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:1198-32943).
| Refe teV2 |
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 | 2.16.840.1.113883.10.20.22.1.14 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-28947) such that it | CONF 8947 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.14 | CONF 8948 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.14" (CONF:1198-28948). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2911 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32911). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code (CONF:1198-28949). This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ReferralDocumentType urn:oid:2.16.840.1.113883.1.11.20.2.3 DYNAMIC (CONF:1198-32967). The Referral Note recommends use of the document type code 57133-1 "Referral Note", 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 Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author). | CONF:1198‑28949 CONF:1198‑32967 |
| CONF | |
cda:informationRecipient
| | 1 … 1 | M | SHALL contain exactly one [1..1] informationRecipient (CONF:1198-31589). | CONF 1589 |
cda:intendedRecipient
| | 1 … 1 | M | This informationRecipient SHALL contain exactly one [1..1] intendedRecipient (CONF:1198-31590). | CONF 1590 |
cda:addr
| AD | 0 … * | R | This intendedRecipient SHOULD contain zero or more [0..*] addr (CONF:1198-31591). | CONF 1591 |
cda:telecom
| TEL | 0 … * | R | This intendedRecipient SHOULD contain zero or more [0..*] telecom (CONF:1198-31592). | CONF 1592 |
cda:informationRecipient
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13) | CONF 1593 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31642) such that it | CONF 1642 |
where [@typeCode='IND'] | |
@typeCode
| cs | 1 … 1 | F | IND | CONF 1924 |
| SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31924). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31643). | CONF 1643 |
@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:1198-31925). | CONF 1925 |
| CONF | |
cda:associatedPerson
| | 1 … 1 | | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31644). This associatedPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:1198-31645). Contains 2.16.840.1.113883.10.20.22.5.1 US Realm Patient Name (PTN.US.FIELDED) (2015‑08‑13) | CONF 1644 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31647) such that it This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. | CONF 1647 |
where [@typeCode='CALLBCK'] | |
@typeCode
| cs | 1 … 1 | F | CALLBCK | CONF 1648 |
| SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC) (CONF:1198-31648). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31649). | CONF 1649 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF 2419 |
| This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110) (CONF:1198-32419). |
cda:id
| II | 1 … * | | This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31650). | CONF 1650 |
cda:addr
| AD | 0 … * | R | This associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1198-31651). | CONF 1651 |
cda:telecom
| TEL | 1 … * | | This associatedEntity SHALL contain at least one [1..*] telecom (CONF:1198-31652). | CONF 1652 |
cda:associatedPerson
| | 1 … 1 | M | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31653). | CONF 1653 |
cda:name
| | 1 … * | R | This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31654). | CONF 1654 |
cda:scopingOrganization
| | 0 … 1 | | This associatedEntity MAY contain zero or one [0..1] scopingOrganization (CONF:1198-31655). | CONF 1655 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-29062). | CONF 9062 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-29063). | CONF 9063 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF 9066 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (V3) (2015‑08‑01) | CONF 9068 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13) | CONF 9074 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF 9076 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2.1 Immunizations Section (entries required) (V3) (2015‑08‑01) | CONF 9082 |
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 9086 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09) | CONF 9088 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01) | CONF 9090 |
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 9092 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF 9094 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01) | CONF 9096 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF 9098 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01) | CONF 9100 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF 0780 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01) | CONF 0796 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09) | CONF 0798 |
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 0911 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13) | CONF 0913 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09) | CONF 0915 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01) | CONF 0917 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13) | CONF 0919 |
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 0922 |
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 0924 |
| 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 | SHALL include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan Section (2.16.840.1.113883.10.20.22.2.10). | |
| 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 | SHALL NOT include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9) when an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (2.16.840.1.113883.10.20.22.2.10) are present | |