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 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:1198-32939).
| Hist alV3 |
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 | 2.16.840.1.113883.10.20.22.1.3 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8283) such that it | CONF 8283 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.3 | CONF 0046 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.3" (CONF:1198-10046). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2518 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32518). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code (CONF:1198-17185).The H&P Note recommends use of a single document type code, 34117-2 "History and physical 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. | CONF 7185 |
cda:informationRecipient
| | 0 … * | | MAY contain zero or more [0..*] informationRecipient (CONF:1198-32482). | CONF 2482 |
cda:intendedRecipient
| | 1 … 1 | | The informationRecipient, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:1198-32483). | CONF 2483 |
cda:participant
| | 0 … * | | MAY contain zero or more [0..*] participant (CONF:1198-8286).The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. | CONF 8286 |
| Constraint | When participant/@typeCode is IND, associatedEntity/@classCode *SHALL* be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 |
cda:inFulfillmentOf
| | 0 … * | | MAY contain zero or more [0..*] inFulfillmentOf (CONF:1198-8336).inFulfillmentOf elements describe 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 the H&P Note may be in partial fulfillment of that referral. | CONF 8336 |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:1198-8338).The H&P Note is always associated with an encounter. | CONF 8338 |
cda:encompassingEncounter
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13) | CONF 8339 |
cda:id
| II | 1 … * | | This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-8340). | CONF 8340 |
cda:responsibleParty
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8345).The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. | CONF 8345 |
| Schematron assert | role | error | |
| test | 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. | |
cda:encounterParticipant
| | 0 … * | | This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8342).The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. | CONF 8342 |
| Schematron assert | role | error | |
| test | 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. | |
cda:location
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] location (CONF:1198-8344). | CONF 8344 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-8349). | CONF 8349 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30570).In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. | CONF 0570 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.6 Allergies and Intolerances Section (entries optional) (V3) (2015‑08‑01) | CONF 0571 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13) | CONF 0573 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF 0575 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09) | CONF 0577 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2015‑08‑13) | CONF 0579 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2015‑08‑13) | CONF 0581 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF 0583 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13) | CONF 0585 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01) | CONF 0587 |
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 0589 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01) | CONF 0591 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (V2) (2014‑06‑09) | CONF 0593 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (V2) (2014‑06‑09) | CONF 0595 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01) | CONF 0597 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (V3) (2015‑08‑01) | CONF 0599 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09) | CONF 0601 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13) | CONF 0603 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (V3) (2015‑08‑01) | CONF 0605 |
cda:component
| | 1 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13) | CONF 0607 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF 0609 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (2015‑08‑01) | CONF 0611 |
| Schematron assert | role | 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 | This structuredBody *SHALL* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) | |
| Schematron assert | role | error | |
| test | //cd:templateId[@root='2.16.840.1.113883.10.20.22.2.9' or (//cd:templateId[@root='2.16.840.1.113883.10.20.22.2.8' and //cd: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(//cd:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or (not(//cd:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cd: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. | |
| Schematron assert | role | error | |
| test | not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13']) or //cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] or //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'] | |
| Message | This structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present | |