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:1198-32938).
| Disc ryV3 |
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 | 2.16.840.1.113883.10.20.22.1.8 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8463) such that it | CONF 8463 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.8 | CONF 0044 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.8" (CONF:1198-10044). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2517 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32517). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code (CONF:1198-17178).The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", 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 7178 |
cda:participant
| | 0 … * | | MAY contain zero or more [0..*] participant (CONF:1198-8467).The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. | CONF 8467 |
| 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:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:1198-8471).The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | CONF 8471 |
cda:encompassingEncounter
| | 1 … 1 | M | This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-8472). | CONF 8472 |
cda:effectiveTime
| IVL_TS | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:1198-32611). | CONF 2611 |
cda:low
| TS | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-8473).The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | CONF 8473 |
cda:high
| TS | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] high (CONF:1198-8475).The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | CONF 8475 |
cda:dischargeDispositionCode
| CE | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] dischargeDispositionCode, which SHOULD be selected from ValueSet NUBC UB-04 FL17 Patient Status urn:oid:2.16.840.1.113883.3.88.12.80.33 DYNAMIC (CONF:1198-8476).The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements. The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered. | CONF 8476 |
| CONF | |
cda:responsibleParty
| | 0 … 1 | | This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8479).The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | CONF 8479 |
cda:assignedEntity
| | 1 … 1 | M | The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32613). | CONF 2613 |
| 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:1198-8478).The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | CONF 8478 |
cda:assignedEntity
| | 1 … 1 | M | The encounterParticipant, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32615). | CONF 2615 |
| 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:1198-9539). | CONF 9539 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30518).In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. | CONF 0518 |
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 0519 |
cda:component
| | 1 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (2015‑08‑13) | CONF 0521 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.24 Discharge Diagnosis Section (V3) (2015‑08‑01) | CONF 0523 |
cda:component
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.20.22.2.11 Discharge Medications Section (entries optional) (V3) (2015‑08‑01) | CONF 0525 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF 0527 |
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 0529 |
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 0531 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF 0533 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01) | CONF 0535 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09) | CONF 0537 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01) | CONF 0539 |
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 0541 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.43 Admission Diagnosis Section (V3) (2015‑08‑01) | CONF 0543 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.44 Admission Medications Section (entries optional) (V3) (2015‑08‑01) | CONF 0545 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (2015‑08‑13) | CONF 0547 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (2015‑08‑13) | CONF 0549 |
cda:component
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (2015‑08‑13) | CONF 0551 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (2015‑08‑13) | CONF 0553 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01) | CONF 0555 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (V3) (2015‑08‑01) | CONF 0557 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09) | CONF 0559 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13) | CONF 0561 |
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 0563 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01) | CONF 0565 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (2015‑08‑01) | CONF 0567 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.11.1 Discharge Medications Section (entries required) (V3) (2015‑08‑01) | CONF 1586 |
| Schematron assert | role | error | |
| test | not( count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])>0 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])>0 ) and not( count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])>0 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])>0 ) | |
| 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 (CONF:1198-30569) | |