6
treeblank treeblank treetree cda:code
0..1 R conf‑9942
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.6.101
alert Error: Cannot find value set "2.16.840.1.113883.6.101"
treeblank treeblank treetree cda:addr
AD 1..* M conf‑5452
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treeblank treeblank treetree cda:telecom
TEL 1..* M conf‑5428
treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treetree cda:assignedPerson
1..1 M conf‑5430
Schematron assert Role red error
Test count(cda:assignedPerson | cda:assignedAuthoringDevice)=1
Message
This assignedAuthor SHALL contain exactly one [1..1] assignedPerson or assignedAuthoringDevice
Schematron assert Role red error
Test cda:name
Message
If present this assignedPerson SHALL contain at least one [1..*] US RealmPerson Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1)
Schematron assert Role red error
Test count(cda:assignedAuthoringDevice)=0 or count(cda:assignedAuthoringDevice/cda:manufacturerModelName)>0
Message
If present this assignedAuthoringDevice SHALL contain at least one [1..1] manufacturerModelName
Schematron assert Role red error
Test count(cda:assignedAuthoringDevice)=0 or count(cda:assignedAuthoringDevice/cda:softwareName)qgt;0
Message
If present this assignedAuthoringDevice SHALL contain at least 1..1 softwareName
treetree cda:dataEnterer
0..1 O conf‑5441
treeblank treetree cda:assignedEntity
1..1 M 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‑5442
treeblank treeblank treetree cda:id
II 1..* M SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier conf‑5443
treeblank treeblank treetree cda:addr
AD 1..* M conf‑5460
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treeblank treeblank treetree cda:telecom
TEL 1..* M conf‑5466
treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treetree cda:assignedPerson
1..1 M conf‑5469
treeblank treeblank treeblank treetree cda:name
PN 1..* M conf‑5470
Schematron assert Role red error
Test (cda:given and cda:family) or (count(../cda:name[*])=0 and string-length(../cda:name)!=0)
Message
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)
treetree cda:informant
0..* O 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‑8001
Schematron assert Role red error
Test count(cda:assignedEntity | cda:relatedEntity)=1
Message
SHALL contain exactly one [1..1] assignedEntity OR exactly one [1..1] relatedEntity
treeblank treetree cda:id
II 0..* R 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‑9945
treeblank treetree cda:addr
AD 1..* R conf‑8220
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
Schematron assert Role red error
Test count(//cda:assignedPerson | //cda:relatedPerson)=1
Message
SHALL contain exactly one [1..1] assignedPerson OR exactly one [1..1] relatedPerson
treeblank treetree cda:name
PN 1..* M conf‑8222
Schematron assert Role red error
Test (cda:given and cda:family) or (count(../cda:name[*])=0 and string-length(../cda:name)!=0)
Message
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)
treetree cda:custodian
1..1 M conf‑5519
treeblank treetree cda:assignedCustodian
1..1 M conf‑5520
treeblank treeblank treetree cda:representedCustodianOrganization
1..1 M conf‑5521
treeblank treeblank treeblank treetree cda:id
II 1..* M conf‑5522
Schematron assert Role red error
Test @root='2.16.840.1.113883.4.6'
Message
The id SHOULD include zero or one [0..1] id where id/@root="2.16.840.1.113883.4.6" National Provider Identifier
treeblank treeblank treeblank treetree cda:name
PN 1..1 M conf‑5524
treeblank treeblank treeblank treetree cda:telecom
TEL 1..1 M conf‑5525
treeblank treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treeblank treetree cda:addr
AD 1..* M conf‑5559
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treetree cda:informationRecipient
0..* O conf‑5565
treeblank treetree cda:intendedRecipient
1..1 M conf‑5566
treeblank treeblank treetree cda:informationRecipient
0..1 O conf‑5567
treeblank treeblank treeblank treetree cda:name
PN 1..* M conf‑5568
Schematron assert Role red error
Test (cda:given and cda:family) or (count(../cda:name[*])=0 and string-length(../cda:name)!=0)
Message
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)
treeblank treeblank treetree cda:receivedOrganization
0..1 O conf‑5577
treeblank treeblank treeblank treetree cda:name
PN 1..1 M conf‑5578
treetree cda:legalAuthenticator
0..1 R conf‑5579
treeblank treetree cda:time
IVL_TS 1..1 M conf‑5580
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of time SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
treeblank treetree cda:signatureCode
CS 1..1 M conf‑5583
treeblank treeblank treetree @code
1..1
treeblank treeblank treetree @value
1..1 F S
treeblank treetree cda:assignedEntity
1..1 M 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‑5585
treeblank treeblank treetree cda:id
II 1..* M SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier conf‑5586
treeblank treeblank treetree cda:addr
AD 1..* M conf‑5589
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treeblank treeblank treetree cda:telecom
TEL 1..* M conf‑5595
treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treetree cda:assignedPerson
1..1 M conf‑5597
treeblank treeblank treeblank treetree cda:name
PN 1..* M conf‑5598
Schematron assert Role red error
Test (cda:given and cda:family) or (count(../cda:name[*])=0 and string-length(../cda:name)!=0)
Message
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)
treetree cda:authenticator
0..* O conf‑5607
treeblank treetree cda:time
IVL_TS 1..1 M conf‑5608
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of time SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
treeblank treetree cda:signatureCode
CS 1..1 M conf‑5610
treeblank treeblank treetree @code
1..1
treeblank treeblank treetree @value
1..1 F S
treeblank treetree cda:assignedEntity
1..1 M 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‑5612
treeblank treeblank treetree cda:id
II 1..* M conf‑5613
Schematron assert Role red error
Test true()
Message
SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier
treeblank treeblank treetree cda:addr
AD 1..* M conf‑5616
Schematron assert Role red error
Test cda:streetAddressLine and cda:city and (cda:country!='US' or (cda:country='US' and cda:state and cda:postalCode))
Message
The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)
treeblank treeblank treetree cda:telecom
TEL 1..* M conf‑5622
treeblank treeblank treeblank treetree @use
1..1
CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.11.20.9.20 flexibility dynamic
treeblank treeblank treetree cda:assignedPerson
1..1 M conf‑5624
treeblank treeblank treeblank treetree cda:name
PN 1..* M conf‑5625
Schematron assert Role red error
Test (cda:given and cda:family) or (count(../cda:name[*])=0 and string-length(../cda:name)!=0)
Message
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)
treetree cda:participant
0..* O 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‑10003
treeblank treetree cda:time
IVL_TS 0..1 O conf‑10004
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of time SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
Schematron assert Role red error
Test //cda:associatedEntity[cda:associatedPerson | cda:scopingOrganization]
Message
Such participants, if present, SHALL have an associatedPerson or scopingOrganization element under participant/associatedEntity
treetree cda:inFulfillmentOf
0..* O conf‑9952
treeblank treetree cda:order
1..1 M conf‑9953
treeblank treeblank treetree cda:id
II 1..* M conf‑9954
treetree cda:componentOf
0..1 O conf‑9955
treeblank treetree cda:encompassingEncounter
1..1 M conf‑9956
treeblank treeblank treetree cda:id
II 1..* M conf‑9959
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑9958
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)