Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | C | 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:1198-32942).
| Prog 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 | 2.16.840.1.113883.10.20.22.1.9 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-7588) such that it | CONF 7588 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.9 | CONF 0052 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.9" (CONF:1198-10052). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2521 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32521). |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code (CONF:1198-17189).The Progress Note recommends use of a single document type code, 11506-3 "Subsequent evaluation 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 7189 |
cda:documentationOf
| | 0 … 1 | R | SHOULD contain zero or one [0..1] documentationOf (CONF:1198-7603).A documentationOf can contain a serviceEvent to further specialize the act inherent in the ClinicalDocument/code. In a Progress Note, a serviceEvent can represent the event of writing the Progress Note. The serviceEvent/effectiveTime is the time period the note documents. | CONF 7603 |
cda:serviceEvent
| | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:1198-9481). Contains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13) | CONF 7604 |
@classCode
| cs | 1 … 1 | F | PCPR | CONF 6420 |
| 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:1198-26420). |
cda:effectiveTime
| | 1 … 1 | M | | CONF 7604 |
cda:low
| | 1 … 1 | M | This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-32976). If a width element is not present, the serviceEvent SHALL include effectiveTime/high (CONF:1198-10066) | CONF:1198‑32976 CONF:1198‑10066 |
| Schematron assert | role | error | |
| test | count(cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:high | cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:width)=1 | |
| Message | | |
cda:componentOf
| | 1 … 1 | M | SHALL contain exactly one [1..1] componentOf (CONF:1198-7595).
The Progress Note is always associated with an encounter by the componentOf/encompassingEncounter element in the header. The effectiveTime element for an encompassingEncounter represents the time or time interval in which the encounter took place. A single encounter may contain multiple Progress Notes; hence the effectiveTime elements for a Progress Note (recorded in serviceEvent) and for an encounter (recorded in encompassingEncounter) represent different time intervals. For outpatient encounters that are a point in time, set effectiveTime/high, effectiveTime/low, and effectiveTime/@value to the same time. All visits take place at a specific location. When available, the location ID is included in the encompassingEncounter/location/healthCareFacility/id element. | CONF 7595 |
| Schematron assert | role | error | |
| test | (cda:encompassingEncounter[count(cda:effectiveTime)=1]) and (string-length(cda:encompassingEncounter/cda:effectiveTime//@value)>=8) | |
| Message | This encompassingEncounter SHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:1198-7598). | |
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 7596 |
cda:id
| II | 1 … * | | This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-7597). | CONF 7597 |
cda:location
| | 1 … 1 | M | This encompassingEncounter SHALL contain exactly one [1..1] location (CONF:1198-30879). | CONF 0879 |
cda:healthCareFacility
| | 1 … 1 | M | This location SHALL contain exactly one [1..1] healthCareFacility (CONF:1198-30880). | CONF 0880 |
cda:id
| II | 1 … * | | This healthCareFacility SHALL contain at least one [1..*] id (CONF:1198-30881). | CONF 0881 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-9591). | CONF 9591 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30617).In this template (templateId 2.16.840.1.113883.10.20.22.1.9.2), coded entries are optional | CONF 0617 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13) | CONF 0618 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09) | CONF 0620 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09) | CONF 0622 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.6 Allergies and Intolerances Section (entries optional) (V3) (2015‑08‑01) | CONF 0624 |
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 0626 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.21.2.3 Interventions Section (V3) (2015‑08‑01) | CONF 0628 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (V2) (2014‑06‑09) | CONF 0639 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (V2) (2014‑06‑09) | CONF 0641 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.21.2.1 Objective Section (2015‑08‑13) | CONF 0643 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01) | CONF 0645 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (V3) (2015‑08‑01) | CONF 0647 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (V3) (2015‑08‑01) | CONF 0649 |
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 0651 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.21.2.2 Subjective Section (2015‑08‑13) | CONF 0653 |
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 0655 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13) | CONF 2626 |
| 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 | |