Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | | | CareanV2 |
| Constraint | 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-see below).
|
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 $uscditemplate | |
cda:templateId
| II | 0 … 1 | | templateId root without an extension to be used if instance declares conformity with USCDI | uscdecks |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.10.3.1 |
| Example | <templateId root="2.16.840.1.113883.3.1937.10.3.1"/> |
| Schematron assert | role | warning | |
| test | not($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 | CONF2936 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.15 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-28741) such that it | CONF8741 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.15 | CONF8742 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.15" (CONF:1198-28742). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF2877 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32877). |
cda:code
| | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-28745).
This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Care Plan Document Type urn:oid:2.16.840.1.113762.1.4.1099.10 DYNAMIC (CONF:1198-32959).
| CONF8745 |
| CONF | |
cda:setId
| | 0 … 1 | R | SHOULD contain zero or one [0..1] setId (CONF:1198-32321). | CONF2321 |
cda:versionNumber
| | 0 … 1 | R | SHOULD contain zero or one [0..1] versionNumber (CONF:1198-32322). | CONF2322 |
cda:informationRecipient
| | 0 … * | R | SHOULD contain zero or more [0..*] informationRecipient (CONF:1198-31993) such that it | CONF1993 |
cda:intendedRecipient
| | 1 … 1 | M | SHALL contain exactly one [1..1] intendedRecipient (CONF:1198-31994). | CONF1994 |
cda:id
| II | 1 … * | R | This intendedRecipient SHALL contain at least one [1..*] id (CONF:1198-31996). | CONF1996 |
cda:addr
| AD | 0 … * | R | This intendedRecipient SHOULD contain zero or more [0..*] addr (CONF:1198-31997). | CONF1997 |
cda:telecom
| TEL | 0 … * | R | This intendedRecipient SHOULD contain zero or more [0..*] telecom (CONF:1198-31998). | CONF1998 |
cda:informationRecipient
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13) | CONF1999 |
cda:receivedOrganization
| | 0 … 1 | R | This intendedRecipient SHOULD contain zero or one [0..1] receivedOrganization (CONF:1198-32000). | CONF2000 |
cda:id
| II | 0 … * | R | The receivedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1198-32001). | CONF2001 |
cda:name
| | 1 … * | R | The receivedOrganization, if present, SHALL contain at least one [1..*] name (CONF:1198-32002). | CONF2002 |
cda:standardIndustryClassCode
| | 0 … 1 | R | The receivedOrganization, if present, SHOULD contain zero or one [0..1] standardIndustryClassCode, which SHALL be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32003). | CONF2003 |
| CONF | |
cda:authenticator
| | 0 … 1 | R | SHOULD contain zero or one [0..1] authenticator (CONF:1198-31910) such that it | CONF1910 |
cda:time
| | 1 … 1 | R | SHALL contain exactly one [1..1] time (CONF:1198-31911). | CONF1911 |
cda:signatureCode
| | 1 … 1 | R | SHALL contain exactly one [1..1] signatureCode (CONF:1198-31912). | CONF1912 |
sdtc:signatureText
| | 0 … 1 | | MAY contain zero or one [0..1] sdtc:signatureText (CONF:1198-31913). | CONF1913 |
cda:assignedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] assignedEntity (CONF:1198-31914). | CONF1914 |
cda:id
| II | 1 … * | R | This assignedEntity SHALL contain at least one [1..*] id (CONF:1198-31915). | CONF1915 |
cda:code
| CE | 1 … 1 | M | This assignedEntity SHALL contain exactly one [1..1] code (CONF:1198-31916). | CONF1916 |
@code
| CONF | 1 … 1 | F | ONESELF |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.5.111 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31677) such that it | CONF1677 |
where [@typeCode='VRF'] | |
@typeCode
| cs | 1 … 1 | F | VRF | CONF1678 |
| SHALL contain exactly one [1..1] @typeCode="VRF" Verifier (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31678). |
cda:functionCode
| CE | 1 … 1 | M | SHALL contain exactly one [1..1] functionCode (CONF:1198-31679). | CONF1679 |
@code
| | 1 … 1 | F | 425268008 | CONF1680 |
| This functionCode SHALL contain exactly one [1..1] @code="425268008" Review of Care Plan (CONF:1198-31680). |
@codeSystem
| | 1 … 1 | F | 2.16.840.1.113883.6.96 | CONF1681 |
| This functionCode SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1198-31681). |
cda:time
| | 1 … 1 | R | SHALL contain exactly one [1..1] time (CONF:1198-31682). | CONF1682 |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31683). | CONF1683 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF1686 |
| This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110) (CONF:1198-31686). |
cda:id
| II | 1 … * | R | This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31684). | CONF1684 |
cda:code
| | 0 … 1 | R | This associatedEntity SHOULD contain zero or one [0..1] code (CONF:1198-31685). | CONF1685 |
@code
| | 1 … 1 | R | SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:1198-32367).
| CONF2367 |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31895) such that it | CONF1895 |
where [@typeCode='IND'] | |
@typeCode
| cs | 1 … 1 | F | IND | CONF1896 |
| SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31896). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31897). | CONF1897 |
@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:1198-31898). | CONF1898 |
| CONF | |
cda:associatedPerson
| | 1 … 1 | M | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31899). | CONF1899 |
cda:name
| | 1 … * | R | This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31900). | CONF1900 |
cda:documentationOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] documentationOf (CONF:1198-31901) such that it The serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). | CONF1901 |
cda:serviceEvent
| | 1 … 1 | M | SHALL contain exactly one [1..1] serviceEvent (CONF:1198-31902). | CONF1902 |
@classCode
| cs | 1 … 1 | F | PCPR | CONF1903 |
| This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-31903). |
cda:effectiveTime
| | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:1198-31904). | CONF1904 |
cda:low
| | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-32330). | CONF2330 |
cda:high
| | 0 … 1 | R | This effectiveTime MAY contain zero or one [0..1] high (CONF:1198-32331). | CONF2331 |
cda:performer
| | 1 … * | M | This serviceEvent SHALL contain at least one [1..*] performer (CONF:1198-31905) such that it | CONF1905 |
cda:assignedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] assignedEntity (CONF:1198-31907). | CONF1907 |
cda:id
| II | 1 … * | R | This assignedEntity SHALL contain at least one [1..*] id (CONF:1198-31908). | CONF1908 |
cda:code
| CE | 0 … 1 | | This assignedEntity MAY contain zero or one [0..1] code (CONF:1198-31909). | CONF1909 |
cda:assignedPerson
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13) | CONF2328 |
cda:relatedDocument
| | 0 … * | | MAY contain zero or more [0..*] relatedDocument (CONF:1198-29893) such that it | CONF9893 |
@typeCode
| cs | 1 … 1 | R | SHALL contain exactly one [1..1] @typeCode, which SHALL be selected from ValueSet x_ActRelationshipDocument urn:oid:2.16.840.1.113883.1.11.11610 STATIC (CONF:1198-31889).
| CONF1889 |
| CONF | |
cda:parentDocument
| | 1 … 1 | M | SHALL contain exactly one [1..1] parentDocument (CONF:1198-29894). | CONF9894 |
cda:id
| II | 1 … 1 | R | . This parentDocument SHALL contain at least one [1..*] id (CONF:1198-32949).
| CONF2949 |
cda:setId
| | 1 … 1 | R | This parentDocument SHALL contain exactly one [1..1] setId (CONF:1198-29895). | CONF9895 |
cda:versionNumber
| | 1 … 1 | R | This parentDocument SHALL contain exactly one [1..1] versionNumber (CONF:1198-29896). | CONF9896 |
cda:componentOf
| | 0 … 1 | R | SHOULD contain zero or one [0..1] componentOf (CONF:1198-32004) such that it | CONF2004 |
cda:encompassingEncounter
| | 1 … 1 | M | SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-32005). | CONF2005 |
cda:effectiveTime
| | 1 … 1 | R | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:1198-32007). | CONF2007 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-28753). | CONF8753 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-28754). | CONF8754 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.58 Health Concerns Section (V2) (2015‑08‑01) | CONF8755 |
cda:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.60 Goals Section (2015‑08‑13) | CONF8761 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.21.2.3 Interventions Section (V3) (2015‑08‑01) | CONF8763 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.61 Health Status Evaluations and Outcomes Section (2015‑08‑13) | CONF9596 |
cda:component
| | | NP | This structuredBody *SHALL NOT* contain a Plan of Treatment Section (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF8754 |