Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | R | When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALLinclude 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:1198-32934).
| Cont CDV3 |
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 | 2.16.840.1.113883.10.20.22.1.2 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8450) such that it | CONF 8450 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.2 | CONF 0038 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.2" (CONF:1198-10038). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2516 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32516). |
cda:code
| | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-17180). | CONF 7180 |
@code
| CONF | 1 … 1 | F | 34133-9 |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.6.1 |
cda:author
| | 1 … * | M | SHALL contain at least one [1..*] author (CONF:1198-9442). | CONF 9442 |
| Schematron assert | role | error | |
| test | count(cda:assignedAuthor[count(cda:assignedPerson | (cda:representedOrganization and cda:assignedAuthoringDevice)) > 1])=0 | |
| Message | Such assignedAuthors *SHALL* contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456) | |
cda:assignedAuthor
| | 1 … 1 | M | Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:1198-9443). | CONF 9443 |
| Schematron assert | role | error | |
| test | not(cda:representedOrganization) or cda:assignedPerson or cda:assignedAuthoringDevice or cda:id/@nullFlavor='NA' | |
| 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. | |
cda:documentationOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] documentationOf (CONF:1198-8452).The documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | CONF 8452 |
cda:serviceEvent
| | 1 … 1 | M | This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:1198-8480).The main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided 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). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present. | CONF 8480 |
@classCode
| cs | 1 … 1 | F | PCPR | CONF 8453 |
| This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-8453). |
cda:effectiveTime
| | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:1198-8481). | CONF 8481 |
cda:low
| | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-8454). | CONF 8454 |
cda:high
| | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] high (CONF:1198-8455). | CONF 8455 |
cda:performer
| | 0 … * | R | This serviceEvent SHOULD contain zero or more [0..*] performer (CONF:1198-8482).The 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 |
@typeCode
| cs | 1 … 1 | F | PRF | CONF 8458 |
| The performer, if present, SHALL contain exactly one [1..1] @typeCode="PRF" Participation physical performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8458). |
cda:assignedEntity
| | 0 … 1 | | The performer, if present, MAY contain zero or one [0..1] assignedEntity (CONF:1198-8459). | CONF 8459 |
cda:id
| II | 1 … * | | The assignedEntity, if present, SHALL contain at least one [1..*] id (CONF:1198-30882) such that it | CONF 0882 |
| Schematron assert | role | warning | |
| test | not(cda:assignedPerson) or cda:id/@root='2.16.840.1.113883.4.6' | |
| Message | If this assignedEntity is an assignedPerson, the assignedEntity/id SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466). | |
cda:assignedPerson
| | 0 … 1 | | The assignedEntity, if present, MAY contain zero or one [0..1] assignedPerson (CONF:1198-32467). | CONF 2467 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-30659). | CONF 0659 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30660). | CONF 0660 |
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 0661 |
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 0663 |
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 0665 |
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 0667 |
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 0669 |
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 0671 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.22 Encounters Section (entries optional) (V3) (2015‑08‑01) | CONF 0673 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF 0675 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF 0677 |
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 0679 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09) | CONF 0681 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (V3) (2015‑08‑01) | CONF 0683 |
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 0685 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF 0687 |
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 0689 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01) | CONF 2143 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF 2624 |