Header
Contents
1 CDA Overview
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2 Introduction to CDA Technical Artifacts
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3 CDA Document Exchange in HL7 Messages
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4 CDA R-MIM
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4.1 Header
The purpose of the CDA header is to enable clinical document exchange across and within institutions; facilitate clinical document management; and facilitate compilation of an individual patient's clinical documents into a lifetime electronic patient record.
4.1.1 Header Attributes
This section describes attributes of the root ClinicalDocument class.
The table below identifies the attributes for the ClinicalDocument class. For each attribute the name, data type, cardinality, code bindings, and binding strength are provided. The links will enable the access to the attribute definitions, data type definitions, and when appropriate, the value set or concept domain associated with the codes found in the class.
| RIM Attribute(s) | Data Type | Cardinality | Code Binding | Binding Type |
|---|---|---|---|---|
| classCode | CS | [1..1] | DOCCLIN | Fixed |
| moodCode | CS | [1..1] | EVN | Fixed |
| id | II | [1..1] | ||
| code | CE | [1..1] | D:DocumentType | Open |
| title | TS | [0..1] | ||
| effectiveTime | TS | [0..1] | ||
| confidentialityCode | SET<CE> | [0..*] | V:x_BasicConfidentialityKind | Open |
| languageCode | CE | [0..1] | D:HumanLanguage | Closed |
| setId | II | [0..1] | ||
| versionNumber | ST.SIMPLE | [0..1] | ||
| copyTime (Deprecated) | TS | [0..1] |
| Code | Display Name |
|---|---|
| DOCCLIN | clinical document |
| Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6 | |
| Code | Display Name |
|---|---|
| EVN | event |
| Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001 | |
4.1.1.1 ClinicalDocument.id
Represents the unique instance identifier of a clinical document.
4.1.1.2 ClinicalDocument.code
The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note). The value set is drawn from LOINC, and has a CWE coding strength.
Within the LOINC database, beginning with version 2.09, May 2003, document type codes are those that have a value of "DOC" in the Scale component. This subset of LOINC is included in the appendix (see LOINC Document Codes).
- NOTE: The hierarchical relationship among LOINC document codes is in evolution. Per the LOINC version 2.14 (December 2004) manual: As soon as possible, the component terms used in the creation of the names of document type codes will be mapped to either the UMLS Metathesaurus or SNOMED CT. This mapping will help to establish the meaning of the terms and will allow aggregation and classification of document type codes based on definitions, computable relationships, and subsumption hierarchies that exist in the reference terminology.
4.1.1.3 ClinicalDocument.title
Represents the title of the document. It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of ClinicalDocument.code (e.g. a "consultation" or "progress note"). Where these display names are rendered to the clinician, or where the document has a unique title, the ClinicalDocument.title component should be used. In the example document in the appendix (see Sample Document), the value of ClinicalDocument.title = "Good Health Clinic Consultation Note".
4.1.1.4 ClinicalDocument.effectiveTime
Signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA.
5 CDA Hierarchical Description
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6 CDA XML Implementation
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7 Appendix
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