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:1198-32935).
| Cons teV3 |
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 | 2.16.840.1.113883.10.20.22.1.4 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8375) such that it | CONF 8375 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.4 | CONF 0040 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.4" (CONF:1198-10040). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2502 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32502). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code (CONF:1198-17176). This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ConsultDocumentType urn:oid:2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:1198-32969).The Consultation Note recommends use of the document type code 11488-4 "Consult 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 7176 |
| CONF | |
cda:participant
| | 0 … * | R | SHOULD contain zero or more [0..*] participant (CONF:1198-31656) such that it | CONF 1656 |
@typeCode
| cs | 1 … 1 | F | CALLBCK | CONF 1657 |
| SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC) (CONF:1198-31657). |
cda:associatedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31658). | CONF 1658 |
@classCode
| cs | 1 … 1 | F | ASSIGNED | CONF 1659 |
| This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 DYNAMIC) (CONF:1198-31659). |
cda:id
| II | 1 … * | | This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31660). | CONF 1660 |
cda:addr
| AD | 0 … * | R | This associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1198-31661). | CONF 1661 |
cda:telecom
| TEL | 1 … * | | This associatedEntity SHALL contain at least one [1..*] telecom (CONF:1198-31662). | CONF 1662 |
cda:associatedPerson
| | 1 … 1 | M | This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31663). | CONF 1663 |
cda:name
| | 1 … * | R | This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31664). | CONF 1664 |
cda:scopingOrganization
| | 0 … 1 | | This associatedEntity MAY contain zero or one [0..1] scopingOrganization (CONF:1198-31665). | CONF 1665 |
cda:inFulfillmentOf
| | 1 … * | M | SHALL contain at least one [1..*] inFulfillmentOf (CONF:1198-8382).The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | CONF 8382 |
cda:order
| | 1 … 1 | M | Such inFulfillmentOfs SHALL contain exactly one [1..1] order (CONF:1198-29923). | CONF 9923 |
cda:id
| II | 1 … * | | This order SHALL contain at least one [1..*] id (CONF:1198-29924).Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | CONF 9924 |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:1198-8386). A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | CONF 8386 |
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 8387 |
cda:id
| II | 1 … * | | This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-8388). | CONF 8388 |
cda:responsibleParty
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8391). | CONF 8391 |
cda:assignedEntity
| | 1 … 1 | M | The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32904). | CONF 2904 |
| Schematron assert | role | error | |
| test | cda:assignedPerson | cda:representedOrganization | |
| Message | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both | |
cda:encounterParticipant
| | 0 … * | | This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8392).The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | CONF 8392 |
cda:assignedEntity
| | 1 … 1 | M | The encounterParticipant, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32902). | CONF 2902 |
| Schematron assert | role | error | |
| test | cda:assignedPerson | cda:representedOrganization | |
| Message | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both | |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-8397). | CONF 8397 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-28895). | CONF 8895 |
| Constraint | 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 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13) | CONF 8896 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09) | CONF 8898 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF 8900 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13) | CONF 8904 |
cda:component
| | 1 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13) | CONF 8906 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01) | CONF 8908 |
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 8910 |
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 8912 |
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 8915 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF 8917 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13) | CONF 8919 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01) | CONF 8921 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01) | CONF 8923 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09) | CONF 8925 |
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 8928 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09) | CONF 8930 |
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 8932 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF 8934 |
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 8936 |
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 8942 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF 8944 |
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 0237 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09) | CONF 0904 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01) | CONF 0906 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF 0909 |
| Schematron assert | role | error | |
| test | //cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.1' or //cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12' | |
| Message | *SHALL* include a Reason for Referral or Reason for Visit section | |
| 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 | |