Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | C | When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALL include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32946).
| Tran ryV2 |
Included | | | from 2.16.840.1.113883.3.1937.99.3.10.1 Conditional USCDI Conformance Checks (2023‑11‑27 14:32:11) |
| Variable let | Name | uscdilabel | |
| Value | starts-with($scenariolabel, 'uscdi_') | |
| Variable let | Name | uscditemplate | |
| Value | //cda:templateId[@root='2.16.840.1.113883.3.1937.10.3.1'] | |
| Variable let | Name | uscdi | |
| Value | $uscdilabel or $uscditemplate | |
cda:templateId
| II | 0 … 1 | | templateId root without an extension to be used if instance declares conformity with USCDI | uscd ecks |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.10.3.1 |
| Example | <templateId root="2.16.840.1.113883.3.1937.10.3.1"/> |
| Schematron assert | role | warning | |
| test | not($uscdi) or //cda:author[cda:templateId[@root='2.16.840.1.113883.10.20.22.5.6']] | |
| Message | (USCDI Data Provenance and Traceability) A sending system SHALL include provenance information, when available, at the entry level for allergies, immunizations, medications and problems as specified by USCDI v1 or the most current version when a companion guide specification is published by HL7. This information SHALL include author organization and time stamp. | |
| Schematron assert | role | warning | |
| test | not($uscdi) or empty(//cda:substanceAdministration[@moodCode='EVN'][cda:templateId[@root='2.16.840.1.113883.10.20.22.4.52']]) or //cda:substanceAdministration[@moodCode='EVN'][cda:templateId[@root='2.16.840.1.113883.10.20.22.4.52']] [cda:consumable/cda:manufacturedProduct/cda:manufacturedMaterial[cda:code[@codeSystem='2.16.840.1.113883.12.292']]] | |
| Message | (USCDI Effective Use of Codes) Organizations SHALL include the relevant CVX code (OID 2.16.840.1.113883.12.292) for all immunizations administered, when a valid code exists. | |
| Schematron assert | role | warning | |
| test | not($uscdi) or empty(//cda:substanceAdministration[@moodCode='EVN'][cda:templateId[@root='2.16.840.1.113883.10.20.22.4.52']]) or //cda:substanceAdministration[@moodCode='EVN'][cda:templateId[@root='2.16.840.1.113883.10.20.22.4.52']] [cda:consumable/cda:manufacturedProduct/cda:manufacturedMaterial[cda:lotNumberText[string-length(.)>0]]] | |
| Message | (USCDI Effective Use of Codes) Organizations SHALL include the relevant CVX code (OID 2.16.840.1.113883.12.292) for all immunizations administered, when a valid code exists. | |
| Schematron assert | role | warning | |
| test | not($uscdi) or empty(//cda:substanceAdministration[@moodCode='EVN'][cda:templateId[@root='2.16.840.1.113883.10.20.22.4.16']]) or //cda:substanceAdministration[@moodCode='EVN'][cda:templateId[@root='2.16.840.1.113883.10.20.22.4.16']] [cda:entryRelationship[cda:act[cda:templateId[@root='2.16.840.1.113883.10.20.22.4.118']]]/cda:sequenceNumber] | |
| Message | (USCDI Reducing impact of Duplicates) Organizations SHALL send an appropriate sequence number for an immunization that is administered as part of a series, if known. This improves the guidance documented in the C-CDA Companion Guide and JDCWG C-CDA Whitepaper. | |
| Schematron assert | role | warning | |
| test | not($uscdi) or not(empty(//cda:section/cda:text[string-length(normalize-space(.))>0])) | |
| Message | (USCDI Effective Use of Narrative) Implementers SHALL, at minimum, include available narrative discharge summaries and ED provider notes at time of document creation. Processes that make these narrative summaries available as soon as possible are strongly encouraged. | |
| Schematron assert | role | warning | |
| test | not($uscdi) or empty(//cda:ClinicalDocument[cda:code[@code='34133-9'][@codeSystem='2.16.840.1.113883.6.1']]) or //cda:ClinicalDocument[cda:code[@code='34133-9'][@codeSystem='2.16.840.1.113883.6.1']] [//cda:section[cda:templateId[@root=('2.16.840.1.113883.10.20.22.2.5', '2.16.840.1.113883.10.20.22.2.5.1')]]] [//cda:section[cda:templateId[@root=('2.16.840.1.113883.10.20.22.2.1', '2.16.840.1.113883.10.20.22.2.1.1')]]] [//cda:section[cda:templateId[@root=('2.16.840.1.113883.10.20.22.2.6', '2.16.840.1.113883.10.20.22.2.6')]]] [//cda:section[cda:templateId[@root=('2.16.840.1.113883.10.20.22.2.2', '2.16.840.1.113883.10.20.22.2.2.1')]]] | |
| Message | (USCDI Data Integrity, Format and Trust) When generating a current Patient Summary Document for a patient as C-CDA Continuity of Care (CCD) document type with LOINC code 34133-9, responding systems SHALL at a minimum include active problems, medications, allergies, and immunizations | |
cda:templateId
| II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF 2936 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.13 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-28239) such that it | CONF 8239 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.13 | CONF 8240 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.13" (CONF:1198-28240). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2907 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32907). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code (CONF:1198-28243). This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet TransferDocumentType urn:oid:2.16.840.1.113883.1.11.20.2.4 DYNAMIC (CONF:1198-32968).The Transfer Summary recommends use of the document type code 18761-7 "Provider Unspecified Transfer Summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Transfer Summary note would not be authored by a Pediatric Cardiologist. Pre-coordinated codes are those that indicate the specialty or service provided in the LOINC Long Common Name (Print Name in the TransferDocumentType valueSet table). When using a generic type of code such as 18761-7 (Provider - Unspecified Transfer Summary), the types of services involved in the care are handled in documentationOf/serviceEvent with the use of serviceEvent/code (e.g., use a SNOMED CT procedure code such as 69031006 (Excision of breast tissue) while performers/providers involved in the care can be identified using the functionCode (bound to Healthcare Provider Taxonomy role codes). | CONF:1198‑28243 CONF:1198‑32968 |
| CONF | |
cda:title
| | 1 … 1 | | SHALL contain exactly one [1..1] title (CONF:1198-29838). | CONF 9838 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31599) such that it | CONF 1599 |
where [@typeCode='IND'] | |
@typeCode
| cs | 1 … 1 | F | IND | CONF 1872 |
| SHALL contain exactly one [1..1] @typeCode="IND" indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31872). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31600). | CONF 1600 |
@classCode
| cs | 1 … 1 | R | This associatedEntity SHALL contain exactly one [1..1] @classCode, which SHALL be selected from ValueSet INDRoleclassCodes urn:oid:2.16.840.1.113883.11.20.9.33 DYNAMIC (CONF:1198-31873). | CONF 1873 |
| CONF | |
cda:associatedPerson
| | 1 … 1 | M | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31601). | CONF 1601 |
cda:name
| | 1 … * | R | This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31602). | CONF 1602 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31626) such that it | CONF 1626 |
where [@typeCode='CALLBCK'] | |
@typeCode
| cs | 1 … 1 | F | CALLBCK | CONF 1627 |
| SHALL contain exactly one [1..1] @typeCode="CALLBCK" Call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31627). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31628). | CONF 1628 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF 1641 |
| This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110) (CONF:1198-31641). |
cda:id
| II | 1 … * | | This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31629). | CONF 1629 |
cda:addr
| AD | 0 … * | R | This associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1198-31630). | CONF 1630 |
cda:telecom
| TEL | 1 … * | | This associatedEntity SHALL contain at least one [1..*] telecom (CONF:1198-31631). | CONF 1631 |
cda:associatedPerson
| | 1 … 1 | M | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31632). | CONF 1632 |
cda:name
| | 1 … * | R | This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31633). | CONF 1633 |
cda:scopingOrganization
| | 0 … 1 | | This associatedEntity MAY contain zero or one [0..1] scopingOrganization (CONF:1198-31634). | CONF 1634 |
cda:documentationOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] documentationOf (CONF:1198-31570). | CONF 1570 |
cda:serviceEvent
| | 1 … 1 | M | This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:1198-31571).The serviceEvent in a Transfer Note contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | CONF 1571 |
@classCode
| cs | 1 … 1 | F | PCPR | CONF 1572 |
| This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-31572). |
cda:code
| | 0 … 1 | | This serviceEvent MAY contain zero or one [0..1] code (CONF:1198-32650).Use serviceEvent/code when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the service. | CONF 2650 |
cda:performer
| | 1 … * | M | This serviceEvent SHALL contain at least one [1..*] performer (CONF:1198-31574) such that it | CONF 1574 |
@typeCode
| cs | 1 … 1 | F | PRF | CONF 1575 |
| SHALL contain exactly one [1..1] @typeCode="PRF" Participation of Physical Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC) (CONF:1198-31575). |
cda:functionCode
| CE | 0 … 1 | | MAY contain zero or one [0..1] functionCode, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32651).Use performer/functionCode when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the provider. | CONF 2651 |
| CONF | |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-28251). | CONF 8251 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-28252). | CONF 8252 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.21.1 Advance Directives Section (entries required) (V3) (2015‑08‑01) | CONF 8253 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies and Intolerances Section (entries required) (V3) (2015‑08‑01) | CONF 8255 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01) | CONF 8257 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.22.1 Encounters Section (entries required) (V3) (2015‑08‑01) | CONF 8261 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF 8263 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF 8265 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.24 Discharge Diagnosis Section (V3) (2015‑08‑01) | CONF 8271 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01) | CONF 8273 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09) | CONF 8275 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09) | CONF 8277 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (V3) (2015‑08‑01) | CONF 8279 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF 8281 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (2015‑08‑01) | CONF 8283 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (V2) (2014‑06‑09) | CONF 8285 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01) | CONF 8287 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF 8289 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01) | CONF 8291 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01) | CONF 8327 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13) | CONF 8838 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13) | CONF 0239 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF 0776 |
cda:component
| | 1 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 Reason for Referral Section (V2) (2014‑06‑09) | CONF 1342 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01) | CONF 1561 |
cda:component
| | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13) | CONF 1563 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09) | CONF 1565 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13) | CONF 1567 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.44 Admission Medications Section (entries optional) (V3) (2015‑08‑01) | CONF 2445 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.43 Admission Diagnosis Section (V3) (2015‑08‑01) | CONF 2447 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.64 Course of Care Section (2015‑08‑13) | CONF 2648 |
| Schematron assert | role | error | |
| test | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'] or ( //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] and //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'] ) | |
| Message | This structuredBody *SHALL* contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09). | |
| Schematron assert | role | error | |
| test | not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or ( not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) ) | |
| Message | This structuredBody *SHALL NOT* contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. | |