DECOR Information for Project: Trifolia conversion (ccda-)

Transaction Representing Templates

 Consultation Note / ConsultationNote [2.16.840.1.113883.10.20.22.1.4] - 2012‑01‑12

Template Consultation Note / ConsultationNote
Id 2.16.840.1.113883.10.20.22.1.4
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑734
Version valid from 2012‑01‑12 status draft
Description For the purpose of this Implementation Guide, a consultation visit is defined by the evaluation and management guidelines for a consultation established by the Centers for Medicare and Medicaid Services (CMS). According to those guidelines, a Consultation Note must be generated as a result of a physician or nonphysician practitioner's (NPP) request for an opinion or advice from another physician or NPP. Consultations must involve face-to-face time with the patient or fall under guidelines for telemedicine visits.

A Consultation Note must be provided to the referring physician or NPP and must include the reason for the referral, history of present illness, physical examination, and decision-making component (Assessment and Plan).

An NPP is defined as any licensed medical professional as recognized by the state in which the professional practices, including, but not limited to, physician assistants, nurse practitioners, clinical nurse specialists, social workers, registered dietitians, physical therapists, and speech therapists.

Reports on visits requested by a patient, family member, or other third party are not covered by this specification. Second opinions, sometimes called "confirmatory consultations," also are not covered here. Any question on use of the Consultation Note defined here should be resolved by reference to CMS or American Medical Association (AMA) guidelines.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-734
treetree cda:templateId
II 1..1 M conf‑9477
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8375
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.4
treetree cda:code
1..1 M conf‑8376
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.31 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.9.31"
treetree cda:inFulfillmentOf
1..1 M conf‑8382
treeblank treetree cda:order
1..1 R conf‑8385
treeblank treeblank treetree cda:id
II 1..* M conf‑9102
treetree cda:componentOf
1..1 M conf‑8386
treeblank treetree cda:encompassingEncounter
1..1 M conf‑8387
treeblank treeblank treetree cda:id
II 1..1 M conf‑8388
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8389
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)
treeblank treeblank treetree cda:responsibleParty
0..1 O The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. conf‑8391
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson or cda:representedOrganization]
Message
The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treeblank treeblank treetree cda:encounterParticipant
0..* O The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care. conf‑8392
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson or cda:representedOrganization]
Message
An encounterParticipant element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treetree cda:component
1..1 M A Consultation Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.4), coded entries are optional. conf‑8397
Schematron assert Role red error
Test count(cda:structuredBody | cda:nonXMLBody)=1
Message
A Consultation Note can have either a structuredBody or a nonXMLBody.
treeblank treetree cda:structuredBody
If structuredBody, the component/structuredBody SHALL conform to the section constraints below conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.8 with overridden cardinality 0 .. *
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan of Care Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
Schematron assert Role red error
Test //cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.1' or //cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12'
Message
SHALL include a Reason for Referral or Reason for Visit section
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a combined Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.8 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.10 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.9 with overridden cardinality 0 .. 1
1..1 M conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.3.4 with overridden cardinality 1 .. 1 mandatory
1..1 R conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.2.10 with overridden cardinality 1 .. 1 required
0..1 O conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.3.1 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.12 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.6 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.13 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.15 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.2.5 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.20 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.2 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.1 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.5 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.7 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.3 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.3.18 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.17 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.4 with overridden cardinality 0 .. 1

 Continuity of Care Document (CCD) / ContinuityofCareDocumentCCD [2.16.840.1.113883.10.20.22.1.2] - 2012‑01‑12

Template Continuity of Care Document (CCD) / ContinuityofCareDocumentCCD
Id 2.16.840.1.113883.10.20.22.1.2
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑737
Version valid from 2012‑01‑12 status draft
Description This section—Continuity of Care Document (CCD) Release 1.1—describes CDA constraints in accordance with Stage 1 Meaningful Use. The CCD requirements in this guide supersede CCD Release 1; in the near future, this guide could supersede HITSP C32.

The CCD is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. The primary use case for the CCD is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient . More specific use cases, such as a Discharge Summary or Progress Note, are available as alternative documents in this guide.
Item DT Card Conf Desc Label
cda:ClinicalDocument
The component/structuredBody SHALL conform to the section constraints below conf-737
treetree cda:templateId
II 1..1 M conf‑9441
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8450
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.2
treetree cda:code
CD 1..1 M conf‑8451
treeblank treetree @code
1..1 F 34133-9
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Summarization of Episode Note
treetree cda:documentationOf
1..1 M conf‑8452
treeblank treetree cda:serviceEvent
1..1 M conf‑8480
treeblank treeblank treetree @classCode
1..1 F PCPR
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8481
treeblank treeblank treeblank treetree cda:low
TS 1..1 M conf‑8454
treeblank treeblank treeblank treetree cda:high
TS 1..1 M conf‑8455
treeblank treeblank treetree cda:performer
0..* R serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors conf‑8482
treeblank treeblank treeblank treetree @typeCode
1..1 F PRF
treeblank treeblank treeblank treetree cda:assignedEntity
0..1 O conf‑8459
treeblank treeblank treeblank treeblank treetree cda:id
II 1..* M conf‑8460
Schematron assert Role red error
Test @root='2.16.840.1.113883.4.6'
Message
SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier
treeblank treeblank treeblank treeblank treetree cda:code
CE 0..1 O conf‑8461
Schematron assert Role red error
Test true()
Message
i. The code MAY be the NUCC Health Care Provider Taxonomy (CodeSystem: 2.16.840.1.113883.6.101). (See http://www.nucc.org)
treetree cda:author
1..* M conf‑9442
treeblank treetree cda:assignedAuthor
1..1 M conf‑9443
Schematron assert Role red error
Test count(cda:assignedPerson | cda:representedOrganization)=1
Message
SHALL contain exactly one [1..1] assignedPerson exactly one [1..1] representedOrganization
Schematron assert Role red error
Test (count(cda:representedOrganization[cda:assignedPerson | cda:assignedAuthoringDevice])=0 and (//cda:ClinicalDocument/cda:author/cda:assignedAuthor/cda:id/@nullFlavor='NA')) or (count(cda:representedOrganization[cda:assignedPerson | cda:assignedAuthoringDevice])>0) or (count(cda:representedOrganization)=0)
Message
If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” SHALL be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC.

 Progress Note / ProgressNote [2.16.840.1.113883.10.20.22.1.9] - 2012‑01‑12

Template Progress Note / ProgressNote
Id 2.16.840.1.113883.10.20.22.1.9
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑642
Version valid from 2012‑01‑12 status draft
Description A Progress Note documents a patient’s clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.

Taber’s medical dictionary defines a Progress Note as “An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.”

Mosby’s medical dictionary defines a Progress Note as “Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned.”

A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-642
treetree cda:templateId
II 1..1 M conf‑9483
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑7588
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.9
treetree cda:code
1..1 M conf‑7589
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.8.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.8.1"
treetree cda:documentationOf
0..1 R conf‑7603
treeblank treetree cda:serviceEvent/@classCode
1..1 M conf‑7604
treeblank treeblank treetree @code
1..1 F PCPR
treeblank treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.6
treeblank treeblank treetree @displayName
1..1 F Care Provision
treeblank treeblank treetree cda:templateId
II 1..1 M conf‑9480
treeblank treeblank treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.21.3.1
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 R conf‑9481
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)
Schematron assert Role red error
Test cda:low
Message
The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element
Schematron assert Role red error
Test count(cda:high | cda:width)=1
Message
If a width element is not present, the serviceEvent SHALL include effectiveTime/high
treetree cda:componentOf
1..1 M conf‑7595
treeblank treetree cda:encompassingEncounter
1..1 M conf‑7596
treeblank treeblank treetree cda:id
II 1..* M conf‑7597
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑7598
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)
treeblank treeblank treeblank treetree cda:low
TS 1..1 M conf‑7599
treeblank treeblank treetree cda:location
_cda:healthCareFacility
__cda:id
II 1..1 M conf‑7611
treetree cda:component
1..1 M A Progress Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.9), coded entries are optional
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑9591
Schematron assert Role red error
Test count(//cda:structuredBody | cda:nonXMLBody)=1
Message
A Progress Note can have either a structuredBody or a nonXMLBody
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present

 Procedure Note / ProcedureNote [2.16.840.1.113883.10.20.22.1.6] - 2012‑01‑12

Template Procedure Note / ProcedureNote
Id 2.16.840.1.113883.10.20.22.1.6
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑750
Version valid from 2012‑01‑12 status draft
Description Procedure Note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are documents that are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient’s tolerance of the procedure. The document should be sufficiently detailed to justify the procedure, describe the course of the procedure, and provide continuity of care.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-750
treetree cda:templateId
II 1..1 M conf‑9969
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8496
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.6
treetree cda:code
0..1 R conf‑8497
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.6.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.6.1"
treetree cda:componentOf
_cda:encompassingEncounter
0..1 R conf‑8499
treeblank treetree cda:code
CE 1..1 M conf‑8501
treeblank treetree cda:location
_cda:healthCareFacility
__cda:id
II 1..* M conf‑8500
treeblank treetree cda:encounterParticipant
1..1 conf‑8502
treeblank treeblank treetree @typeCode
1..1 F REF
treetree cda:participant
0..* O conf‑8504
treeblank treetree @typeCode
1..1 F IND
treeblank treetree cda:functionCode
CE 1..1 M conf‑8506
treeblank treeblank treetree @code
1..1 F PCP
treeblank treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.90
treeblank treeblank treetree @displayName
1..1 F Primary Care Physician
treeblank treetree cda:associatedEntity/@classCode
1..1 M conf‑8507
treeblank treeblank treetree @code
1..1 F PROV
treeblank treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.90
treeblank treeblank treetree @displayName
1..1 F Provider
treeblank treeblank treetree cda:associatedPerson
1..1 M conf‑8508
treetree cda:documentationOf
1..* M Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF). conf‑8510
treeblank treetree cda:serviceEvent
1..1 M conf‑10061
Schematron assert Role red error
Test cda:code[@codeSystem='2.16.840.1.113883.6.96' or @codeSystem='2.16.840.1.113883.6.12' or @codeSystem='2.16.840.1.113883.6.104']
Message
The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC.
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M 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) conf‑10062
Schematron assert Role red error
Test cda:low
Message
The serviceEvent/effectiveTime SHALL be present with effectiveTime/low
Schematron assert Role red error
Test count(cda:high | cda:width)=1
Message
If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high
Schematron assert Role red error
Test count(cda:high | cda:width)=1
Message
When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present
treeblank treeblank treetree cda:performer
1..1 M conf‑8520
treeblank treeblank treeblank treetree @typeCode
1..1 F PPRF
treeblank treeblank treeblank treetree cda:code
CE 0..1 R conf‑8522
treeblank treeblank treeblank treeblank treetree @code
0..1
CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.114222.4.11.1066"
treetree cda:component
1..1 M A Procedure Note can have either a structuredBody or a nonXMLBody
A Procedure Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.6), coded entries are optional.
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑9588
Schematron assert Role red error
Test count(//cda:section[not (cda:title)])=0 and not(//cda:section/cda:title[string-length()=0])
Message
Each section SHALL have a title and the title SHALL NOT be empty
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section

 Operative Note / OperativeNote [2.16.840.1.113883.10.20.22.1.7] - 2012‑01‑12

Template Operative Note / OperativeNote
Id 2.16.840.1.113883.10.20.22.1.7
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑749
Version valid from 2012‑01‑12 status draft
Description The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.
The Operative Note or Report is created immediately following a surgical or other high-risk procedure and records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-749
treetree cda:templateId
II 1..1 M conf‑9914
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8483
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.7
treetree cda:code
1..1 M conf‑8484
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.1.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.1.1"
treetree cda:documentationOf
1..* M Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF). conf‑8486
treeblank treetree cda:serviceEvent
1..1 M conf‑8493
Schematron assert Role red error
Test cda:code[@codeSystem='2.16.840.1.113883.6.96' or @codeSystem='2.16.840.1.113883.6.12' or @codeSystem='2.16.840.1.113883.6.104']
Message
i. The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8494
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)
Schematron assert Role red error
Test cda:low
Message
The serviceEvent/effectiveTime SHALL be present with effectiveTime/low.
Schematron assert Role red error
Test count(cda:high | cda:width) = 1
Message
If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high
Schematron assert Role red error
Test count(cda:high | cda:width) = 1
Message
When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present
treeblank treeblank treetree cda:performer
1..1 M conf‑8489
treeblank treeblank treeblank treetree @typeCode
1..1 F PPRF
treeblank treeblank treeblank treetree cda:assignedEntity
1..1 M conf‑10917
treeblank treeblank treeblank treeblank treetree cda:code
CE 1..1 M conf‑8490
treeblank treeblank treeblank treeblank treeblank treetree @code
1..1
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.4 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.3221.4"
treetree cda:component
1..1 M An Operative Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.7), coded entries are optional
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑9585
Schematron assert Role red error
Test count(//cda:structuredBody | //cda:nonXMLBody)=1
Message
An Operative Note can have either a structuredBody or a nonXMLBody

 History and Physical / HistoryandPhysical [2.16.840.1.113883.10.20.22.1.3] - 2012‑01‑12

Template History and Physical / HistoryandPhysical
Id 2.16.840.1.113883.10.20.22.1.3
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑731
Version valid from 2012‑01‑12 status draft
Description A History and Physical (H&P) Note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.

The first portion of the report is a current collection of organized information unique to an individual, typically supplied by the patient or their caregiver, about the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.

The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.

The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.

A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P Note.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-731
treetree cda:templateId
II 1..1 M conf‑9968
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8283
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.3
treetree cda:code
1..1 M conf‑8335
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.22 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.20.22"
treetree cda:inFulfillmentOf
0..* O An inFulfillmentOf element records the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and this H&P Note may be in partial fulfillment of that referral. conf‑8336
treetree cda:componentOf
1..1 M conf‑8338
treeblank treetree cda:encompassingEncounter
1..1 M conf‑8339
treeblank treeblank treetree cda:id
II 1..1 M conf‑8340
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8341
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)
treeblank treeblank treetree cda:location
0..1 O conf‑8344
treeblank treeblank treetree cda:responsibleParty
0..1 O The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. conf‑8345
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson | cda:representedOrganization]
Message
The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treeblank treeblank treetree cda:encounterParticipant
0..* O The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care. conf‑8342
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson | cda:representedOrganization]
Message
An encounterParticipant element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treetree cda:component
1..1 M A History and Physical document can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.3), coded entries are optional.
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑8349
Schematron assert Role red error
Test count(cda:structuredBody | cda:nonXMLBody)=1
Message
A History and Physical document can have either a structuredBody or a nonXMLBody.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
Schematron assert Role red error
Test //cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1' or //cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12' or //cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.13'
Message
SHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit Section
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section

 Discharge Summary / DischargeSummary [2.16.840.1.113883.10.20.22.1.8] - 2012‑01‑12

Template Discharge Summary / DischargeSummary
Id 2.16.840.1.113883.10.20.22.1.8
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑738
Version valid from 2012‑01‑12 status draft
Description The Discharge Summary is a document that is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary:
• The reason for hospitalization
• The procedures performed
• The care, treatment, and services provided
• The patient’s condition and disposition at discharge
• Information provided to the patient and family
• Provisions for follow-up care
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-738
treetree cda:templateId
II 1..1 M conf‑9479
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8463
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.8
treetree cda:code
1..1 M conf‑8466
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.4.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.4.1"
treetree cda:componentOf
1..1 M conf‑8471
treeblank treetree cda:encompassingEncounter
1..1 M The dischargeDispositionCode SHALL be present where the value of code SHOULD be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status DYNAMIC (www.nubc.org)
The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, SHALL be displayed when the document is rendered
The responsibleParty element MAY be present. If present, the responsibleParty/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.
The encounterParticipant elements MAY be present. If present, the encounterParticipant/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.
conf‑8472
treeblank treeblank treetree cda:effectiveTime
_cda:low
TS 1..1 M conf‑8473
treeblank treeblank treetree cda:effectiveTime
_cda:high
TS 1..1 M conf‑8475
treetree cda:component
1..1 M A Discharge Summary can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.8), coded entries are optional.
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑9539
Schematron assert Role red error
Test count(//cda:structuredBody | //cda:nonXMLBody)=1
Message
A Discharge Summary can have either a structuredBody or a nonXMLBody.
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section

 Diagnostic Imaging Report / DiagnosticImagingReport [2.16.840.1.113883.10.20.22.1.5] - 2012‑01‑12

Template Diagnostic Imaging Report / DiagnosticImagingReport
Id 2.16.840.1.113883.10.20.22.1.5
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑732
Version valid from 2012‑01‑12 status draft
Description A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist’s interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.
Item DT Card Conf Desc Label
cda:ClinicalDocument
Descriptions for sections is under development in DICOM in cooperation with the RSNA reporting initiative
All sections defined in the DIR Section Type Codes table SHALL be top-level sections
A section element SHALL have a code element which SHALL contain a LOINC code or DCM code for sections which have no LOINC equivalent. This only applies to sections described inthe DIR Section Type Codes table
The text elements (and their children) MAY contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink
If clinical statements are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text
If the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
If the subject of a section is a fetus, the section SHALL contain a subject element containing a Fetus Subject Context (templateId 2.16.840.1.113883.10.20.6.2.3)
: If the author of a section is different from the author(s) listed in the Header, an author element SHALL be present containing Observer Context (templateId 2.16.840.1.113883.10.20.6.2.4)
conf-732
treetree cda:templateId
II 1..1 M conf‑9405
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8404
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.5
Schematron assert Role red error
Test //cda:ClinicalDocument/cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID.
Schematron assert Role red error
Test //cda:ClinicalDocument/cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+
Schematron assert Role red error
Test string-length(//cda:ClinicalDocument/cda:id/@root)<65
Message
OIDs SHALL be no more than 64 characters in length.
treetree cda:code
1..1 M conf‑8408
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.32 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.9.32"
treetree cda:informant
NP conf‑8410
treetree cda:informationRecipient
0..* O The physician requesting the imaging procedure (ClincalDocument/participant[@typeCode=REF]/associatedEntity), if present, SHOULD also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report.
When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient MAY be absent. The intendedRecipient MAY also be the health chart of the patient, in which case the receivedOrganization SHALL be the scoping organization of that chart.
conf‑8411
treetree cda:participant
0..1 O conf‑8414
treeblank treetree cda:assignedEntity
_cda:assignedPerson
1..1 M conf‑8415
Schematron assert Role red error
Test true()
Message
If participant is present, the assignedEntity/assignedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF).
treeblank treeblank treetree cda:name
PN 1..1 M conf‑9406
Schematron assert Role red error
Test cda:given|cda:family or (count(*)=0 and string-length(.)!=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:documentationOf
1..1 M conf‑8416
treeblank treetree cda:serviceEvent
1..1 M conf‑8431
treeblank treeblank treetree @classCode
1..1 F ACT
Contains inherited template rules 2.16.840.1.113883.10.20.6.2.1 with overridden cardinality 1 .. 1 mandatory
treeblank treeblank treetree cda:id
II 0..* R conf‑8418
treeblank treeblank treetree cda:code
CE 1..1 M The value of serviceEvent/code SHALL NOT conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor SHALL be used on serviceEvent/code. conf‑8419
treetree cda:relatedDocument
0..1 O When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode SHALL be XFRM, and relatedDocument/parentDocument/id SHALL contain the SOP Instance UID of the original DICOM SR document. conf‑8432
Schematron assert Role red error
Test cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
The relatedDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID
Schematron assert Role red error
Test cda:id[contains(@root,'.') and (starts-with(@root,'0.') or starts-with(@root,'1.') or starts-with(@root,'2.'))]
Message
OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+
Schematron assert Role red error
Test string-length(cda:id/@root)<65
Message
OIDs SHALL be no more than 64 characters in length
treeblank treetree cda:componentOf
0..1 O conf‑8434
treeblank treeblank treetree cda:encompassingEncounter
1..1 M conf‑8449
Contains inherited template rules 2.16.840.1.113883.10.20.6.2.2 with overridden cardinality 1 .. 1 mandatory
treeblank treeblank treeblank treetree cda:id
II 1..* M In the case of transformed DICOM SR documents, an appropriate null flavor MAY be used if the id is unavailable. conf‑8435
treeblank treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8437
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)
treeblank treeblank treeblank treetree cda:responsibleParty
0..1 O conf‑8438
treeblank treeblank treeblank treeblank treetree cda:assignedEntity
1..1 M conf‑9407
Schematron assert Role red error
Test count(cda:assignedPerson | cda:representedOrganization)<2
Message
SHOULD contain zero or one [0..1] assignedPerson OR SHOULD contain zero or one [0..1] representedOrganization
Schematron assert Role red error
Test //cda:component[1]/cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.6.1.1'
Message
The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, SHALL be the first section in the document Body
Schematron assert Role red error
Test //cda:component/cda:structuredBody//cda:section[not(cda:templateId/@root='2.16.840.1.113883.10.20.6.1.1') and(cda:title)]
Message
With the exception of the DICOM Object Catalog (templateId 2.16.840.1.113883.10.20.6.1.1), all sections within the Diagnostic Imaging Report content SHOULD contain a title element
Schematron assert Role red error
Test //cda:section/cda:code[@codeSystem='1.2.840.10008.2.16.4 ' or @codeSystem='2.16.840.1.113883.6.1']
Message
The section/code SHOULD be selected from LOINC® or DICOM for sections not listed in the DIR Section Type Codes table
Schematron assert Role red error
Test //cda:component/cda:structuredBody//cda:section[not(cda:templateId/@root='2.16.840.1.113883.10.20.6.1.1') and ((//cda:component) or (//cda:text))]
Message
Apart from the DICOM Object Catalog (templateId 2.16.840.1.113883.10.20.6.1.1), all other instances of section SHALL contain at least one text element or one or more component elements
Schematron assert Role red error
Test not(//cda:text[count(*)=0 and string-length()=0]) and not(//cda:component[count(*)=0])
Message
All text or component elements SHALL contain content. text elements SHALL contain PCDATA or child elements, and component elements SHALL contain child elements

Templates

 Admission Medication / AdmissionMedication [2.16.840.1.113883.10.20.22.4.36] - 2012‑01‑12

Template Admission Medication / AdmissionMedication
Id 2.16.840.1.113883.10.20.22.4.36
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.36
Label conf‑656
Version valid from 2012‑01‑12 status draft
Description The Admission Medications entry codes medications that the patient took prior to admission.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.2.44 HospitalAdmissionMedicationsSectionentriesoptional  Hospital Admission Medications Section (entries optional) 2012‑01‑12
Item DT Card Conf Desc Label
cda:act
conf-656
treetree @classCode
1..1 F ACT
treetree @moodCode
1..1 F EVN
treetree cda:code
CD 1..1 M conf‑7700
treeblank treetree @code
1..1 F 42346-7
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Admission medication
treetree cda:entryRelationship
1..* M conf‑7701
treeblank treetree @typeCode
1..1 F SUBJ
Contains an element with template id 2.16.840.1.113883.10.20.22.4.16 with overridden cardinality 1 .. * mandatory

 Advance Directive Observation / AdvanceDirectiveObservation [2.16.840.1.113883.10.20.22.4.48] - 2012‑01‑12

Template Advance Directive Observation / AdvanceDirectiveObservation
Id 2.16.840.1.113883.10.20.22.4.48
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.48
Label conf‑779
Version valid from 2012‑01‑12 status draft
Description Advance Directives Observatations assert findings (e.g., “resuscitation status is Full Code”) rather than orders, and should not be considered legal documents. A legal document can be referenced using the reference/externalReference construct.
Used in 2 templates:

Id Name as of
2.16.840.1.113883.10.20.22.2.21 AdvanceDirectivesSectionentriesoptional  Advance Directives Section (entries optional) 2012‑01‑12
2.16.840.1.113883.10.20.22.2.21.1 AdvanceDirectivesSectionentriesrequired  Advance Directives Section (entries required) 2012‑01‑12
Item DT Card Conf Desc Label
cda:observation
conf-779
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑8655
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.48
treetree cda:id
II 1..* M conf‑8654
treetree cda:code
CE 1..1 M conf‑8651
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.2 flexibility 2006-10-17T00:00:00
alert Error: Cannot find value set "2.16.840.1.113883.1.11.20.2"
treetree cda:statusCode
CS 1..1 M conf‑8652
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8656
treeblank treetree cda:low
TS 1..1 M If the starting time is unknown, the low element SHALL have the nullFlavor attribute set to UNK conf‑8657
treeblank treetree cda:high
TS 1..1 M If the ending time is unknown, the high element SHALL have the nullFlavor attribute set to UNK.
If the Advance Directive does not have a specified ending time, the high element SHALL have the nullFlavor attribute set to NA
conf‑8659
treetree cda:participant
1..* R conf‑8662
treeblank treetree @typeCode
1..1 F VRF
treeblank treetree cda:templateId
II 1..1 M conf‑8664
treeblank treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.1.58
treeblank treetree cda:time
IVL_TS 0..1 R The data type of Observation/participant/time in a verification SHALL be TS (time stamp). conf‑8665
treeblank treetree cda:participantRole
1..1 M conf‑8825
treetree cda:participant
1..1 R conf‑8667
treeblank treetree @typeCode
1..1 F CST
treeblank treetree cda:participantRole
1..1 M conf‑8669
treeblank treeblank treetree @classCode
1..1 F AGNT
treeblank treeblank treetree cda:addr
AD 0..1 R conf‑8671
treeblank treeblank treetree cda:telecom
TEL 0..1 R conf‑8672
treeblank treeblank treetree cda:playingEntity
1..1 M conf‑8824
treeblank treeblank treeblank treetree cda:name
PN 1..1 M The name of the agent who can provide a copy of the Advance Directive SHALL be recorded in the name element inside the playingEntity element. conf‑8673
treetree cda:reference
1..* R conf‑8692
treeblank treetree @typeCode
1..1 F REFR
treeblank treetree cda:externalDocument
1..1 M conf‑8693
treeblank treeblank treetree cda:id
II 1..* M conf‑8695
treeblank treeblank treetree cda:text
ED 0..1 O conf‑8696
treeblank treeblank treeblank treetree @mediaType
0..1
treeblank treeblank treeblank treetree cda:reference
0..1 O The URL of a referenced advance directive document MAY be present, and SHALL be represented in Observation/reference/ExternalDocument/text/reference.
If a URL is referenced, then it SHOULD have a corresponding linkHTML element in narrative block.
conf‑8697

 Advance Directives Section (entries optional) / AdvanceDirectivesSectionentriesoptional [2.16.840.1.113883.10.20.22.2.21] - 2012‑01‑12

Template Advance Directives Section (entries optional) / AdvanceDirectivesSectionentriesoptional
Id 2.16.840.1.113883.10.20.22.2.21
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.21
Label conf‑699
Version valid from 2012‑01‑12 status draft
Description This section contains data defining the patient’s advance directives and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. This section contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status. If referenced documents are available, they can be included in the CCD exchange package.

NOTE: The descriptions in this section differentiate between “advance directives” and “advance directive documents”. The former are the directions whereas the latter are legal documents containing those directions. Thus, an advance directive might be “no cardiopulmonary resuscitation”, and this directive might be stated in a legal advance directive document.
Item DT Card Conf Desc Label
cda:section
conf-699
treetree cda:templateId
II 1..1 M conf‑7928
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.21
treetree cda:code
CD 1..1 M conf‑7929
treeblank treetree @code
1..1 F 42348-3
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Advance Directives
treetree cda:title
ST 1..1 M conf‑7930
treetree cda:text
ED 1..1 M conf‑7931
treetree cda:entry
0..* O conf‑7957
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.48 with overridden cardinality 0 .. *

 Advance Directives Section (entries required) / AdvanceDirectivesSectionentriesrequired [2.16.840.1.113883.10.20.22.2.21.1] - 2012‑01‑12

Template Advance Directives Section (entries required) / AdvanceDirectivesSectionentriesrequired
Id 2.16.840.1.113883.10.20.22.2.21.1
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.21.1
Label conf‑778
Version valid from 2012‑01‑12 status draft
Description This section contains data defining the patient’s advance directives and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. This section contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status. If referenced documents are available, they can be included in the CCD exchange package.

NOTE: The descriptions in this section differentiate between “advance directives” and “advance directive documents”. The former are the directions whereas the latter are legal documents containing those directions. Thus, an advance directive might be “no cardiopulmonary resuscitation”, and this directive might be stated in a legal advance directive document.
Item DT Card Conf Desc Label
cda:section
conf-778
treetree cda:templateId
II 1..1 M conf‑8643
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.21.1
treetree cda:code
CD 1..1 M conf‑8644
treeblank treetree @code
1..1 F 42348-3
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Advance Directives
treetree cda:title
ST 1..1 M conf‑8645
treetree cda:text
ED 1..1 M conf‑8646
treetree cda:entry
1..* M conf‑8647
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.48 with overridden cardinality 1 .. * mandatory

 Allergies Section (entries optional) / AllergiesSectionentriesoptional [2.16.840.1.113883.10.20.22.2.6] - 2012‑01‑12

Template Allergies Section (entries optional) / AllergiesSectionentriesoptional
Id 2.16.840.1.113883.10.20.22.2.6
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.6
Label conf‑671
Version valid from 2012‑01‑12 status draft
Description This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives) used to assure the safety of health care delivery. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-671
treetree cda:templateId
II 1..1 M conf‑7800
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.6
treetree cda:code
CD 1..1 M conf‑7801
treeblank treetree @code
1..1 F 48765-2
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Allergies, adverse reactions, alerts
treetree cda:title
ST 1..1 M conf‑7802
treetree cda:text
ED 1..1 M conf‑7803
treetree cda:entry
0..* R conf‑7804
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.30 with overridden cardinality 0 .. * required

 Allergies Section (entries required) / AllergiesSectionentriesrequired [2.16.840.1.113883.10.20.22.2.6.1] - 2012‑01‑12

Template Allergies Section (entries required) / AllergiesSectionentriesrequired
Id 2.16.840.1.113883.10.20.22.2.6.1
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.6.1
Label conf‑608
Version valid from 2012‑01‑12 status draft
Description This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives) used to assure the safety of health care delivery. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
Item DT Card Conf Desc Label
cda:section
conf-608
treetree cda:templateId
II 1..1 M conf‑7527
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.6.1
treetree cda:code
CD 1..1 M conf‑7528
treeblank treetree @code
1..1 F 48765-2
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Allergies, adverse reactions, alerts
treetree cda:title
ST 1..1 M conf‑7534
treetree cda:text
ED 1..1 M conf‑7530
treetree cda:entry
1..* M conf‑7531
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.30 with overridden cardinality 1 .. * mandatory

 Allergy Observation / AllergyObservation [2.16.840.1.113883.10.20.22.4.7] - 2012‑01‑12

Template Allergy Observation / AllergyObservation
Id 2.16.840.1.113883.10.20.22.4.7
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.7
Label conf‑629
Version valid from 2012‑01‑12 status draft
Description This clinical statement represents that an allergy or adverse reaction exists or does not exist. The agent that is the cause of the allergy or adverse reaction is represented as a manufactured material participant playing entity in the allergy observation. While the agent is often implicit in the alert observation (e.g. "allergy to penicillin"), it should also be asserted explicitly as an entity. The manufactured material participant is used to represent natural and non-natural occuring substances.

NOTE: The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.4.30 AllergyProblemAct  Allergy Problem Act 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.6 AllergiesSectionentriesoptional  Allergies Section (entries optional) 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.6.1 AllergiesSectionentriesrequired  Allergies Section (entries required) 2012‑01‑12
Item DT Card Conf Desc Label
cda:observation
conf-629
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑7381
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.7
treetree cda:id
II 1..* M conf‑7382
treetree cda:code
CD 1..1 M conf‑7383
treeblank treetree @code
1..1 F ASSERTION
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.4
treeblank treetree @displayName
1..1 F Assertion
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:statusCode
CS 1..1 M conf‑7386
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:effectiveTime
IVL_TS 1..1 M If it is unknown when the allergy began, this effectiveTime SHALL contain low/@nullFLavor="UNK"
If the allergy is no longer a concern, this effectiveTime MAY contain zero or one [0..1] high
conf‑7387
treetree cda:value
CD 1..1 M conf‑7390
treeblank treetree @code
1..1
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.6.2 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.3221.6.2"
treeblank treetree cda:originalText
ED 0..1 R conf‑7422
treeblank treeblank treetree cda:reference/@value
0..1 R conf‑7400
Schematron assert Role red error
Test starts-with(@value,'#')
Message
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)
treetree cda:participant
0..1 R conf‑7402
treeblank treetree @typeCode
1..1 F CSM
treeblank treetree cda:participantRole
1..1 M conf‑7404
treeblank treeblank treetree @classCode
1..1 F MANU
treeblank treeblank treetree cda:playingEntity
1..1 M conf‑7406
treeblank treeblank treeblank treetree @classCode
1..1 F MMAT
treeblank treeblank treeblank treetree cda:code
CE 1..1 M In an allergy to a specific medication the code SHALL be selected from the ValueSet 2.16.840.1.113883.3.88.12.80.16 Medication Brand Name DYNAMIC or the ValueSet 2.16.840.1.113883.3.88.12.80.17 Medication Clinical Drug DYNAMIC
In an allergy to a class of medications the code SHALL be selected from the ValueSet 2.16.840.1.113883.3.88.12.80.18 Medication Drug Class DYNAMIC
In an allergy to a food or other substance the code SHALL be selected from the ValueSet 2.16.840.1.113883.3.88.12.80.20 Ingredient Name DYNAMIC
conf‑7419
treeblank treeblank treeblank treeblank treetree cda:originalText
ED 0..1 R conf‑7424
treeblank treeblank treeblank treeblank treeblank treetree cda:reference
0..1 R conf‑7425
Schematron assert Role red error
Test starts-with(@value,'#')
Message
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)
treeblank treeblank treeblank treeblank treetree cda:translation
PQR 0..* O conf‑7431
treetree cda:entryRelationship
0..1 O conf‑7440
treeblank treetree @typeCode
1..1 F SUBJ
treeblank treetree @inversionInd
1..1
treeblank treetree @value
1..1 F true
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.28 with overridden cardinality 0 .. 1
treetree cda:entryRelationship
0..* R conf‑7447
treeblank treetree @typeCode
1..1 F MFST
treeblank treetree @inversionInd
1..1
treeblank treetree @value
1..1 F true
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.9 with overridden cardinality 0 .. * required
treetree cda:entryRelationship
0..1 O conf‑9961
treeblank treetree @typeCode
1..1 F SUBJ
treeblank treetree @inversionInd
1..1
treeblank treetree @value
1..1 F true
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.8 with overridden cardinality 0 .. 1

 Allergy Problem Act / AllergyProblemAct [2.16.840.1.113883.10.20.22.4.30] - 2012‑01‑12

Template Allergy Problem Act / AllergyProblemAct
Id 2.16.840.1.113883.10.20.22.4.30
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.30
Label conf‑634
Version valid from 2012‑01‑12 status draft
Description This clinical statement act represents a concern relating to a patient's allergies or adverse events. A concern is a term used when referring to patient's problems that are related to one another. Observations of problems or other clinical statements captured at a point in time are wrapped in a Allergy Problem Act, or "Concern" act, which represents the ongoing process tracked over time. This outer Allergy Problem Act (representing the "Concern") can contain nested problem observations or other nested clinical statements relevant to the allergy concern.
Used in 2 templates:

Id Name as of
2.16.840.1.113883.10.20.22.2.6 AllergiesSectionentriesoptional  Allergies Section (entries optional) 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
2.16.840.1.113883.10.20.22.2.6.1 AllergiesSectionentriesrequired  Allergies Section (entries required) 2012‑01‑12
Item DT Card Conf Desc Label
cda:act
conf-634
treetree @classCode
1..1 F ACT
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑7471
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.30
treetree cda:id
II 1..* M conf‑7472
treetree cda:code
CE 1..1 M conf‑7477
treeblank treetree @code
1..1 F 48765-2
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Allergies, adverse reactions, alerts
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:statusCode
CS 1..1 M conf‑7485
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.68 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.80.68"
treetree cda:effectiveTime
IVL_TS 1..1 M conf‑7498
Schematron assert Role red error
Test ((../cda:statusCode[@code='55561003']) and (cda:low)) or not(../cda:statusCode[@code='73425007' or @code='413322009'])
Message
If statusCode = "55561003" Active, then effectiveTime SHALL contain [1..1] low
Schematron assert Role red error
Test ((../cda:statusCode[@code='413322009']) and (cda:high)) or not(../cda:statusCode[@code='413322009'])
Message
If statusCode="413322009" Resolved, then effectiveTime SHALL contain [1..1] high
treetree cda:entryRelationship
1..* M conf‑7509
treeblank treetree @typeCode
1..1 F SUBJ
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.7 with overridden cardinality 1 .. * mandatory

 Allergy Status Observation / AllergyStatusObservation [2.16.840.1.113883.10.20.22.4.28] - 2012‑01‑12

Template Allergy Status Observation / AllergyStatusObservation
Id 2.16.840.1.113883.10.20.22.4.28
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.28
Label conf‑622
Version valid from 2012‑01‑12 status draft
Description This template represents the status of the allergy indicating whether it is active, no longer active, or is an historic allergy. There can be only one allergy status observation per alert observation.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.4.7 AllergyObservation  Allergy Observation 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.4.30 AllergyProblemAct  Allergy Problem Act 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.6 AllergiesSectionentriesoptional  Allergies Section (entries optional) 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.6.1 AllergiesSectionentriesrequired  Allergies Section (entries required) 2012‑01‑12
Item DT Card Conf Desc Label
cda:observation
conf-622
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑7317
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.28
treetree cda:code
CE 1..1 M conf‑7320
treeblank treetree @code
1..1 F 33999-4
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Status
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:statusCode
CS 1..1 M conf‑7321
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:value
CE 1..1 M conf‑7322
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.68 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.80.68"

 Anesthesia Section / AnesthesiaSection [2.16.840.1.113883.10.20.22.2.25] - 2012‑01‑12

Template Anesthesia Section / AnesthesiaSection
Id 2.16.840.1.113883.10.20.22.2.25
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.25
Label conf‑718
Version valid from 2012‑01‑12 status draft
Description The Anesthesia section briefly records the type of anesthesia (e.g., general or local) and may state the actual agent used. This may or may not be a subsection of the Procedure Description section. The full details of anesthesia are usually found in a separate Anesthesia Note.
Item DT Card Conf Desc Label
cda:section
conf-718
treetree cda:templateId
II 1..1 M conf‑8066
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.25
treetree cda:code
CD 1..1 M conf‑8067
treeblank treetree @code
1..1 F 59774-0
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Anesthesia
treetree cda:title
ST 1..1 M conf‑8068
treetree cda:text
ED 1..1 M conf‑8069
treetree cda:entry
0..* O conf‑8092
Contains an element with template id 2.16.840.1.113883.10.20.22.4.14 with overridden cardinality 0 .. *
treetree cda:entry
0..* O conf‑8094
Contains an element with template id 2.16.840.1.113883.10.20.22.4.16 with overridden cardinality 0 .. *

 Assessment Section / AssessmentSection [2.16.840.1.113883.10.20.22.2.8] - 2012‑01‑12

Template Assessment Section / AssessmentSection
Id 2.16.840.1.113883.10.20.22.2.8
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.8
Label conf‑658
Version valid from 2012‑01‑12 status draft
Description The Assessment section (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block.
Used in 2 templates:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-658
treetree cda:templateId
II 1..1 M conf‑7711
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.8
treetree cda:code
CD 1..1 M conf‑7712
treeblank treetree @code
1..1 F 51848-0
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Assessments
treetree cda:text
ED 1..1 M conf‑7713

 Assessment and Plan Section / AssessmentandPlanSection [2.16.840.1.113883.10.20.22.2.9] - 2012‑01‑12

Template Assessment and Plan Section / AssessmentandPlanSection
Id 2.16.840.1.113883.10.20.22.2.9
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.9
Label conf‑663
Version valid from 2012‑01‑12 status draft
Description The Assessment and Plan sections may be combined or separated to meet local policy requirements.

The Assessment and Plan section represents both the clinician’s conclusions and working assumptions that will guide treatment of the patient (see Assessment Section above) and pending orders, interventions, encounters, services, and procedures for the patient (see Plan of Care Section below).
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-663
treetree cda:templateId
II 1..1 M conf‑7705
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.9
treetree cda:code
CD 1..1 M conf‑7706
treeblank treetree @code
1..1 F 51847-2
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Assessment and Plan
treetree cda:text
ED 1..1 M conf‑7707
treetree cda:entry
0..* O conf‑7708
Contains an element with template id 2.16.840.1.113883.10.20.22.4.39 with overridden cardinality 0 .. *

 Authorization Activity / AuthorizationActivity [2.16.840.1.113883.10.20.1.19] - 2012‑01‑12

Template Authorization Activity / AuthorizationActivity
Id 2.16.840.1.113883.10.20.1.19
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.1.19
Label conf‑790
Version valid from 2012‑01‑12 status draft
Description An Authorization Activity represents authorizations or pre-authorizations currently active for the patient for the particular payer.

Authorizations are represented using an act subordinate to the policy or program that provided it. The authorization refers to the policy or program. Authorized treatments can be grouped into an organizer class, where common properties, such as the reason for the authorization, can be expressed. Subordinate acts represent what was authorized.
Item DT Card Conf Desc Label
cda:act
conf-790
treetree @classCode
1..1 F ACT
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑8946
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.1.19
treetree cda:id
II 1..1 M conf‑8947
treetree cda:entryRelationship
1..* M The target of an authorization activity with act/entryRelationship/@typeCode="SUBJ" SHALL be a clinical statement with moodCode="PRMS" Promise
The target of an authorization activity MAY contain one or more performer, to indicate the providers that have been authorized to provide treatment
conf‑8948
treeblank treetree @typeCode
1..1 F SUBJ

 Boundary Observation / BoundaryObservation [2.16.840.1.113883.10.20.6.2.11] - 2012‑01‑12

Template Boundary Observation / BoundaryObservation
Id 2.16.840.1.113883.10.20.6.2.11
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.6.2.11
Label conf‑806
Version valid from 2012‑01‑12 status draft
Description A Boundary Observation contains a list of integer values for the referenced frames of a DICOM multiframe image SOP instance. It identifies the frame numbers within the referenced SOP instance to which the reference applies. The CDA Boundary Observation numbers frames using the same convention as DICOM, with the first frame in the referenced object being Frame 1. A Boundary Observation must be used if a referenced DICOM SOP instance is a multiframe image and the reference does not apply to all frames.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.6.2.10 ReferencedFramesObservation  Referenced Frames Observation 2012‑01‑12
Item DT Card Conf Desc Label
cda:observation
conf-806
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:code
CE 1..1 M conf‑9284
treeblank treetree @code
1..1 F 113036
treeblank treetree @codeSystem
1..1 F 1.2.840.10008.2.16.4
treeblank treetree @displayName
1..1 F Frames for Display
treetree cda:value
1..* M conf‑9285
treeblank treetree @xsi:type
1..1
treeblank treetree @value
1..1 F INT

 Chief Complaint Section / ChiefComplaintSection [1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1] - 2012‑01‑12

Template Chief Complaint Section / ChiefComplaintSection
Id 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Classification cdasectionlevel
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Label conf‑681
Version valid from 2012‑01‑12 status draft
Description This section records the patient's chief complaint (the patient’s own description).
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-681
treetree cda:templateId
II 1..1 M conf‑7832
treeblank treetree @root
1..1 F 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
treetree cda:code
CE 1..1 M conf‑7833
treeblank treetree @code
1..1 F 10154-3
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Chief Complaint
treetree cda:title
ST 1..1 M conf‑7834
treetree cda:text
ED 1..1 M conf‑7835

 Chief Complaint and Reason for Visit Section / ChiefComplaintandReasonforVisitSection [2.16.840.1.113883.10.20.22.2.13] - 2012‑01‑12

Template Chief Complaint and Reason for Visit Section / ChiefComplaintandReasonforVisitSection
Id 2.16.840.1.113883.10.20.22.2.13
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.13
Label conf‑684
Version valid from 2012‑01‑12 status draft
Description This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-684
treetree cda:templateId
II 1..1 M conf‑7840
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.13
treetree cda:code
CD 1..1 M conf‑7841
treeblank treetree @code
1..1 F 46239-0
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Chief Complaint and Reason for Visit
treetree cda:title
ST 1..1 M conf‑7842
treetree cda:text
ED 1..1 M conf‑7843

 Code Observations / CodeObservations [2.16.840.1.113883.10.20.6.2.13] - 2012‑01‑12

Template Code Observations / CodeObservations
Id 2.16.840.1.113883.10.20.6.2.13
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.6.2.13
Label conf‑808
Version valid from 2012‑01‑12 status draft
Description DICOM Template 2000 specifies that Imaging Report Elements of Value Type Code are contained in sections. The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations that consist of image references and measurements (linear, area, volume, and numeric). Coded DICOM Imaging Report Elements in this context are mapped to CDA-coded observations that are section components and are related to the SOP Instance Observations (templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT (Support) act relationship.
Item DT Card Conf Desc Label
cda:observation
Code Observations SHALL be rendered into section/text in separate paragraphs conf-808
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:templateId/@root
1..1 M conf‑9306
treeblank treetree @code
1..1 F 2.16.840.1.113883.10.20.6.2.13
treetree cda:code
CE 1..1 M conf‑9307
treetree cda:value
1..1 M conf‑9308
treetree cda:effectiveTime
IVL_TS 0..1 R conf‑9309
treetree cda:entryRelationship
0..* O conf‑9311
treeblank treetree @typeCode
1..1 F SPRT
Contains an element with template id 2.16.840.1.113883.10.20.6.2.8 with overridden cardinality 0 .. *
treetree cda:entryRelationship
0..* O conf‑9314
treeblank treetree @typeCode
1..1 F SPRT
Contains inherited template rules 2.16.840.1.113883.10.20.6.2.14 with overridden cardinality 0 .. *

 Comment Activity / CommentActivity [2.16.840.1.113883.10.20.22.4.64] - 2012‑01‑12

Template Comment Activity / CommentActivity
Id 2.16.840.1.113883.10.20.22.4.64
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.64
Label conf‑825
Version valid from 2012‑01‑12 status draft
Description Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. For example, a free text description of the severity of an allergic reaction would not be recorded in a comment.
Item DT Card Conf Desc Label
cda:act
Data elements defined elsewhere in the specification SHALL NOT be recorded using the Comment Activity conf-825
treetree @classCode
1..1 F ACT
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑9427
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.64
treetree cda:code
CE 1..1 M conf‑9428
treeblank treetree @code
1..1 F 48767-8
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Annotation Comment
treetree cda:text
ED 1..1 M conf‑9430
treeblank treetree cda:reference/@value
1..1 M conf‑9431
Schematron assert Role red error
Test starts-with(@value,'#')
Message
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)
treetree cda:author
0..1 O conf‑9433
treeblank treetree cda:time
IVL_TS 1..1 M conf‑9434
treeblank treetree cda:assignedAuthor
1..1 M conf‑9435
treeblank treeblank treetree cda:id
II 1..1 M conf‑9436
treeblank treeblank treetree cda:addr
AD 1..1 M conf‑9437
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 cda:assignedPerson/cda:name or cda:representedOrganization/cda:name
Message
SHALL include assignedPerson/name or representedOrganization/name
Schematron assert Role red error
Test cda:assignedPerson/cda:name[cda:given and cda:family] or (count(cda:assignedPerson/cda:name[*])=0 and string-length(cda:assignedPerson/cda:name)!=0)
Message
An assignedPerson/name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1)

 Complications Section / ComplicationsSection [2.16.840.1.113883.10.20.22.2.37] - 2012‑01‑12

Template Complications Section / ComplicationsSection
Id 2.16.840.1.113883.10.20.22.2.37
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.37
Label conf‑729
Version valid from 2012‑01‑12 status draft
Description The Complications section records problems that occurred during the procedure or other activity. The complications may have been known risks or unanticipated problems.
Item DT Card Conf Desc Label
cda:section
There SHALL be a statement providing details of the complication(s) or it SHALL explicitly state there were no complications. conf-729
treetree cda:templateId
II 1..1 M conf‑8174
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.37
treetree cda:code
CD 1..1 M conf‑8175
treeblank treetree @code
1..1 F 55109-3
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Complications
treetree cda:title
ST 1..1 M conf‑8176
treetree cda:text
ED 1..1 M conf‑8177
treetree cda:entry
0..* O conf‑8795
Contains an element with template id 2.16.840.1.113883.10.20.22.4.4 with overridden cardinality 0 .. *

 Coverage Activity / CoverageActivity [2.16.840.1.113883.10.20.22.4.60] - 2012‑01‑12

Template Coverage Activity / CoverageActivity
Id 2.16.840.1.113883.10.20.22.4.60
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.60
Label conf‑788
Version valid from 2012‑01‑12 status draft
Description A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources. A Coverage Activity contains one or more policy activities, each of which contains zero or more authorization activities. The Coverage Activity id is the Id from the patient's insurance card. The sequenceNumber/@value shows the policy order of preference.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.2.18 PayersSection  Payers Section 2012‑01‑12
Item DT Card Conf Desc Label
cda:act
conf-788
treetree @classCode
1..1 F ACT
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑8897
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.60
treetree cda:id
II 1..* M conf‑8874
treetree cda:statusCode
CS 1..1 M conf‑8875
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treetree cda:code
CE 1..1 M conf‑8876
treeblank treetree @code
1..1 F 48768-6
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Payment Sources
treetree cda:entryRelationship
1..* M conf‑8878
treeblank treetree @typeCode
1..1 F COMP
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.61 with overridden cardinality 1 .. * mandatory
treeblank treetree cda:sequenceNumber/@value
0..1 O conf‑8973

 DICOM Object Catalog Section - DCM 121181 / DICOMObjectCatalogSection-DCM121181 [2.16.840.1.113883.10.20.6.1.1] - 2012‑01‑12

Template DICOM Object Catalog Section - DCM 121181 / DICOMObjectCatalogSection-DCM121181
Id 2.16.840.1.113883.10.20.6.1.1
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.6.1.1
Label conf‑751
Version valid from 2012‑01‑12 status draft
Description DICOM Object Catalog lists all referenced objects and their parent Series and Studies, plus other DICOM attributes required for retrieving the objects.

DICOM Object Catalog sections are not intended for viewing and contain empty section text.
Item DT Card Conf Desc Label
cda:section
A DICOM Object Catalog SHALL be present if the document contains references to DICOM Images. If present, it SHALL be the first section in the document. conf-751
treetree cda:templateId
II 1..1 M conf‑8525
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.6.1.1
treetree cda:code
CE 1..1 M conf‑8526
treeblank treetree @code
1..1 F 121181
treeblank treetree @codeSystem
1..1 F 1.2.840.10008.2.16.4
treeblank treetree @displayName
1..1 F Dicom Object Catalog
treetree cda:entry
1..* M conf‑8530
Contains inherited template rules 2.16.840.1.113883.10.20.6.2.6 with overridden cardinality 1 .. * mandatory

 Discharge Diet Section / DischargeDietSection [1.3.6.1.4.1.19376.1.5.3.1.3.33] - 2012‑01‑12

Template Discharge Diet Section / DischargeDietSection
Id 1.3.6.1.4.1.19376.1.5.3.1.3.33
Classification cdasectionlevel
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.3.33
Label conf‑705
Version valid from 2012‑01‑12 status draft
Description This section records a narrative description of the expectations for diet and nutrition, including nutrition prescription, proposals, goals, and order requests for monitoring, tracking, or improving the nutritional status of the patient, used in a discharge from a facility such as an emergency department, hospital, or nursing home.
Item DT Card Conf Desc Label
cda:section
conf-705
treetree cda:templateId
II 1..1 M conf‑7975
treeblank treetree @root
1..1 F 1.3.6.1.4.1.19376.1.5.3.1.3.33
treetree cda:code
CE 1..1 M conf‑7976
treeblank treetree @code
1..1 F 42344-2
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Discharge Diet
treetree cda:title
ST 1..1 M conf‑7977
treetree cda:text
ED 1..1 M conf‑7978

 Discharge Medication / DischargeMedication [2.16.840.1.113883.10.20.22.4.35] - 2012‑01‑12

Template Discharge Medication / DischargeMedication
Id 2.16.840.1.113883.10.20.22.4.35
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.35
Label conf‑655
Version valid from 2012‑01‑12 status draft
Description The Discharge Medications entry codes medications that the patient is intended to take (or stop) after discharge.
Used in 2 templates:

Id Name as of
2.16.840.1.113883.10.20.22.2.11 HospitalDischargeMedicationsSectionentriesoptional  Hospital Discharge Medications Section (entries optional) 2012‑01‑12
2.16.840.1.113883.10.20.22.2.11.1 HospitalDischargeMedicationsSectionentriesrequired  Hospital Discharge Medications Section (entries required) 2012‑01‑12
Item DT Card Conf Desc Label
cda:act
conf-655
treetree @classCode
1..1 F ACT
treetree @moodCode
1..1 F EVN
treetree cda:code
CE 1..1 M conf‑7691
treeblank treetree @code
1..1 F 10183-2
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Discharge medication
treetree cda:entryRelationship
1..1 M conf‑7692
treeblank treetree @typeCode
1..1 F SUBJ
Contains an element with template id 2.16.840.1.113883.10.20.22.4.16 with overridden cardinality 1 .. 1 mandatory

 Drug Vehicle / DrugVehicle [2.16.840.1.113883.10.20.22.4.24] - 2012‑01‑12

Template Drug Vehicle / DrugVehicle
Id 2.16.840.1.113883.10.20.22.4.24
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.24
Label conf‑636
Version valid from 2012‑01‑12 status draft
Description This template represents the vehicle (e.g. saline, dextrose) for administering a medication.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.4.52 ImmunizationActivity  Immunization Activity 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.2 ImmunizationsSectionentriesoptional  Immunizations Section (entries optional) 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.2.1 ImmunizationsSectionentriesrequired  Immunizations Section (entries required) 2012‑01‑12
Item DT Card Conf Desc Label
cda:participantRole
conf-636
treetree @classCode
1..1 F MANU
treetree cda:templateId
II 1..1 M conf‑7495
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.24
treetree cda:code
CE 1..1 M conf‑7491
treeblank treetree @code
1..1 F 412307009
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.96
treeblank treetree @displayName
1..1 F Drug Vehicle
treetree cda:playingEntity
1..1 M conf‑7492
treeblank treetree cda:code
CE 1..1 M This playingEntity/code is used to supply a coded term for the drug vehicle conf‑7493
treeblank treetree cda:name
PN 0..1 O This playingEntity/name MAY be used for the vehicle name in text, such as Normal Saline conf‑7494

 Encounter Activities / EncounterActivities [2.16.840.1.113883.10.20.22.4.49] - 2012‑01‑12

Template Encounter Activities / EncounterActivities
Id 2.16.840.1.113883.10.20.22.4.49
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.49
Label conf‑783
Version valid from 2012‑01‑12 status draft
Description This clinical statement describes the interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.
Used in 2 templates:

Id Name as of
2.16.840.1.113883.10.20.22.2.22 EncountersSectionentriesoptional  Encounters Section (entries optional) 2012‑01‑12
2.16.840.1.113883.10.20.22.2.22.1 EncountersSectionentriesrequired  Encounters Section (entries required) 2012‑01‑12
Item DT Card Conf Desc Label
cda:encounter
MAY have a sdtc:dischargeDispositionCode which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status DYNAMIC or, if access to NUBC is unavailable, from CodeSystem 2.16.840.1.113883.12.112 HL7 Discharge Disposition. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element conf-783
treetree @classCode
1..1 F ENC
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑8712
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.49
treetree cda:id
II 1..* M conf‑8713
treetree cda:code
CE 0..1 R conf‑8714
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.32 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.80.32"
treeblank treetree cda:originalText
ED 0..1 R conf‑8719
treeblank treeblank treetree cda:reference/@value
0..1 R conf‑8720
Schematron assert Role red error
Test starts-with(@value,'#')
Message
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)
treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8715
treetree cda:performer
0..* O conf‑8725
treeblank treetree cda:assignedEntity
1..1 M conf‑8726
treeblank treeblank treetree cda:code
CE 0..1 O conf‑8727
treetree cda:participant
0..* O conf‑8738
treeblank treetree @typeCode
1..1 F LOC
Contains an element with template id 2.16.840.1.113883.10.20.22.4.32 with overridden cardinality 0 .. *
treetree cda:entryRelationship
0..* O conf‑8722
treeblank treetree @typeCode
1..1 F RSON
Contains an element with template id 2.16.840.1.113883.10.20.22.4.19 with overridden cardinality 0 .. *

 Encounters Section (entries optional) / EncountersSectionentriesoptional [2.16.840.1.113883.10.20.22.2.22] - 2012‑01‑12

Template Encounters Section (entries optional) / EncountersSectionentriesoptional
Id 2.16.840.1.113883.10.20.22.2.22
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.22
Label conf‑702
Version valid from 2012‑01‑12 status draft
Description This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An Encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment. This section may contain all encounters for the time period being summarized, but should include notable encounters.
Item DT Card Conf Desc Label
cda:section
conf-702
treetree cda:templateId
II 1..1 M conf‑7940
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.22
treetree cda:code
CD 1..1 M conf‑7941
treeblank treetree @code
1..1 F 46240-8
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Encounters
treetree cda:title
ST 1..1 M conf‑7942
treetree cda:text
ED 1..1 M conf‑7943
treetree cda:entry
0..* R conf‑7951
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.49 with overridden cardinality 0 .. * required

 Encounters Section (entries required) / EncountersSectionentriesrequired [2.16.840.1.113883.10.20.22.2.22.1] - 2012‑01‑12

Template Encounters Section (entries required) / EncountersSectionentriesrequired
Id 2.16.840.1.113883.10.20.22.2.22.1
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.22.1
Label conf‑782
Version valid from 2012‑01‑12 status draft
Description This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An Encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment. This section may contain all encounters for the time period being summarized, but should include notable encounters.
Item DT Card Conf Desc Label
cda:section
conf-782
treetree cda:templateId
II 1..1 M conf‑8705
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.22.1
treetree cda:code
CD 1..1 M conf‑8706
treeblank treetree @code
1..1 F 46240-8
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Encounters
treetree cda:title
ST 1..1 M conf‑8707
treetree cda:text
ED 1..1 M conf‑8708
treetree cda:entry
1..* M conf‑8709
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.49 with overridden cardinality 1 .. * mandatory

 Estimated Date of Delivery / EstimatedDateofDelivery [2.16.840.1.113883.10.20.15.3.1] - 2012‑01‑12

Template Estimated Date of Delivery / EstimatedDateofDelivery
Id 2.16.840.1.113883.10.20.15.3.1
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.15.3.1
Label conf‑180
Version valid from 2012‑01‑12 status draft
Description This clinical statement represents the anticipated date when a woman will give birth.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.15.3.8 PregnancyObservation  Pregnancy Observation 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.17 SocialHistorySection  Social History Section 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:observation
conf-180
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:code
CE 1..1 M conf‑446
treeblank treetree @code
1..1 F 11778-8
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Estimated date of delivery
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:statusCode
CS 1..1 M conf‑448
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:value
TS 1..1 M conf‑450

 Family History Observation / FamilyHistoryObservation [2.16.840.1.113883.10.20.22.4.46] - 2012‑01‑12

Template Family History Observation / FamilyHistoryObservation
Id 2.16.840.1.113883.10.20.22.4.46
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.46
Label conf‑771
Version valid from 2012‑01‑12 status draft
Description Family History Observations related to a particular family member are contained within a Family History Organizer. The effectiveTime in the Family History Observation is the biologically or clinically relevant time of the observation. The biologically or clinically relevant time is the time at which the observation holds (is effective) for the family member (the subject of the observation).
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.4.45 FamilyHistoryOrganizer  Family History Organizer 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.2.15 FamilyHistorySection  Family History Section 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:observation
conf-771
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑8599
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.46
treetree cda:id
II 1..* M conf‑8592
treetree cda:code
CE 1..1 M conf‑8589
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 flexibility 2008-12-18T00:00:00
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.3221.7.2"
treetree cda:statusCode
CS 1..1 M conf‑8590
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treetree cda:effectiveTime
IVL_TS 0..1 R conf‑8593
treetree cda:value
CD 1..1 M conf‑8591
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.4 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.3221.7.4"
treetree cda:entryRelationship
0..1 O conf‑8675
treeblank treetree @typeCode
1..1 F SUBJ
treeblank treetree @inversionInd
1..1
treeblank treetree @value
1..1 F true
Contains an element with template id 2.16.840.1.113883.10.20.22.4.31 with overridden cardinality 0 .. 1
treetree cda:entryRelationship
0..1 O conf‑8678
treeblank treetree @typeCode
1..1 F CAUS
Contains an element with template id 2.16.840.1.113883.10.20.22.4.47 with overridden cardinality 0 .. 1

 Family History Organizer / FamilyHistoryOrganizer [2.16.840.1.113883.10.20.22.4.45] - 2012‑01‑12

Template Family History Organizer / FamilyHistoryOrganizer
Id 2.16.840.1.113883.10.20.22.4.45
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.45
Label conf‑772
Version valid from 2012‑01‑12 status draft
Description The Family History Oranizer associates a set of observations with a family member. For example, the Family History Organizer can group a set of observations about the patient’s father.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.2.15 FamilyHistorySection  Family History Section 2012‑01‑12
link11 Dependency: 2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:organizer
conf-772
treetree @classCode
1..1 F CLUSTER
treetree @moodCode
1..1 F EVN
treetree cda:templateId
II 1..1 M conf‑8604
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.4.45
treetree cda:statusCode
CS 1..1 M conf‑8602
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treetree cda:subject
1..1 M conf‑8609
treeblank treetree cda:relatedSubject/@classCode
1..1 M conf‑8610
treeblank treeblank treetree @code
1..1 F PRS
treeblank treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.41
treeblank treeblank treetree @displayName
1..1 F Person
treeblank treeblank treetree cda:code
CE 1..1 M conf‑8611
Schematron assert Role red error
Test true()
Message
1. The value for "RelatedSubject/code" SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.19579 FamilyHistoryRelatedSubjectCode DYNAMIC
treeblank treeblank treetree cda:subject
0..1 R The age of a relative at the time of a family history observation SHOULD be inferred by comparing RelatedSubject/subject/birthTime with Observation/effectiveTime
The age of a relative at the time of death MAY be inferred by comparing RelatedSubject/subject/birthTime with RelatedSubject/subject/sdwg:deceasedTime.
conf‑8613
Schematron assert Role red error
Test sdtc:id or not(cda:id)
Message
The subject SHOULD contain zero or more [0..*] sdtc:id. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the id element
treeblank treeblank treeblank treetree cda:administrativeGenderCode
CE 1..1 M conf‑8614
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 0..1 R conf‑8615
Schematron assert Role red error
Test sdtc:deceasedInd
Message
The subject MAY contain zero or one sdtc:deceasedInd. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedInd element
Schematron assert Role red error
Test sdtc:deceasedTime
Message
The subject MAY contain zero or one sdtc:deceasedTime. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedTime element
treetree cda:component
1..* M conf‑8607
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.46 with overridden cardinality 1 .. * mandatory

 Family History Section / FamilyHistorySection [2.16.840.1.113883.10.20.22.2.15] - 2012‑01‑12

Template Family History Section / FamilyHistorySection
Id 2.16.840.1.113883.10.20.22.2.15
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.15
Label conf‑700
Version valid from 2012‑01‑12 status draft
Description This section contains data defining the patient’s genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient’s healthcare risk profile.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-700
treetree cda:templateId
II 1..1 M conf‑7932
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.15
treetree cda:code
CD 1..1 M conf‑7933
treeblank treetree @code
1..1 F 10157-6
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Family History
treetree cda:title
ST 1..1 M conf‑7934
treetree cda:text
ED 1..1 M conf‑7935
treetree cda:entry
0..* O conf‑7955
Contains inherited template rules 2.16.840.1.113883.10.20.22.4.45 with overridden cardinality 0 .. *

 Fetus Subject Context / FetusSubjectContext [2.16.840.1.113883.10.20.6.2.3] - 2012‑01‑12

Template Fetus Subject Context / FetusSubjectContext
Id 2.16.840.1.113883.10.20.6.2.3
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.6.2.3
Label conf‑799
Version valid from 2012‑01‑12 status draft
Description For reports on mothers and their fetus(es), information on a mother is mapped to recordTarget, PatientRole, and Patient. Information on the fetus is mapped to subject, relatedSubject, and SubjectPerson at the CDA section level. Both context information on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.
Item DT Card Conf Desc Label
cda:section
conf-799
treetree cda:templateId
II 1..1 M conf‑9189
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.6.2.3
treetree cda:code
CD 1..1 M conf‑9190
treeblank treetree @code
1..1 F 121026
treeblank treetree @codeSystem
1..1 F 1.2.840.10008.2.16.4
treetree cda:subject
1..1 M conf‑9191
treetree cda:name
1..1 M The name element is used to store the DICOM fetus ID, typically a pseudonym such as fetus_1. conf‑9192

 Findings Section (DIR) / FindingsSectionDIR [2.16.840.1.113883.10.20.6.1.2] - 2012‑01‑12

Template Findings Section (DIR) / FindingsSectionDIR
Id 2.16.840.1.113883.10.20.6.1.2
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.6.1.2
Label conf‑753
Version valid from 2012‑01‑12 status draft
Description The Findings section contains the main narrative body of the report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.
Item DT Card Conf Desc Label
cda:section
This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section. conf-753
treetree cda:templateId
II 1..1 M conf‑8531
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.6.1.2

 Functional Status Section / FunctionalStatusSection [2.16.840.1.113883.10.20.22.2.14] - 2012‑01‑12

Template Functional Status Section / FunctionalStatusSection
Id 2.16.840.1.113883.10.20.22.2.14
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.14
Label conf‑697
Version valid from 2012‑01‑12 status draft
Description The Functional Status section describes the patient’s status of normal functioning at the time the Care Record was created. Functional statuses include information regarding the patient relative to:

• Ambulatory ability
• Mental status or competency
• Activities of Daily Living (ADLs), including bathing, dressing, feeding, grooming
• Home / living situation having an effect on the health status of the patient
• Ability to care for self
• Social activity, including issues with social cognition, participation with friends and acquaintances other than family members
• Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family
• Communication ability, including issues with speech, writing or cognition required for communication
• Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance

Any deviation from normal function that the patient displays and is recorded in the record should be included. Of particular interest are those limitations that would in any way interfere with self care or the medical therapeutic process. In addition, an improvement, any change in or noting that the patient has normal functioning status is also valid for inclusion.
Item DT Card Conf Desc Label
cda:section
conf-697
treetree cda:templateId
II 1..1 M conf‑7920
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.14
treetree cda:code
CD 1..1 M conf‑7921
treeblank treetree @code
1..1 F 47420-5
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Functional Status
treetree cda:title
ST 1..1 M conf‑7922
treetree cda:text
ED 1..1 M conf‑7923
treetree cda:entry
0..* O conf‑7961
Contains an element with template id 2.16.840.1.113883.10.20.22.4.4 with overridden cardinality 0 .. *
treetree cda:entry
0..* O conf‑9081
Contains an element with template id 2.16.840.1.113883.10.20.22.4.2 with overridden cardinality 0 .. *

 General Status Section / GeneralStatusSection [2.16.840.1.113883.10.20.2.5] - 2012‑01‑12

Template General Status Section / GeneralStatusSection
Id 2.16.840.1.113883.10.20.2.5
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.2.5
Label conf‑707
Version valid from 2012‑01‑12 status draft
Description The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-707
treetree cda:templateId
II 1..1 M conf‑7985
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.2.5
treetree cda:code
CE 1..1 M conf‑7986
treeblank treetree @code
1..1 F 10210-3
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F General Status
treetree cda:title
ST 1..1 M conf‑7987
treetree cda:text
ED 1..1 M conf‑7988

 Health Status Observation / HealthStatusObservation [2.16.840.1.113883.10.20.22.4.5] - 2012‑01‑12

Template Health Status Observation / HealthStatusObservation
Id 2.16.840.1.113883.10.20.22.4.5
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.5
Label conf‑794
Version valid from 2012‑01‑12 status draft
Description The Health Status Observation records information about the current health status of the patient.
Item DT Card Conf Desc Label
cda:observation
conf-794
treetree @classCode
1..1 F OBS
treetree @moodCode
1..1 F EVN
treetree cda:code
CE 1..1 M conf‑9073
treeblank treetree @code
1..1 F 11323-3
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Health status
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:text
ED 0..1 R conf‑9270
treeblank treetree cda:reference/@value
0..1 R conf‑9271
Schematron assert Role red error
Test starts-with(@value,'#')
Message
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)
treetree cda:statusCode
CS 1..1 M conf‑9074
treeblank treetree @code
1..1 F completed
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.14
treeblank treetree @displayName
1..1 F Completed
treeblank treetree @flexibility
1..1 F dynamic
treetree cda:value
CD 1..1 M conf‑9075
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.68 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.80.68"

 History of Past Illness Section / HistoryofPastIllnessSection [2.16.840.1.113883.10.20.22.2.20] - 2012‑01‑12

Template History of Past Illness Section / HistoryofPastIllnessSection
Id 2.16.840.1.113883.10.20.22.2.20
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.20
Label conf‑680
Version valid from 2012‑01‑12 status draft
Description This section describes the history related to the patient’s current complaints, problems, or diagnoses. It records the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-680
treetree cda:templateId
II 1..1 M conf‑7828
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.2.20
treetree cda:code
CD 1..1 M conf‑7829
treeblank treetree @code
1..1 F 11348-0
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F History of Past Illness
treetree cda:title
ST 1..1 M conf‑7830
treetree cda:text
ED 1..1 M conf‑7831
treetree cda:entry
0..* O conf‑8791
Contains an element with template id 2.16.840.1.113883.10.20.22.4.4 with overridden cardinality 0 .. *

 History of Present Illness Section / HistoryofPresentIllnessSection [1.3.6.1.4.1.19376.1.5.3.1.3.4] - 2012‑01‑12

Template History of Present Illness Section / HistoryofPresentIllnessSection
Id 1.3.6.1.4.1.19376.1.5.3.1.3.4
Classification cdasectionlevel
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.3.4
Label conf‑686
Version valid from 2012‑01‑12 status draft
Description The History of Present Illness section describes the history related to the reason for the encounter. It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-686
treetree cda:templateId
II 1..1 M conf‑7848
treeblank treetree @root
1..1 F 1.3.6.1.4.1.19376.1.5.3.1.3.4
treetree cda:code
CD 1..1 M conf‑7849
treeblank treetree @code
1..1 F 10164-2
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F History of Present Illness
treetree cda:title
ST 1..1 M conf‑7850
treetree cda:text
ED 1..1 M conf‑7851

 Hospital Admission Diagnosis / HospitalAdmissionDiagnosis [2.16.840.1.113883.10.20.22.4.34] - 2012‑01‑12

Template Hospital Admission Diagnosis / HospitalAdmissionDiagnosis
Id 2.16.840.1.113883.10.20.22.4.34
Classification cdaentrylevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.34
Label conf‑654
Version valid from 2012‑01‑12 status draft
Description The Hospital Admission Diagnosis entry describes the relevant problems or diagnoses at the time of admission.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.2.43 HospitalAdmissionDiagnosisSection  Hospital Admission Diagnosis Section 2012‑01‑12
Item DT Card Conf Desc Label
cda:act
<