Item | DT | Card | Conf | Description | Label |
---|
cda:act
| | | | | Heal ctV2 |
@classCode
| cs | 1 … 1 | F | ACT | CONF 0750 |
| SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-30750). |
@moodCode
| cs | 1 … 1 | F | EVN | CONF 0751 |
| SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-30751). |
cda:templateId
| II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF 2936 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.132 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-30752) such that it | CONF 0752 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.132 | CONF 0753 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.132" (CONF:1198-30753). |
@extension
| st | 1 … 1 | F | 2015-08-01 | CONF 2861 |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32861). |
cda:id
| II | 1 … * | | SHALL contain at least one [1..*] id (CONF:1198-30754). | CONF 0754 |
cda:code
| CD | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-32310). | CONF 2310 |
@code
| CONF | 1 … 1 | F | 75310-3 |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.6.1 |
cda:statusCode
| CS | 1 … 1 | R | SHALL contain exactly one [1..1] statusCode (CONF:1198-30758). | CONF 0758 |
cda:effectiveTime
| | 0 … 1 | | MAY contain zero or one [0..1] effectiveTime (CONF:1198-30759). | CONF 0759 |
cda:author
| | 0 … * | R | SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31546).A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | CONF 1546 |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01) | CONF 0761 |
where [@typeCode='REFR'] | |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 0762 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-30762). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.7 Allergy - Intolerance Observation (V2) (2014‑06‑09) | CONF 1007 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1008 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31008). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF 1157 |
where [@typeCode='REFR'] | |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1158 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31158). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF 1160 |
where [@typeCode='COMP'] | |
@typeCode
| cs | 1 … 1 | F | COMP | CONF 1161 |
| SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31161). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (2015‑08‑13) | CONF 1190 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1191 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31191). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.128 Self-Care Activities (ADL and IADL) (2015‑08‑13) | CONF 1232 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1264 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31264). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.74 Mental Status Observation (V3) (2015‑08‑01) | CONF 1234 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1268 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31268). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.78 Smoking Status - Meaningful Use (V2) (2014‑06‑09) | CONF 1235 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1269 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31269). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.80 Encounter Diagnosis (V3) (2015‑08‑01) | CONF 1236 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1270 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31270). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.45 Family History Organizer (V3) (2015‑08‑01) | CONF 1237 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1279 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers To (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31279). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.67 Functional Status Observation (V2) (2014‑06‑09) | CONF 1238 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1282 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31282). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.34 Hospital Admission Diagnosis (V3) (2015‑08‑01) | CONF 1241 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1291 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31291). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.138 Nutrition Assessment (2015‑08‑13) | CONF 1244 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1300 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31300). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.51 Postprocedure Diagnosis (V3) (2015‑08‑01) | CONF 1246 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1306 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31306). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.15.3.8 Pregnancy Observation (2015‑08‑13) | CONF 1247 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1309 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31309). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.65 Preoperative Diagnosis (V3) (2015‑08‑01) | CONF 1248 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1312 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31312). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09) | CONF 1250 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1318 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31318). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01) | CONF 1251 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1321 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31321). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.127 Sensory Status (2015‑08‑13) | CONF 1252 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1324 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31324). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.38 Social History Observation (V3) (2015‑08‑01) | CONF 1253 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1327 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31327). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.24.3.90 Substance or Device Allergy - Intolerance Observation (V2) (2014‑06‑09) | CONF 1254 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1330 |
| MAY contain zero or one [0..1] typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31330). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.85 Tobacco Use (V2) (2014‑06‑09) | CONF 1255 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1333 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31333). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.27 Vital Sign Observation (V2) (2014‑06‑09) | CONF 1256 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1336 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31336). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.114 Longitudinal Care Wound Observation (V2) (2015‑08‑01) | CONF 1257 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1339 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31339). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. Contains 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01) | CONF 1365 |
where [@typeCode='SPRT'] | |
@typeCode
| cs | 1 … 1 | F | SPRT | CONF 1366 |
| SHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31366). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.72 Caregiver Characteristics (2015‑08‑13) | CONF 1368 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1369 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31369). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.111 Cultural and Religious Observation (2015‑08‑13) | CONF 1371 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1372 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31372). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.109 Characteristics of Home Environment (2015‑08‑13) | CONF 1374 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1375 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31375). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.124 Nutritional Status Observation (2015‑08‑13) | CONF 1377 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1378 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31378). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.1 Result Organizer (V3) (2015‑08‑01) | CONF 1380 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1381 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31381). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) | CONF 1442 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1443 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31443). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.3 Problem Concern Act (V3) (2015‑08‑01) | CONF 1544 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1547 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31547). |
cda:entryRelationship
| | 0 … * | | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF 1549 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 1550 |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31550). |
cda:reference
| | 0 … * | | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. Contains 2.16.840.1.113883.10.20.22.4.115 External Document Reference (2014‑06‑09) | CONF 2757 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF 2758 |
| The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-32758). |