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 Templating

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5 CDA R-MIM

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5.1 Header

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5.2 Body

5.2.1 Body Choice

The CDA body choice can be either a document body in a format other than XML, or the CDA structured body. Every CDA document has exactly one body, associated with the ClinicalDocument class through the component relationship.

5.2.1.1 component

The component class relates the ClinicalDocument header to the body choice; NonXMLBody or StructuredBody.

Table X: documentationOf Attributes
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
typeCode	CS	[0..1]	DOC	Fixed
contextConductionInd	BL	[0..1]

component.typeCode

The component.typeCode is fixed to "COMP", which indicates that the body is a component part of the StructuredDocument.

Table X: Fixed component.typeCode
Code	Display Name
COMP	has component
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

component.contextConductionInd

The component.contextConductionInd indicator is fixed to "true". Ancestor elements () which propagate, will conduct through this component class to the associated child element.

5.2.1.2 NonXMLBody

The NonXMLBody class represents a document body that is in some format other than XML. The NonXMLBody can be used to represent scanned document(s) or legacy document(s) needing to be transferred using the CDA standard.

Table X: NonXMLBody Attributes
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[0..1]	DOCCLIN	Fixed
moodCode	CS	[0..1]	EVN	Fixed
text	ED	[1..1]
confidentialityCode	SET<CE>	[0..*]	V:x_BasicConfidentialityKind	Open
languageCode	CE	[0..1]	D:HumanLanguage	Closed

NonXMLBody.typeCode

The ClinicalDocument.classCode in the CDA model is fixed to "DOCCLIN".

Table X: Fixed NonXMLBody.classCode
Code	Display Name
DOCBODY	document body
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

NonXMLBody.moodCode

The NonXMLBody.moodCode is fixed to "EVN" or event mood to indicate that this is documentation of a past service.

Table X: Fixed NonXMLBody.moodCode
Code	Display Name
EVN	event
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

NonXMLBody.text

NonXMLBody.text is used to reference data that is stored externally to the CDA document or to encode the data directly inline. Rendering a referenced non-XML body requires a software tool that recognizes the particular MIME media type for this type of body.

NonXMLBody.confidentialityCode

Confidentiality is a required contextual component of CDA, where the value expressed in the ClinicalDocument can be overridden for the NonXMLBody of the document.

Table X: Value set for NonXMLBody.confidentialityCode
X_BasicConfidentialityKind [2.16.840.1.113883.1.11.16926] (OPEN)
Code	Display Name	Code	Display Name
N	normal	R	restricted
V	very restricted
Code System: Confidentiality (HL7) Code System OID: 2.16.840.1.113883.5.25

* The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.

NonXMLBody.languageCode

Specifies the human language of character data (whether they be in contents or attribute values). The values of the attribute are language identifiers as defined by the IETF (Internet Engineering Task Force) RFC 3066 for the Identification of Languages, ed. H. Alvestrand. 1995, which obsoletes RFC 1766. The HL7 code system for these values is "2.16.840.1.113883.6.121". Language is a contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by the NonXMLBody (as further described in CDA Context).

5.2.1.3 StructuredBody

The StructuredBody class represents a CDA document body that is comprised of one or more document sections.

Table X: StructuredBody Attributes
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[0..1]	DOCCLIN	Fixed
moodCode	CS	[0..1]	EVN	Fixed
confidentialityCode	SET<CE>	[0..*]	V:x_BasicConfidentialityKind	Open
languageCode	CE	[0..1]	D:HumanLanguage	Closed

StructuredBody.classCode

Table X: Fixed StructuredBody.classCode
Code	Display Name
DOCBODY	document body
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

StructuredBody.moodCode

Table X: Fixed StructuredBody.moodCode
Code	Display Name
EVN	event
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

StructuredBody.confidentialityCode

Table X: Value set for StructuredBody.confidentialityCode
X_BasicConfidentialityKind [2.16.840.1.113883.1.11.16926] (OPEN)
Code	Display Name	Code	Display Name
N	normal	R	restricted
V	very restricted
Code System: Confidentiality (HL7) Code System OID: 2.16.840.1.113883.5.25

* The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.

confidentialityCode.HumanLanguage

5.2.1.3.1 component

A component class is used to relate the body choice (NonXMLBody, StructuredBody) to it's component Section(s). See component for its attributes.

5.2.2 Section Attributes

Section

Document sections can nest, can override context propagated from the header (see CDA Context, and can contain narrative and CDA entries.

Table X: Section Attributes
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[0..1]	DOCSECT	Fixed
moodCode	CS	[0..1]	EVN	Fixed
id	ii	[0..1]
code	CE	[1..1]	D:DocumentSectionType	Open
title	ST	[0..1]
text	ED.STRUCTURED_TEXT	[0..1]
confidentialityCode	SET<CE>	[0..*]	V:x_BasicConfidentialityKind	Open
languageCode	CE	[0..1]	D:HumanLanguage	Closed

An XML attribute "ID" of type XML ID, is added to Section within the CDA Schema. This attribute serves as the target of a reference (see reference). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).

Section.classCode

The Section.classCode is fixed to "DOCSECT", which represents a context that subdivides the body of a document. Document sections are typically used for human navigation, to give a reader a clue as to the expected content. Document sections are used to organize and provide consistency to the contents of a document body. Document sections can contain document sections and can contain entries.

Table X: Fixed Section.classCode
Code	Display Name
DOCSECT	document section
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Section.moodCode

The Section.moodCode is fixed to "EVN" (event) which indicates the section is about a service that actually happens, may be an ongoing service or a documentation of a past service.

Table X: Fixed Section.moodCode
Code	Display Name
EVN	event
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Section.id

The unique instance identifier of a particular document section.

Section.code

The code specifying the particular kind of section (e.g. Chief Complaint, Review of Systems, Assessment). The value set is drawn from LOINC, and has a CWE coding strength.

Section.title

Represents the label of a section. If valued, it is to be rendered as part of the narrative content of the clinical document body.

Section.text

Used to store narrative to be rendered. Also referred to as the CDA Narrative Block. See Section Narrative Block for details.

Section.confidentialityCode

A value for Section.confidentialityCode overrides the value propagated from StructuredBody. See CDA Context for more details.

Table X: Value set for Section.confidentialityCode
X_BasicConfidentialityKind [2.16.840.1.113883.1.11.16926] (OPEN)
Code	Display Name	Code	Display Name
N	normal	R	restricted
V	very restricted
Code System: Confidentiality (HL7) Code System OID: 2.16.840.1.113883.5.25

* The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.

Section.languageCode

Specifies the human language of character data (whether they be in contents or attribute values). The values of the attribute are language identifiers as defined by the IETF (Internet Engineering Task Force) RFC 3066: Tags for the Identification of Languages, ed. H. Alvestrand. 1995 , which obsoletes RFC 1766. The HL7 code system for these values is "2.16.840.1.113883.6.121".

A value for Section.languageCode overrides the value propagated from StructuredBody. See CDA Context for more details.

5.2.3 Section Participants

5.2.3.1 author

The author participant (described above, see author), can be ascribed to a CDA section, where it overrides the value(s) propagated from the CDA header.

5.2.3.2 informant

The informant participant (described above, see informant), can be ascribed to a CDA section where it overrides the value(s) propagated from the CDA header.

5.2.3.3 subject

The subject participant represents the primary target of the entries recorded in the document. Most of the time the subject is the same as the recordTarget (see recordTarget), but need not be, for instance when the subject is a fetus observed in an obstetrical ultrasound.

The subject participant can be ascribed to a CDA section or a CDA entry. It propagates to nested components, unless overridden. The subject of a document is presumed to be the patient.

Table X: informant
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
typeCode	CS	[0..1]	INF	Fixed
contextControlCode	CS	[0..1]	OP	Fixed

subject.typeCode

The subject.typeCode is fixed to "SBJ" to indicate that a participant that is the principle target (subject) of the service acts documented.

Table X: Fixed subject.typeCode
Code	Display Name
SBJ	subject
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

subject.contextControlCode

The subject.contextControlCode is fixed to "OP". Any subject(s) defined for a section will override the the Patient in recordTarget (an implicit subject) and propagate to the sub-sections and entries this section contains.

Table X: Fixed subject.contextControlCode
Code	Display Name
OP	overriding, propagating
Code System: ContextControl (HL7) Code System OID: 2.16.840.1.113883.5.1057

5.2.3.3.1 RelatedSubject

A subject is a person playing one of several possible roles (RelatedSubject class).

Table X: RelatedSubject
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[0..1]	x_DocumentSubject	Closed
code	CE	[0..1]	D:PersonalRelationshipRoleType	Open
addr	SET<AD>	[0..*]
telecom	SET<TEL>	[0..*]

RelatedSubject.classCode

The RelatedSubject.classCode can take two codes; "PAT" a Role of a LivingSubject (player) as a recipient of health care services from a healthcare provider (scoper) and "PRS" which links two people in a personal relationship. The character of the relationship must be defined by a PersonalRelationshipRoleType code.

Table X: Value set for RelatedSubject.classCode
v:x_DocumentSubject [2.16.840.1.113883.1.11.19368] (CLOSED)
Code	Display Name	Code	Display Name
PAT (Default)	patient	PRS	personal relationship
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

RelatedSubject.code

The RelatedSubject.code is bound to the PersonalRelationshipRoleType concept domain

RelatedSubject.addr

An optional postal address for the subject.

RelatedSubject.telecom

An optional phone number for the subject.

5.2.3.3.2 SubjectPerson

The entity playing in the role RelatedSubject, is a person (SubjectPerson class).

Table X: SubjectPerson
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[0..1]	PSN	Fixed
determinerCode	CS	[0..1]	INSTANCE	Fixed
id	SET<II>	[0..*]
name	SET<PN>	[0..*]
desc	ED	[0..1]
administrativeGenderCode	CE	[0..1]	D:administrativeGender	Open
birthTime	TS	[0..1]
deceasedInd	BL	[0..1]
deceasedTime	TS	[0..1]
multipleBirthInd	BL	[0..1]
multipleBirthOrderNumber	INT	[0..1]
maritalStatusCode	CE	[0..1]	D:MaritalStatus	Open
religiousAffiliationCode	CE	[0..1]	D:ReligousAffiliation	Open
raceCode	SET<CE>	[0..*]	D:Race	Open
ethnicGroupCode	SET<CE>	[0..*]	D:Ethnicity	Open

SubjectPerson.classCode

The SubjectPerson.classCode is fixed to "PSN", indicating that the entity is a person.

Table X: Fixed SubjectPerson.classCode
Code	Display Name
PSN	person
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

SubjectPerson.determinerCode

The determinerCode is fixed to "INSTANCE", which indicates a specific person is a SubjectPerson.

Table X: Fixed SubjectPerson.determinerCode
Code	Display Name
INSTANCE	specific
Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30

SubjectPerson.id

Optional identifier for the SubjectPerson.

SubjectPerson.name

The subject's name.

Note: The person name data type "PN" supports current, and historical names using validTime, and the specification of different use codes can indicate legal name, tribal name, stage name and others.

SubjectPerson.desc

A textual or multimedia depiction of the subject.

SubjectPerson.administrativeGenderCode

The gender (i.e., the behavioral, cultural, or psychological traits typically associated with one sex) of a living subject as defined for administrative purposes.

SubjectPerson.birthTime

The date and time of the subject's birth.

SubjectPerson.deceasedInd

An indication that the subject is dead.

SubjectPerson.deceasedTime

The date and time that the Subject's death occurred.

SubjectPerson.multipleBirthInd

An indication as to whether the subject was part of a multiple birth.

SubjectPerson.multipleBirthOrderNumber

The order within a multiple birth in which this subject was born.

SubjectPerson.maritalStatusCode

The domestic partnership status of the subject.

SubjectPerson.religiousAffiliationCode

The primary religious preference of the subject.

SubjectPerson.raceCode

The race of the subject.

Note: More than one race code is now supported in CDA R2.1.

SubjectPerson.ethnicGroupCode

The ethnic group of the subject.

Note: More than one race code is now supported in CDA R2.1.

5.2.4 Section Relationships

5.2.4.1 component

The "component" Act Relationship is used to nest a Section within a Section. Context propagates to nested sections (see CDA Context). Refer to component above for more information.

5.2.4.2 entry

The relationship between a section and its entries is encoded in the intervening "entry" Act Relationship.

The narrative of each Section, together with the multimedia content referenced in the narrative, comprises the complete authenticated content of the Section. This multimedia content consists of ObservationMedia and RegionOfInterest entries referenced by tags in the Section.text. This is the only case where the entries contain authenticated content that must be rendered with the narrative.

NOTE: See Referencing in and out of the narrative block for a discussion of referencing in and out of a section's narrative block.

Table X: entry Attributes
Attribute Name	Data Type	Cardinality	Code Binding	Binding Type
typeCode	CS	[0..1]	V:x_ActRelationshipEntry	Fixed
contextConductionInd	BL	[0..1]

entry.typeCode

In terms of the relationship between a section and its entries, CDA defines a default general case, and a more specific case that can be used when applicable.

The entry relationship is defaulted to "COMP" (component), for the general case where the only assertion is that the related entries are contained within the source section and no other semantics are implied. In this case, the narrative is the original authenticated content. The CDA entries are created by various techniques (e.g., natural language processing, a human coder, a structured data entry tool that outputs both entries and a text report). The method of entry creation may be indicated by the entry participants (e.g., by identifying the algorithm or person that generated them). Relationships between various entries (such as two Observations or an Observation and an ObservationMedia) are encoded using the relationship types defined in entryRelationship.

A section may also have no narrative content in the case where the entries represent information that is not part of the clinical content of the document. A report may embed information referencing evidence data, reagents, calibration or other information that may be used for later processing but is not part of the clinical content. Such entries are also linked to the Section with ActRelationships possessing typeCode="COMP".

The entry relationship "DRIV" (is derived from) can be used in the special case where the narrative is fully derived from CDA Entries. When a report consisting entirely of structured entries is transformed into CDA, the encoding application must ensure that the authenticated content (narrative plus multimedia) is a faithful and complete rendering of the clinical content of the structured source data. This ensures that the narrative plus multimedia represents, as in all CDA documents, the complete authenticated content of the Section. In this case, narrative plus multimedia does not contain any clinical content that is not present in the Entries. An example of this case is a DICOM Structured Reporting document of obstetrical measurements made by ultrasound, rendered into a tabular report by a program converting it to CDA narrative block. If the typeCode of the ActRelationship linking these Entries to the Section was "DRIV", it would indicate to a receiving application: 1) the source of the narrative block is the Entries; 2) the contents of the two are equivalent.

The entries sourced from a Section may have a mix of ActRelationship typeCodes. In such a case, the union of the targets with a "DRIV" relationship are those used to generate the narrative block, and are those that, taken in total, are equivalent to the narrative block. Additional entries with "COMP" relationships are contained within the same section, with no implied semantics.

Table X: Value set for entry.typeCode
V:x_ActRelationshipEntry [2.16.840.1.113883.1.11.19446] (CLOSED)
Code	Display Name	Code	Display Name
COMP (Default)	has component	DRIV	is derived from
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

entry.contextConductionInd

The component.contextConductionInd indicator is fixed to "true". Ancestor elements () which propagate, will conduct through this component class to the associated child element.

5.2.5 Section Narrative Block

The Section.text field is used to store narrative to be rendered, as described above in CDA Conformance, and is therefore referred to as the CDA Narrative Block.

The CDA Narrative Block schema can be found here.

The content model of the CDA Narrative Block schema is specially hand crafted to meet the requirements outlined above (see Human Readability and Rendering CDA Documents). The schema is registered as a MIME type (text/x-hl7-text+xml), which is the fixed media type for Section.text. Components of the schema are described in the sections that follow.

5.2.5.1 <content>

The CDA <content> element is used to wrap a string of text so that it can be explicitly referenced, or so that it can suggest rendering characteristics. The <content> element can nest recursively, which enables wrapping a string of plain text down to as small a chunk as desired.

The <content> element contains an optional identifier, that can serve as the target of a reference. All values of attributes of type XML ID must be unique within the document (per the W3C XML specification). The originalText component of a RIM attribute present in any CDA entry can make explicit reference to the identifier, thereby indicating the original text associated with the attribute in the CDA entry.

Note: The <content> element is not the only element which can serve as the target of a reference. All narrative elements (including <text>) contain an ID element which can be referenced by the originalText component in a CDA entry. <content> is simply a tool which can be used to reference only a portion of a longer string contained in another narrative element.

Example X

<section>
   <code code="10153-2" 
    codeSystem="2.16.840.1.113883.6.1" 
    codeSystemName="LOINC"/>
   <title>Past Medical History</title>
   <text>
    There is a history of <content ID="a1">Asthma</content>
   </text>
   <entry>
      <observation classCode="OBS" moodCode="EVN">
         <code code="195967001" 
          codeSystem="2.16.840.1.113883.6.96" 
          codeSystemName="SNOMED CT" 
          displayName="Asthma">
            <originalText>
               <reference value="#a1"/>
            </originalText>
         </code>
         <statusCode code="completed"/>
      </observation>
   </entry>
</section>

There is no requirement that CDA entries must reference into the CDA Narrative Block. The referencing mechanism can be used where it is important to represent the original text component of a coded CDA entry.

The <content> element contains an optional "revised" attribute that can be valued with "insert" or "delete", which can be used to indicate narrative changes from the last version of a CDA document. The attribute is limited to a single generation, in that it only reflects the changes from the preceding version of a document. If applied, it needs to be used in conjunction with standard CDA revision tracking. Changes to a CDA document that has been released for patient care still require a formal versioning and revision, and the revised document can optionally carry the "revised" attribute to show the delta in the narrative. Receivers are required to interpret the "revised" attribute when rendering by visually distinguishing or suppressing deleted narrative.

5.2.5.2 <linkHtml>

The CDA <linkHtml> is a generic referencing mechanism, similar, but not identical, to the HTML anchor tag. It can be used to reference identifiers that are either internal or external to the document.

Multimedia that is integral to a document, and part of the attestable content of the document requires the use of the ObservationMedia CDA entry, which is referenced by the <renderMultiMedia> element (see <renderMultiMedia>). Multimedia that is simply referenced by the document and not an integral part of the document can use <linkHtml>.

The source of a link uses the linkHtml.href attribute. The target of an internal reference is an identifier of type XML ID, which can exist on other elements in the same or a different narrative block, or XML ID attributes that have been added to the <section>, <ObservationMedia>, or <renderMultiMedia> elements of the CDA Schema. The linkHtml.name attribute is deprecated, because attributes of type XML ID provide an alternative and more consistent target for referencing. Following the conventions of HTML, an internal link is prefaced with the pound sign, as shown in the following example.

Example X

<section ID="SECT001">
   <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" 
    codeSystemName="LOINC"/>
   <title>History of Present Illness</title>
   <text>Mr. Smith is a 57 year old male presenting with 
    chest pain. He sustained a myocardial infarction 3 years 
    ago, ...
   </text>
</section>

 ...

<section ID="SECT003">
   <code code="10153-2" codeSystem="2.16.840.1.113883.6.1" 
    codeSystemName="LOINC"/>
   <title>Past Medical History</title>
   <text>History of coronary artery disease, as noted
    <linkHtml href="#SECT001">above</linkHtml>.</text>
</section>

CDA links do not convey shareable meaning. Shareable semantics are only achieved by the inclusion of CDA entries and their associated formalized relationships. There is no requirement that a receiver render an internal or external link, or the target of an external link.

5.2.5.3 <sub> and <sup>

The CDA <sub> and <sup> elements are used to indicate subscripts and superscripts, respectively.

Receivers are required to interpret these elements when rendering by visually distinguishing subscripted and superscripted characters.

5.2.5.4 <br>

The CDA <br/> element is used to indicate a hard line break. It differs from the CDA <paragraph> element in that the <br/> element has no content. Receivers are required to interpret this element when rendering so as to represent a line break.

5.2.5.5 <footnote> and <footnoteRef>

The CDA <footnote> element is used to indicate a footnote. The element contains the footnote, inline with the flow of text to which it is applied.

The <footnoteRef> element can reference an existing footnote in the same or different CDA Narrative Block of the same document. It can be used when the same footnote is being used multiple times. The value of the footnoteRef.IDREF must be an footnote.ID value in the same document.

Receivers are required to interpret these elements when rendering by visually distinguishing footnoted text. The exact rendition is at the discretion of the recipient, and might include a mark at the location of the footnote with a hyperlink to the footnoted text, a simple demarcation (such as "This is the text [this is the footnote] that is being footnoted"), etc.

5.2.5.6 <renderMultiMedia>

The CDA <renderMultiMedia> element references external multimedia that is integral to a document, and part of the attestable content of the document, and serves to show where the referenced multimedia is to be rendered.

The <renderMultiMedia> element has an optional <caption>, and contains a required referencedObject attribute (of type XML IDREFS), the values of which must equal the XML ID value(s) of ObservationMedia or RegionOfInterest CDA entries within the same document.

Example X

<section>
   <code code="8709-8" codeSystem="2.16.840.1.113883.6.1" 
    codeSystemName="LOINC"/>
   <title>Skin exam</title>
   <text>Erythematous rash, palmar surface, left index 
    finger.<renderMultiMedia referencedObject="MM1"/>
   </text>
   <entry>
      <observationMedia classCode="OBS" moodCode="EVN" ID="MM1">
         <id root="2.16.840.1.113883.19.2.1"/>
         <value xsi:type="ED" mediaType="image/jpeg">
            <reference value="left_hand_image.jpeg"/>
         </value>
      </observationMedia>
   </entry>
</section>

Multimedia that is simply referenced by the document and not an integral part of the document must use <linkHtml>.

The expected behavior is that the referenced multimedia should be rendered or referenced at the point of reference. Where a caption is present, it must also be rendered. <renderMultiMedia> can either reference a single ObservationMedia, or one or more RegionOfInterest. If <renderMultiMedia> references a single ObservationMedia, that ObservationMedia should be rendered or referenced at the point of reference. If <renderMultiMedia> references one or more RegionOfInterest, all RegionOfInterests should be rendered or referenced at the point of reference, atop the multimedia they are regions of. If <renderMultiMedia> references more than one RegionOfInterest, each RegionOfInterest must be a region on the same multimedia.

5.2.5.7 <paragraph>

A CDA <paragraph> is similar to the HTML paragraph, which allows blocks of narrative to be broken up into logically consistent structures. A CDA <paragraph> element contains an optional caption, which if present must come first before any other character data.

5.2.5.8 <list>

A CDA <list> is similar to the HTML list. A CDA <list> has an optional caption, and contains one or more <item> elements. A CDA <item> element contains an optional caption, which if present must come first before any other character data. The required listType attribute specifies whether the <list> is ordered or unordered (with unordered being the default). Unordered lists are typically rendered with bullets, whereas ordered lists are typically rendered with numbers, although this is not a requirement.

5.2.5.9 <table>

The CDA <table> is similar to the HTML table. The table markup is for presentation purposes only and, unlike a database table, does not possess meaningful field names. Remember to access the discrete data conveyed in a CDA document, process the RIM models contained within the <entry> element.

CDA modifies the strict XHTML table model by removing formatting tags and by setting the content model of cells to be similar to the contents of other elements in the CDA Narrative Block. A notable enhancement to the CDA R2.1 standard is the support of the <table> element within <td> & <th> elements. The support of tables within tables was not supported in CDA R2.0, but has been added for those implementation requiring complex table layouts.

The table.border, table.cellspacing, and table.cellpadding attributes are deprecated, because the styleCode attribute (see styleCode attribute) provides a more consistent way for senders to suggest rendering characteristics.

5.2.5.10 <caption>

The CDA <caption> is a label for a paragraph, list, list item, table, or table cell. It can also be used within the <renderMultiMedia> element to indicate a label for referenced ObservationMedia and RegionOfInterest entries. A <caption> contains plain text and may contain links and footnotes.

5.2.5.11 styleCode attribute

The styleCode attribute is used within the CDA Narrative Block to give the instance author the ability to suggest rendering characteristics of the nested character data. Receivers are not required to render documents using the style hints provided and can present stylized text in accordance with their local style conventions.

The value set is drawn from the HL7 styleType vocabulary domain, and has a CWE coding strength.

Table X: Value set for styleCode (CWE)
Code	Definition
Font style (Defines font rendering characteristics.)
Bold	Render with a bold font.
Underline	Render with an underlines font.
Italics	Render italicized.
Emphasis	Render with some type of emphasis.
Table rule style (Defines table cell rendering characteristics.
Lrule	Render cell with left-sided rule.
Rrule	Render cell with right-sided rule.
Toprule	Render cell with rule on top.
Botrule	Render cell with rule on bottom.
Ordered list style (Defines rendering characteristics for ordered lists.)
Arabic	List is ordered using Arabic numerals: 1, 2, 3.
LittleRoman	List is ordered using little Roman numerals: i, ii, iii.
BigRoman	List is ordered using big Roman numerals: I, II, III.
LittleAlpha	List is ordered using little alpha characters: a, b, c.
BigAlpha	List is ordered using big alpha characters: A, B, C.
Unordered list style (Defines rendering characteristics for unordered lists.)
Disc	List bullets are simple solid discs.
Circle	List bullets are hollow discs.
Square	List bullets are solid squares.

Local extensions to the styleType vocabulary domain must follow the following convention: [x][A-Za-z][A-Za-z0-9]* (first character is "x", second character is an upper or lower case A-Z, remaining characters are any combination of upper and lower case letters or numbers).

The styleCode attribute can contain multiple values, separated by white space. Where an element containing a styleCode attribute is nested within another element containing a styleCode attribute, the style effects are additive, as in the following example:

Example X

<section>
   <text><content styleCode="Bold">This is rendered bold, 
    <content styleCode="Italics">this is rendered bold and 
    italicized,</content> this is rendered bold. </content>
    <content styleCode="Bold Italics">This is also rendered 
    bold and italicized.</content>
   </text>
</section>

5.2.5.12 Referencing in and out of the narrative block

NOTE: See entry for a discussion of the relationships between a section and its contained entries.

To summarize the mechanisms for referencing in and out of the CDA Narrative Block:

CDA entries can point in to the <content> element of the CDA Narrative Block (see <content>).

The <linkHtml> element of the CDA Narrative Block can reference targets that are either internal or external to the document (see <linkHtml>).

The <footnoteRef> element of the CDA Narrative Block can reference a <footnote> element in the same or different CDA Narrative Block of the same document (see <footnote> and <footnoteRef>).

The <renderMultiMedia> element of the CDA Narrative Block can point out to CDA ObservationMedia and RegionOfInterest entries of the same document (see <renderMultiMedia>).

5.2.6 Entry Acts

CDA entries represent the structured computer-processable components within a document section. Each section can contain zero to many entries.

Clinical documents contain a wide breadth of content, requiring much of the RIM to enable a full and complete encoding. The current set of CDA entries have been developed in response to identified requirements and scenarios that are in CDA's scope. Rather than creating specific entries for each scenario, similar requirements are merged to create broader entries, which can then be constrained within a particular realm or implementation. This approach is consistent with the approach taken by CEN, DICOM, and OpenEHR.

The model for CDA entries is derived from the shared HL7 Clinical Statement model, which is a collaborative project between several committees striving to provide a consistent representation of clinical observations and acts across various V3 specifications.

5.2.6.1 Act

A derivative of the RIM Act class, to be used when the other classes present in the CDA Clinical Statement choice pattern are not appropriate.

Table X: Act Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	V:x_ActClassDocumentEntryAct	Closed
moodCode	CS	[1..1]	V:x_DocumentActMood	Closed
id	SET <II>	[0..*]
code	CD	[1..1]	D:ActCode	Open
actonNegationInd	BL	[0..1]
negationInd (Deprecated)	BL	[0..1]
text	ED	[0..1]
statusCode	CS	[0..1]	V:ActStatus	Closed
effectiveTime	IVL<TS>	[0..1]
activityTime	GTS	[0..1]
availabilityTime	TS	[0..1]
priorityCode	CE	[0..1]	D:ActPriority	Open
confidentialityCode	SET<CE>	[0..*]	D:Confidentiality	Open
uncertaintyCode	CE	[0..1]	D:ActUncertainty	Open
reasonCode	SET<CE>	[0..*]	D:ActReason	Open
languageCode	CE	[0..1]	D:HumanLanguage	Closed

Act.classCode

The major class of Acts to which an Act-instance belongs.

Table X: Value set for Act.classCode
x_ActClassDocumentEntryAct [2.16.840.1.113883.1.11.19599] (CLOSED)
Code	Display Name	Code	Display Name
ACT	Act	ACCM	accommodation
CONS	consent	CTTEVENT	clinical trial timepoint event
INC	incident	INFRM	inform
PCPR	care provision	REG	registration
SPCTRT	specimen treatment	TRNS	transportation
ACSN	accession	CONTREG	container registration
DISPACT	disciplinary action	EXPOS	exposure
AEXPOS	acquisition exposure	TEXPOS	transmission exposure
LIST	working list	MPROT	monitoring program
REV	review	STORE	storage
TRFR	transfer
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Act.moodCode

The intended use of the Act statement: as a report of fact, a command, a possibility, a goal, etc. Since the mood code is a determining factor for the meaning of an entire Act object, the mood must always be known. This means that whenever an act object is instantiated, the mood attribute SHALL be assigned to a valid code, and the mood assignment SHALL NOT change throughout the lifetime of the act object.

Table X: Value set for Act.moodCode
V:x_DocumentActMood [2.16.840.1.113883.1.11.19458] (CLOSED)
Code	Display Name	Code	Display Name
APT	appointment	ARQ	appointment request
EVN	event	DEF	definition
RQO	request	INT	intent
PRMS	promise	PRP	proposal
RSK	risk
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Act.id

A unique identifier for the Act.

Act.code

The particular kind of Act that the Act-instance represents within its class. Act.code, if used, SHALL be a specialization of the Act.classCode. This attribute defines a specific sub-type of a given Act type (determined by the "classCode" attribute). It allows the use of rich terminologies such as LOINC and SNOMED to represent sub-types of the limited set of Act types defined by "classCode." The Act.code is bound to the ActCode concept domain.

Act.actionNegation

Act.actionNegationInd, indicates that the Act statement is a negation of the Act in Event mood as described by the descriptive attributes. For Act, actionNegationInd indicates that the act itself did not occur. I.e. no act took place. Some properties such as Act.id, Act.moodCode, and the participations are not affected. These properties always have the same meaning: i.e., the author remains the author of the negative Act. An act statement with negationInd is still a statement about the specific fact described by the Act.

Act.negationInd

Act.negationInd, is deprecated in RIM 2.35, and CDA R2.1 retains it for backwards compatibility. CDA R2.1 compliant implementation guides should use actionNegationInd moving forward.

Act.text

A renderable textual or multimedia description (or reference to a description) of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the Act. The Act.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

Act.statusCode

The status reflects the state of the activity. The RIM based state machine diagram depicts the allowable state transitions that an Act.StatusCodes can take on.

Table X: Value set for Act.statusCode
V:ActStatus [2.16.840.1.113883.1.11.15933] (CLOSED)
Code	Display Name	Code	Display Name
normal	normal	aborted	aborted
active	active	cancelled	cancelled
completed	completed	held	held
new	new	suspended	suspended
nullified	nullified	obsolete	obsolete
Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14

Act.effectiveTime

Act.effectiveTime is used to indicate the clinically or operationally relevant time of a procedure, exclusive of administrative activity.

Act.activityTime

Act.activityTime is a time expression specifying when an act occurs, inclusive of administrative time E.g. times of component actions, such as preparation and clean-up. Depending on the mood code used, it represents the time the act occurred, is supposed to occur, is scheduled to occur, etc.

Act.availabilityTime

Act.availabilityTime is the point in time at which information about an act instance (regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the act itself.

Act.priorityCode

The urgency under which the Act happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. The Act.priorityCode is bound to the ActPriority concept domain.

Act.confidentialityCode

Constraints around appropriate disclosure of information about this Act, regardless of mood. The Act.confidentialityCode is bound to the Confidentiality concept domain.

Act.uncertaintyCode

An indication that the Act statement as a whole, with its subordinate components has been asserted to be uncertain in some way. The use of the uncertaintyCode is appropriate only if the entirety of the Act and its dependent Acts is questioned. The Act.uncertaintyCode is bound to the ActUncertainty concept domain.

Act.reasonCode

The motivation, cause, or rationale of an Act, when such rationale is not reasonably represented as an ActRelationship of type "has reason" linking to another Act. The Act.reasonCode is bound to the ActReason concept domain.

Most reasons for acts can be clearly expressed by linking the new Act to another prior Act record using an ActRelationship of type "has reason." This simply states that the prior Act is a reason for the new Act (see ActRelationship). The prior act can then be a specific existing act or a textual explanation. This works for most cases, and the more specific the reason data is, the more should this reason ActRelationship be used instead of the reasonCode.

The reasonCode remains as a place for common reasons that are not related to a prior Act or any other condition expressed in Acts. Indicators that something was required by law or was on the request of a patient may qualify. However, if that piece of legislation, regulation, or the contract or the patient request can be represented as an Act (and they usually can), such a representation is preferable to the reasonCode.

Act.languageCode

The primary language in which this Act statement is specified, particularly the language of the Act.text. The Act.languageCode is bound to the HumanLanguage concept domain.

5.2.6.2 Encounter

A derivative of the RIM PatientEncounter class, used to represent related encounters, such as follow-up visits or referenced past encounters.

NOTE: The EncompassingEncounter class in the CDA Header (see Header Relationships) represents the setting of the clinical encounter during which the documented act occurred. The Encounter class in the CDA Body is used to represent other related encounters.

Table X: Encounter Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	ENC	Fixed
moodCode	CS	[1..1]	V:x_DocumentEncounterMood	Closed
id	SET <II>	[0..*]
code	CD	[1..1]	D:ActCode	Open
actonNegationInd	BL	[0..1]
negationInd (Deprecated)	BL	[0..1]
text	ED	[0..1]
statusCode	CS	[0..1]	V:ActStatus	Closed
effectiveTime	IVL<TS>	[0..1]
activityTime	GTS	[0..1]
availabilityTime	TS	[0..1]
priorityCode	CE	[0..1]	D:ActPriority	Open
confidentialityCode	SET<CE>	[0..*]	D:Confidentiality	Open
uncertaintyCode	CE	[0..1]	D:ActUncertainty	Open
reasonCode	SET<CE>	[0..*]	D:ActReason	Open
languageCode	CE	[0..1]	D:HumanLanguage	Closed
admissionReferralSourceCode	<CE>	[0..1]	D:EncounterReferralSource	Open
lengthOfStayQuantity	<PQ>.TIME	[0..1]
dischargeDispositionCode	<CE>	[0..1]	D:EncounterDischargeDisposition	Open
preAdmitTestInd	BL	[0..1]
specialCourtesiesCode	SET<CE>	[0..*]	D:EncounterSpecialCourtesy	Open
specialArrangementCode	SET<CE>	[0..*]	D:SpecialArrangement	Open

Encounter.classCode

The Encounter.classCode is fixed to "ENC" to represent an encounter. The encounter class is used to represent an interaction between a patient and healthcare participant(s) for the purpose of providing patient service(s) or assessing the health status of a patient.

Table X: Fixed Encounter.classCode
Code	Display Name
ENC (Fixed)	encounter
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Encounter.moodCode

The Encounter.moodCode is bound to the x_DocumentEncounterMood value set. This enables to the modeling of both past, present and planned future encounters.

Table X: Value set for Encounter.moodCode
V:x_DocumentEncounterMood [2.16.840.1.113883.1.11.19459] (CLOSED)
Code	Display Name	Code	Display Name
APT	appointment	ARQ	appointment request
EVN	event	DEF	definition
RQO	request	INT	intent
PRMS	promise	PRP	proposal
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Encounter.id

The optional EncompassingEncounter.id can be used to uniquely identify the encounter.

Encounter.code

The optional EncompassingEncounter.code is bound to the ActEncounterCode value set.

Table X: Value set for EncompassingEncounter.code
V:ActEncounterCode [2.16.840.1.113883.1.11.13955] (OPEN)
Code	Display Name	Code	Display Name
AMB	ambulatory	EMER	emergency
FLD	field	HH	home health
IMP	inpatient encounter	ACUTE	inpatient acute
NONAC	virtual	SS	short stay
VR	inpatient non-acute
Code System: ActCode (HL7) Code System OID: 2.16.840.1.113883.5.4

Encounter.actionNegation

Encounter.actionNegationInd, indicates that the Encounter statement is a negation of the Encounter in Event mood as described by the descriptive attributes. For Encounter, actionNegationInd indicates that the Encounter itself did not occur. I.e. no Encounter took place. Some properties such as Encounter.id, Encounter.moodCode, and the participations are not affected. These properties always have the same meaning: i.e., the author remains the author of the negative Encounter.

Encounter.text

A renderable textual or multimedia description (or reference to a description) of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the Encounter. The Encounter.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

Encounter.statusCode

The status reflects the state of the Encounter. The RIM based state machine diagram depicts the allowable state transitions that an Encounter.statusCode can take on.

Encounter.effectiveTime

For Encounters, the effectiveTime is the "administrative" time, i.e., the encounter start and end date as established by business rules. For inpatient encounters, the effectiveTime/low value is the admission date and time and the effectiveTime/high value is the discharge date and time. Note: If the encounter is still active at the time of document creation, the effectiveTime/high element can be omitted to indicate the encounter is on-going.

Encounter.activityTime

Encounter.activityTime is a time expression specifying when an Encounter occurs, inclusive of administrative time E.g. times of component actions, such as preparation and clean-up. Depending on the mood code used, it represents the time the Encounter occurred, is supposed to occur, is scheduled to occur, etc.

Encounter.availabilityTime

Encounter.availabilityTime is the point in time at which information about an Encounter instance (regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the Encounter itself.

Encounter.priorityCode

The urgency under which the Encounter happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. The Encounter.priorityCode is bound to the ActPriority concept domain.

Encounter.confidentialityCode

Constraints around appropriate disclosure of information about this Encounter, regardless of mood. The Encounter.confidentialityCode is bound to the Confidentiality concept domain.

Encounter.reasonCode

The motivation, cause, or rationale of an Encounter, when such rationale is not reasonably represented as an ActRelationship of type "has reason" linking to another Act. The Encounter.reasonCode is bound to the ActReason concept domain.

Encounter.languageCode

The primary language in which this Encounter statement is specified, particularly the language of the Encounter.text. The Encounter.languageCode is bound to the HumanLanguage concept domain.

Encounter.admissionReferralSourceCode

The optional EncompassingEncounter.admissionReferralSourceCode can be use to depict the type of place or organization responsible for the patient's care immediately prior to a patient encounter.

Encounter.lengthOfStayQuantity

The total quantity of time when the subject is expected to be or was resident at a facility as part of an encounter. Note, the actual days quantity cannot be simply calculated from the admission and discharge dates because of possible leaves of absence.

Encounter.dischargeDispositionCode

The optional EncompassingEncounter.dischargeDispositionCode can be used to depict the disposition of the patient at the time of hospital discharge (e.g., discharged to home, expired, against medical advice, etc.).

Encounter.preAdmitTestInd

An indication that pre-admission tests are required for this patient encounter.

Encounter.specialArrangementCode

Extraordinary considerations or services provided within the context of the Patient Encounter. Examples include: Professional courtesy, VIP courtesies, no courtesies

5.2.6.3 Observation

A derivative of the Observation(§ RIM 5.36) class, it is intended to result in new information about a subject. The main difference between Observations and other Acts is that Observations have a value attribute. The code attribute of Observation and the value attribute of Observation must be considered in combination to determine the semantics of the observation.

Table X: Observation Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	V:ActClassObservation	Closed
moodCode	CS	[1..1]	V:x_ActMoodDocumentObservation	Closed
id	SET <II>	[0..*]
code	CD	[1..1]	D:ObservationType	Open
actonNegationInd	BL	[0..1]
negationInd (Deprecated)	BL	[0..1]
derivationExpr	ST	[0..1]
title	ED	[0..1]
text	ED	[0..1]
statusCode	CS	[0..1]	V:ActStatus	Closed
effectiveTime	IVL<TS>	[0..1]
activityTime	GTS	[0..1]
availabilityTime	TS	[0..1]
priorityCode	CE	[0..1]	D:ActPriority	Open
confidentialityCode	SET<CE>	[0..*]	D:Confidentiality	Open
repeatNumber	IVL<INT>	[0..1]
uncertaintyCode	CE	[0..1]	D:ActUncertainty	Open
languageCode	CE	[0..1]	D:HumanLanguage	Closed
value	SET<ANY>	[0..*]	D:ObservationValue	Open
valueNegationInd	BL	[0..1]
interpretationCode	SET<CE>	[0..*]	D:ObservationInterpretation	Open
methodCode	SET<CE>	[0..*]	D:ObservationMethod	Open
targetSiteCode	SET<CD>	[0..*]	D:ActSite	Open

Observation.classCode

The defines a specific sub-type of a given Observation type.

Table X: Value set for Observation.classCode
V:ActClassObservation [2.16.840.1.113883.1.11.11529] (CLOSED)
Code	Display Name	Code	Display Name
OBS (Default)	Observation	ALRT	detected issue
BATTERY	battery	CLNTRL	clinical trial
CONC	concern	COND	Condition
CASE	public health case	OUTB	outbreak
DGIMG	diagnostic image	GEN	genomic observation
DETPOL	determinant peptide	EXP	expression level
LOC	locus	PHN	phenotype
POL	polypeptide	SEQ	bio sequence
SEQVAR	bio sequence variation	INVSTG	investigation
OBSSER	observation series	OBSCOR	correlated observation sequences
POS	position	POSACC	position accuracy
POSCOORD	position coordinate	SPCOBS	specimen observation
VERIF	Verification	ROIBND	bounded ROI
ROIOVL	overlay ROI	LLD (Deprecated)	left lateral decubitus
PRN (Deprecated)	prone	RLD (Deprecated)	right lateral decubitus
SFWL (Deprecated)	Semi-Fowler's	SIT (Deprecated)	sitting
STN (Deprecated)	standing	SUP (Deprecated)	supine
RTRD (Deprecated)	reverse trendelenburg	TRD (Deprecated)	trendelenburg
CNOD (Deprecated)	Condition Node
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Observation.moodCode

The intended use of the Observation statement: as a report of fact, a command, a possibility, a goal, etc. Since the mood code is a determining factor for the meaning of an entire Observation object, the mood must always be known. This means that whenever an Observation is instantiated, the mood attribute SHALL be assigned to a valid code, and the mood assignment SHALL NOT change throughout the lifetime of the Observation.

Table X: Value set for Observation.moodCode
V:x_ActMoodDocumentObservation [2.16.840.1.113883.1.11.19644] (CLOSED)
Code	Display Name	Code	Display Name
APT	appointment	ARQ	appointment request
EVN	event	DEF	definition
GOL	goal	INT	intent
PRMS	promise	PRP	proposal
RSK	risk	RQO	request
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Observation.id

A unique identifier for the Observation.

Observation.code

The particular kind of Observation that the Observation-instance represents within its class. Observation.code, if used, SHALL be a specialization of the Observation.classCode. This attribute defines a specific sub-type of a given Observation type (determined by the "classCode" attribute). The Observation.code is bound to the ActCode concept domain.

Observation.actionNegationInd

Observation.actionNegationInd, indicates that the Act statement is a negation of the Act in Event mood as described by the descriptive attributes. For Observations, actionNegationInd indicates that the act itself did not occur. I.e. no observation took place. To indicate that an observation did occur but the finding was negative, use Observation.valueNegationInd.

Observation.negationInd

Observation.negationInd, is deprecated in RIM 2.35, and CDA R2.1 retains it for backwards compatibility. It was deprecated as the type of negation required knowledge of template documentation to determine the actual type of negation I.e. value or action negation. CDA R2.1 compliant implementation guides should use actionNegationInd or valueNegationInd moving forward.

Observation.derivationExpr

A character string containing a formal language expression that specifies how the Observation's attributes are, should be, or have been derived from input parameters associated with derivation relationships. Derived observations can be defined through association with other observations using ActRelationships of type "derivation." For example, to define a derived observation for Mean Corpuscular Hemoglobin (MCH) one will associate the MCH observation with a Hemoglobin (HGB) observation and a Red Blood cell Count (RBC) observation: the derivation expression value encodes the formula: MCH = HGB / RBC.

Observation.title

A word or phrase by which a specific Observation may be known among people. This is not a formal identifier but rather a human-recognizable common name. However it is similar to the id attribute in that it refers to a specific Observation rather than a 'kind' of Observation. (For definition mood, the title refers to that specific definition, rather than to a broad category that might be conveyed with Observation.code.)

Observation.text

A renderable textual or multimedia description (or reference to a description) of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the Observation. The Observation.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

Observation.statusCode

The status reflects the state of the activity. The RIM based state machine diagram depicts the allowable state transitions that an Observation.StatusCode can take on.

Table X: Value set for Observation.statusCode
V:ActStatus [2.16.840.1.113883.1.11.15933] (CLOSED)
Code	Display Name	Code	Display Name
normal	normal	aborted	aborted
active	active	cancelled	cancelled
completed	completed	held	held
new	new	suspended	suspended
nullified	nullified	obsolete	obsolete
Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14

Observation.effectiveTIme

Observation.effectiveTime is used to indicate the clinically or operationally relevant time of an observation, exclusive of administrative activity. For example, in a Blood Gas Analysis (BGA), a result might not be available for several minutes after the specimen was taken. The effectiveTime is the time the specimen was taken, the availabilityTime would be the time the result was available for review. For clinical Observations, the effectiveTime represents the time at which the observation holds (is effective) for the patient. In V2 the effectiveTime was known as the biologically relevant time.

Observation.activityTime

Observation.activityTime is a time expression specifying when an Observation occurs, inclusive of administrative time E.g. times of component actions, such as preparation and clean-up. Depending on the mood code used, it represents the time the observation occurred, is supposed to occur, is scheduled to occur, etc. When an observation of a prior symptom is made, the activityTime describes the time the observation is made, as opposed to effectiveTime which is the time the symptom is reported to have occurred. Thus the activityTime may be entirely different from the effectiveTime for the same observation instance.

Observation.availabilityTIme

Observation.availabilityTime is the point in time at which information about an observation instance (regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the Observation itself. For CDA documents, the availabilityTime reported for its contents, would represent the time the observation first became available to a source system generating the CDA document.

Observation.priorityCode

The urgency under which the Act happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. The Act.priorityCode is bound to the ActPriority concept domain.

Observation.confidentialityCode

Constraints around appropriate disclosure of information about this Observation, regardless of mood. The Observation.confidentialityCode is bound to the Confidentiality concept domain.

Observation.repeatNumber

An interval of integer numbers stating the minimal and maximal number of repetitions of the Observation.

Observation.uncertaintyCode

An indication that the Observation statement as a whole, with its subordinate components has been asserted to be uncertain in some way. The use of the uncertaintyCode is appropriate only if the entirety of the Observation and its dependent Acts is questioned. The Observation.uncertaintyCode is bound to the ActUncertainty concept domain.

Observation.languageCode

The primary language in which this Observation statement is specified, particularly the language of the Observation.text. The Observation.languageCode is bound to the HumanLanguage concept domain.

Observation.value

The result of the observation action. Extensive usage notes are available in the RIM, reference Value UsageNotes

Observation.valueNegationInd

Observation.valueNegationInd, indicates that when the observation event occurred, the finding communicated by the value attribute was NOT found. So, when we want to indicate the patient does not have asthma, we can negate a finding of asthma, using this indicator. Note: This attribute should only be used when the terminology used for Observation.value is not itself capable of expressing negated findings. (E.g. ICD9).

Observation.interpretationCode

A qualitative interpretation of the observation. These interpretation codes are sometimes called "abnormal flags," however, the judgment of normalcy is just one of the interpretations, and is often not relevant. For example, the susceptibility interpretations are not about "normalcy," and for any observation of a pathologic condition, it does not make sense to state the normalcy, since pathologic conditions are never considered "normal."

Observation.methodCode

The means or technique used to ascertain the observation. In all observations the method is already partially specified by the Observation.code. In this case, the methodCode NEED NOT be used at all. The methodCode MAY still be used to identify this method more clearly in addition to what is implied from the Observation.code. However, an information consumer system or process SHOULD NOT depend on this methodCode information for method detail that is implied by the Observation.code.

Observation.targetSiteCode

The anatomical site or system that is the focus of the observation. Most observation target sites are implied by the observation definition and Observation.code, or Observation.value. For example, "heart murmur" always has the heart as target. This attribute is used only when the observation target site needs to be refined, to distinguish right from left, etc. If the subject of the Observation is something other than a human patient or animal, the attribute is used analogously to specify a structural landmark of the thing where the Observation focuses. For example, if the subject is a lake, the site could be inflow and outflow, etc. If the subject is a lymphatic node, "hilus," "periphery," or other node sites would be valid target sites.

5.2.6.3.1 Reference Range

An Observation can have zero to many referenceRange relationships, which relate an Observation to the ObservationRange class. Reference ranges are essentially descriptors of a class of result values assumed to be "normal", "abnormal", or "critical." Those can vary by sex, age, or any other criterion.

referenceRange.typeCode

Table X: Fixed referenceRange.typeCode
Code	Display Name
REFV	has reference values
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

5.2.6.3.2 ObservationRange

ObservationRange.classCode

Table X: Value set for ObservationRange.classCode
V:ActClassObservation [2.16.840.1.113883.1.11.11529] (CLOSED)
Code	Display Name	Code	Display Name
OBS (Default)	Observation	ALRT	detected issue
BATTERY	battery	CLNTRL	clinical trial
CONC	concern	COND	Condition
CASE	public health case	OUTB	outbreak
DGIMG	diagnostic image	GEN	genomic observation
DETPOL	determinant peptide	EXP	expression level
LOC	locus	PHN	phenotype
POL	polypeptide	SEQ	bio sequence
SEQVAR	bio sequence variation	INVSTG	investigation
OBSSER	observation series	OBSCOR	correlated observation sequences
POS	position	POSACC	position accuracy
POSCOORD	position coordinate	SPCOBS	specimen observation
VERIF	Verification	ROIBND	bounded ROI
ROIOVL	overlay ROI	LLD (Deprecated)	left lateral decubitus
PRN (Deprecated)	prone	RLD (Deprecated)	right lateral decubitus
SFWL (Deprecated)	Semi-Fowler's	SIT (Deprecated)	sitting
STN (Deprecated)	standing	SUP (Deprecated)	supine
RTRD (Deprecated)	reverse trendelenburg	TRD (Deprecated)	trendelenburg
CNOD (Deprecated)	Condition Node
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

ObservationRange.moodCode

Table X: Fixed ObservationRange.moodCode
Code	Display Name
EVN.CRT	event criterion
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

ObservationRange.code

ObservationRange.actionNegationInd

ObservationRange.text

ObservationRange.isCriterionInd

ObservationRange.value

ObservationRange.valueNegationInd

ObservationRange.interprerationCode

5.2.6.4 ObservationMedia

A derivative of the RIM Observation class that represents multimedia that is logically part of the current document. This class is only for multimedia that is logically part of the attested content of the document. Rendering a referenced ObservationMedia requires a software tool that recognizes the particular MIME media type. The distinction between ObservationMedia and ExternalObservation is that ObservationMedia entries are part of the attested content of the document whereas ExternalObservations are not. For instance, when a clinician draws a picture as part of a progress note, that picture is represented as a CDA ObservationMedia. If that clinician is also describing a finding seen on a chest-x-ray, the referenced chest-x-ray is represented as a CDA ExternalObservation.

Table X: ObservationMedia Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	V:ActClassObservation	Closed
moodCode	CS	[1..1]	EVN	Fixed
id	SET <II>	[0..*]
languageCode	CE	[0..1]	D:HumanLanguage	Closed
value	ED	[1..1]

NOTE: XML ID Attribute added

An XML attribute "ID" of type XML ID, is added to ObservationMedia within the CDA Schema. This attribute serves as the target of a <renderMultiMedia> reference (see <renderMultiMedia>). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).

ObservationMedia.classCode

Table X: Value set for ObservationMedia.classCode
V:ActClassObservation [2.16.840.1.113883.1.11.11529] (CLOSED)
Code	Display Name	Code	Display Name
OBS (Default)	Observation	ALRT	detected issue
BATTERY	battery	CLNTRL	clinical trial
CONC	concern	COND	Condition
CASE	public health case	OUTB	outbreak
DGIMG	diagnostic image	GEN	genomic observation
DETPOL	determinant peptide	EXP	expression level
LOC	locus	PHN	phenotype
POL	polypeptide	SEQ	bio sequence
SEQVAR	bio sequence variation	INVSTG	investigation
OBSSER	observation series	OBSCOR	correlated observation sequences
POS	position	POSACC	position accuracy
POSCOORD	position coordinate	SPCOBS	specimen observation
VERIF	Verification	ROIBND	bounded ROI
ROIOVL	overlay ROI	LLD (Deprecated)	left lateral decubitus
PRN (Deprecated)	prone	RLD (Deprecated)	right lateral decubitus
SFWL (Deprecated)	Semi-Fowler's	SIT (Deprecated)	sitting
STN (Deprecated)	standing	SUP (Deprecated)	supine
RTRD (Deprecated)	reverse trendelenburg	TRD (Deprecated)	trendelenburg
CNOD (Deprecated)	Condition Node
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

ObservationMedia.moodCode

Table X: Fixed ObservationMedia.moodCode
Code	Display Name
EVN	event (occurrence)
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

ObservationMedia.id

ObservationMedia.languageCode

ObservationMedia.value

5.2.6.5 Organizer

A derivative of the RIM Act class, which can be used to create arbitrary groupings of other CDA entries that share a common context. An Organizer can contain other Organizers and/or other CDA entries, by traversing the component relationship. An Organizer can refer to external acts by traversing the reference relationship. An Organizer cannot be the source of an entryRelationship relationship.

NOTE: CDA entries such as Observation can also contain other CDA entries by traversing the entryRelationship class. There is no requirement that the Organizer entry be used in order to group CDA entries.

Table X: Organizer Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	V:x_ActClassDocumentEntryOrganizer	Closed
moodCode	CS	[1..1]	EVN	Fixed
id	SET <II>	[0..*]
code	CD	[1..1]	D:ActCode	Open
text	ED	[0..1]
statusCode	CS	[0..1]	V:ActStatus	Closed
effectiveTime	IVL<TS>	[0..1]
activityTime	GTS	[0..1]
availabilityTime	TS	[0..1]
priorityCode	CE	[0..1]	D:ActPriority	Open
confidentialityCode	SET<CE>	[0..*]	D:Confidentiality	Open

Organizer.classCode

Table X: Value set for Organizer.classCode
V:x_ActClassDocumentEntryOrganizer [2.16.840.1.113883.1.11.19598] (CLOSED)
Code	Display Name	Code	Display Name
BATTERY	battery	CLUSTER	Cluster
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Organizer.moodCode

Table X: Fixed Organizer.moodCode
Code	Display Name
EVN	event (occurrence)
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Organizer.id

Organizer.code

Organizer.text

Organizer.statusCode

Organizer.effectiveTime

Organizer.activityTime

Organizer.availabilityTime

Organizer.priorityCode

Organizer.confidentialityCode

5.2.6.6 Procedure

A derivative of the RIM Procedure class, is represents an act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject.

Table X: Procedure Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	V:ActClassProcedure	Closed
moodCode	CS	[1..1]	V:x_DocumentProcedureMood	Closed
id	SET <II>	[0..*]
code	CD	[1..1]	D:ActProcedureCode	Open
actonNegationInd	BL	[0..1]
negationInd (Deprecated)	BL	[0..1]
text	ED	[0..1]
statusCode	CS	[0..1]	V:ActStatus	Closed
effectiveTime	IVL<TS>	[0..1]
activityTime	GTS	[0..1]
availabilityTime	TS	[0..1]
priorityCode	CE	[0..1]	D:ActPriority	Open
confidentialityCode	SET<CE>	[0..*]	D:Confidentiality	Open
uncertaintyCode	CE	[0..1]	D:ActUncertainty	Open
languageCode	CE	[0..1]	D:HumanLanguage	Closed
isCriterionInd	BL	[0..1]
methodCode	CE	[0..*]	D:ProcedureMethod	Open
approachSiteCode	CE	[0..*]	D:ActSite	Open
targetSiteCode	CE	[0..*]	D:ActSite	Open

Procedure.classCode

Table X: Value set for Procedure.classCode
V:ActClassProcedure [2.16.840.1.113883.1.11.19665] (CLOSED)
Code	Display Name	Code	Display Name
PROC (Default)	procedure	SBEXT	Substance Extraction
SPECCOLLECT	Specimen Collection
Note: Although SBADM is technically allowed, is best used with the SubstanceAdministration Entry Class
SBADM	substance administration
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Procedure..moodCode

Table X: Value set for Procedure.moodCode
V:x_DocumentProcedureMood [2.16.840.1.113883.1.11.19460] (CLOSED)
Code	Display Name	Code	Display Name
APT	appointment	ARQ	appointment request
EVN	event	DEF	definition
RQO	request	INT	intent
PRMS	promise	PRP	proposal
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Procedure.id

Procedure.code

Procedure.actionNegationInd

Procedure.actionNegationInd, when set to "true", indicates that the Procedure statement is a negation of the Procedure in Event mood as described by the descriptive attributes. For Procedure, actionNegationInd indicates that the procedure itself did not occur. For instance, a negated "appendectomy performed" means that the author positively denies that there was ever an appendectomy performed, and that he takes the same responsibility for such statement and the same requirement to have evidence for such statement than if he had not used negation. Some properties such as Procedure.id, Procedure.moodCode, and the participations are not affected.

Procedure.negationInd

Procedure.negationInd, is deprecated in RIM 2.35, and CDA R2.1 retains it for backwards compatibility. CDA R2.1 compliant implementation guides should use actionNegationInd moving forward.

Procedure.text

Procedure.statusCode

Procedure.effectiveTime

Procedure.effectiveTime is used to indicate the clinically or operationally relevant time of a procedure, exclusive of administrative activity. For a surgical procedure (operation), the effectiveTime is the time relevant for the patient, i.e., between incision and last suture. For transportation acts, the effective time is the time the transported payload is en route.

Procedure.activityTime

Procedure.activityTime is a time expression specifying when a procedure occurs, inclusive of administrative time E.g. times of component actions, such as preparation and clean-up. Depending on the mood code used, it represents the time the procedure occurred, is supposed to occur, is scheduled to occur, etc. For Procedures the activityTime can provide a needed administrative function by providing a more inclusive time to be anticipated in scheduling.

Procedure.availabilityTime

Procedure.availabilityTime is the point in time at which information about a procedure instance (regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the procedure itself.

Procedure.priorityCode

Procedure.confidentialityCode

Procedure.uncertaintyCode

Procedure.languageCode

Procedure.isCriterionInd

Procedure.methodCode

Procedure.approachSiteCode

Procedure.targetSiteCode

5.2.6.7 RegionOfInterest

A derivative of the RIM Observation class that represents a region of interest on an image, using an overlay shape. RegionOfInterest is used to make reference to specific regions in images, e.g., to specify the site of a physical finding by "circling" a region in a schematic picture of a human body. The units of the coordinate values in RegionOfInterest.value are in pixels, expressed as a list of integers. The origin is in the upper left hand corner, with positive X values going to the right and positive Y values going down. The relationship between a RegionOfInterest and its referenced ObservationMedia or ExternalObservation is specified by traversing the entryRelationship or reference class, respectively, where typeCode equals "SUBJ". A RegionOfInterest must reference exactly one ObservationMedia or one ExternalObservation. If the RegionOfInterest is the target of a <renderMultimedia> reference, then it shall only reference an ObservationMedia and not an ExternalObservation.

Table X: RegionOfInterest Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	ROIOVL	Fixed
moodCode	CS	[1..1]	EVN	Fixed
id	SET <II>	[0..*]
code	CE	[0..1]	V:ROIOverlayShape	Closed
value	LIST<INT>	[1..*]

NOTE: XML ID Attribute added

An XML attribute "ID" of type XML ID, is added to RegionOfInterest within the CDA Schema. This attribute serves as the target of a <renderMultiMedia> reference (see <renderMultiMedia>). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).

RegionOfInterest.classCode

Table X: Fixed RegionOfInterest.classCode
Code	Display Name
ROIOVL	overlay ROI
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Table X: Fixed RegionOfInterest.moodCode
Code	Display Name
EVN (Fixed)	event (occurrence)
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

RegionOfInterest.moodCode

RegionOfInterest.id

RegionOfInterest.code

Table X: Value set for RegionOfInterest.code
V:ROIOverlayShape [2.16.840.1.113883.1.11.16117] (CLOSED)
Code	Display Name	Code	Display Name
CIRCLE	circle	ELLIPSE	ellipse
POINT	point	POLY	polyline
Code System: ActCode (HL7) Code System OID: 2.16.840.1.113883.5.4

RegionOfInterest.value

EXAMPLE

The following example illustrates one sample use of RegionOfInterest. In this case, the clinician has identified a rash upon physical examination of the skin, and indicates this by creating a region of interest atop a hand image taken from an image library. The narrative block references the RegionOfInterest via the <renderMultiMedia> tag, and the referenced RegionOfInterest references the hand image.

Example X

<section>
   <code code="8709-8" codeSystem="2.16.840.1.113883.6.1" 
    codeSystemName="LOINC"/>
   <title>Skin Exam</title>
   <text>Erythematous rash, palmar surface, left index 
    finger.<renderMultiMedia referencedObject="MM2"/>
   </text>
   <entry>
      <observation classCode="OBS" moodCode="EVN">
         <code code="271807003" 
          codeSystem="2.16.840.1.113883.6.96" 
          codeSystemName="SNOMED CT" 
          displayName="Rash"/>
         <statusCode code="completed"/>
         <targetSiteCode code="48856004" 
          codeSystem="2.16.840.1.113883.6.96" 
          codeSystemName="SNOMED CT" 
          displayName="Skin of palmer surface of index finger">
            <qualifier>
               <name code="78615007" 
                codeSystem="2.16.840.1.113883.6.96" 
                displayName="with laterality"/>
               <value code="7771000" 
                codeSystem="2.16.840.1.113883.6.96" 
                displayName="left"/>
            </qualifier>
         </targetSiteCode>
         <entryRelationship typeCode="SPRT">
            <regionOfInterest classCode="ROIOVL" moodCode="EVN" ID="MM2">
               <id root="2.16.840.1.113883.19.3.1"/>
               <code code="ELLIPSE"/>
               <value value="3"/>
               <value value="1"/>
               <value value="3"/>
               <value value="7"/>
               <value value="2"/>
               <value value="4"/>
               <value value="4"/>
               <value value="4"/>
               <entryRelationship typeCode="SUBJ">
                  <observationMedia classCode="OBS" moodCode="EVN">
                     <id root="2.16.840.1.113883.19.2.1"/>
                     <value mediaType="image/jpeg">
                        <reference value="lefthand.jpeg"/>
                     </value>
                  </observationMedia>
               </entryRelationship>
            </regionOfInterest>
         </entryRelationship>
      </observation>
   </entry>
</section>

5.2.6.8 SubstanceAdministration

A derivative of the RIM SubstanceAdministration class, used for representing medication-related events such as medication history or planned medication administration orders.

Table X: SubstanceAdministration Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	SBADM	Fixed
moodCode	CS	[1..1]	V:x_DocumentSubstanceMood	Closed
id	SET <II>	[0..*]
code	CD	[1..1]	D:ActSubstanceAdministrationCode	Open
actonNegationInd	BL	[0..1]
negationInd (Deprecated)	BL	[0..1]
text	ED	[0..1]
statusCode	CS	[0..1]	V:ActStatus	Closed
effectiveTime	GTS	[0..1]
activityTime	GTS	[0..1]
availabilityTime	TS	[0..1]
priorityCode	CE	[0..1]	D:ActPriority	Open
confidentialityCode	SET<CE>	[0..*]	D:Confidentiality	Open
repeatNumber	IVL<INT>	[0..1]
languageCode	CE	[0..1]	D:HumanLanguage	Closed
isCriterionInd	BL	[0..1]
approachSiteCode	CE	[0..1]	D:RouteOfAdministration	Open
routeSiteCode	SET<CD>	[0..*]	D:ActSite	Open
doseQuantity	IVL<PQ>	[0..*]
rateQuantity	IVL<PQ>	[0..*]
doseCheckQuantity	SET<RTO<PQ,PQ.TIME>>	[0..*]
maxDoseQuantity	SET<RTO<PQ,PQ.TIME>>	[0..*]
administrationUnitCode	CE	[0..1]	D:AdministrableDrugForm	Open

SubstanceAdministration.classCode

Table X: Fixed SubstanceAdministration.classCode
Code	Display Name
SBADM	substance administration
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

SubstanceAdministration..moodCode

Table X: Fixed SubstanceAdministration.moodCode
V:x_DocumentSubstanceMood [2.16.840.1.113883.1.11.19461] (CLOSED)
Code	Display Name	Code	Display Name
EVN	event	DEF	definition
RQO	request	INT	intent
PRMS	promise	PRP	proposal
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

SubstanceAdministration.id

SubstanceAdministration.code

SubstanceAdministration.actionNegationInd

SubstanceAdministration.actionNegationInd, when set to "true", indicates that the SubstanceAdministration statement is a negation of the SubstanceAdministration in Event mood as described by the descriptive attributes. Some properties such as SubstanceAdministration.id, SubstanceAdministration.moodCode, and the participations are not affected. These properties always have the same meaning: i.e., the author remains the author of the action negation SubstanceAdministration. A substance administration statement with negationInd is still a statement about the specific fact described by the SubstanceAdministration. For instance, a negated "aspirin administration" means that the author asserts that aspirin has not been administered, and that he takes the same responsibility for such statement and the same requirement to have evidence for such statement than if he had not used action negation.

SubstanceAdministration.negationInd

SubstanceAdministration.negationInd, is deprecated in RIM 2.35, and CDA R2.1 retains it for backwards compatibility. CDA R2.1 compliant implementation guides should use actionNegationInd moving forward.

SubstanceAdministration.text

SubstanceAdministration.statusCode

SubstanceAdministration.effectiveTime

SubstanceAdministration.effectiveTime is the clinically relevant time of an substance administration act, exclusive of administrative activity. It is used to indicate the time over which the substance is to be administered, including the frequency of administration (e.g., TID for 10 days). SubstanceAdministration.effectiveTime is used to describe the timing of administration. It is modeled using the GTS data type to accommodate various dosing scenarios, as illustrated in the following example.

SubstanceAdministration.activityTime

SubstanceAdministration.activityTime is a time expression specifying when the substance administration activity occurs, inclusive of administrative time E.g. times of component actions, such as preparation and clean-up. The substance administration activityTime can provide a needed administrative function, by providing a more inclusive time to be anticipated in scheduling.

SubstanceAdministration.availabilityTime

SubstanceAdministration.availabilityTime is the point in time at which information about a substance administration instance (regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the substance administration itself.

SubstanceAdministration.priorityCode

SubstanceAdministration.priorityCode categorizes the priority of a substance administration.

SubstanceAdministration.confidentialityCode

SubstanceAdministration.repeatNumber

SubstanceAdministration.languageCode

SubstanceAdministration.isCriterionInd

SubstanceAdministration.approachSiteCode

SubstanceAdministration.routeCode

SubstanceAdministration.doseQuantity

SubstanceAdministration.doseQuantity indicates how much medication is given per dose.

SubstanceAdministration.rateQuantity

SubstanceAdministration.rateQuantity can be used to indicate the rate at which the dose is to be administered (e.g., the flow rate for intravenous infusions).

SubstanceAdministration.doseCheckQuantity

SubstanceAdministration.maxDoseQuantity

SubstanceAdministration.maxDoseQuantity is used to capture the maximum dose of the medication that can be given over a stated time interval (e.g., maximum daily dose of morphine, maximum lifetime dose of doxorubicin).

SubstanceAdministration.administrationUnitCode

Example X

<section>
   <text>Take captopril 25mg PO every 12 hours, starting on 
    Jan 01, 2002, ending on Feb 01, 2002.
   </text>
   <entry>
      <substanceAdministration classCode="SBADM" moodCode="RQO">
         <effectiveTime xsi:type="IVL_TS">
            <low value="20020101"/>
            <high value="20020201"/>
         </effectiveTime>
         <effectiveTime xsi:type="PIVL_TS" operator="A">
            <period value="12" unit="h"/>
         </effectiveTime>
         <routeCode code="PO" 
          codeSystem="2.16.840.1.113883.5.112" 
          codeSystemName="RouteOfAdministration"/>
         <doseQuantity value="1"/>
         <consumable>
            <manufacturedProduct>
               <manufacturedLabeledDrug>
                  <code code="318821008" 
                   codeSystem="2.16.840.1.113883.6.96" 
                   codeSystemName="SNOMED CT" 
                   displayName="Captopril 25mg tablet"/>
               </manufacturedLabeledDrug>
            </manufacturedProduct>
         </consumable>
      </substanceAdministration>
   </entry>
</section>

The capture of medication-related information also involves the interrelationship of SubstanceAdministration with several other classes. The consumable participation is used to bring in the LabeledDrug or Material entity that describes the administered substance. The LabeledDrug class, which is an Entity class playing the Role of Manufactured Product, identifies the drug that is consumed in the substance administration. The medication is identified by means of the LabeledDrug.code or the LabeledDrug.name. The Material entity is used to identify non-drug administered substances such as vaccines and blood products.

5.2.6.8.1 consumable

Table X: Fixed consumable.typeCode
Code	Display Name
CSM	consumable
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

5.2.6.8.2 ManufacturedProduct

ManufacturedProduct.classCode

Table X: Fixed ManufacturedProduct.classCode
Code	Display Name
MANU	manufactured
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

ManufacturedProduct.id

5.2.6.8.3 LabeledDrug

LabeledDrug.classCode

Table X: Fixed LabeledDrug.classCode
Code	Display Name
MMAT	A manufactured material.
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

LabeledDrug.determinerCode

Table X: Fixed LabeledDrug.determinerCode
Code	Display Name
KIND	described
Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30

LabeledDrug.code

LabeledDrug.name'

5.2.6.8.4 Material

Material.classCode

Table X: Fixed Material.classCode
Code	Display Name
MMAT	A manufactured material.
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

Material.determinerCode

Table X: Fixed Material.determinerCode
Code	Display Name
KIND	described
Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30

Material.code

Material.name

Material.desc

Material.formCode

Material.lotNumberText

5.2.6.9 Supply

A derivative of the RIM Supply class, used for representing the provision of a material by one entity to another.

Table X: Supply Attributes
RIM Attribute(s)	Data Type	Cardinality	Code Binding	Binding Type
classCode	CS	[1..1]	SPLY	Fixed
moodCode	CS	[1..1]	V:x_DocumentSubstanceMood	Closed
id	SET <II>	[0..*]
code	CD	[1..1]	D:ActSupplyType	Open
actonNegationInd	BL	[0..1]
text	ED	[0..1]
statusCode	CS	[0..1]	V:ActStatus	Closed
effectiveTime	GTS	[0..1]
activityTime	GTS	[0..1]
availabilityTime	TS	[0..1]
priorityCode	CE	[0..1]	D:ActPriority	Open
confidentialityCode	SET<CE>	[0..*]	D:Confidentiality	Open
repeatNumber	IVL<INT>	[0..1]
independentInd	BL	[0..1]
languageCode	CE	[0..1]	D:HumanLanguage	Closed
isCriterionInd	BL	[0..1]
quantity	PQ	[0..1]
expectedUseTime	IVL<TS>	[0..1]

Supply.classCode

Table X: Fixed Supply.classCode
Code	Display Name
SPLY	supply
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Supply.moodCode

Table X: Value set for Supply.moodCode
V:x_ClinicalStatementSubstanceMood [2.16.840.1.113883.1.11.19645] (CLOSED)
Code	Display Name	Code	Display Name
EVN	event	DEF	definition
RQO	request	INT	intent
PRMS	promise	PRP	proposal
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Supply.id

Supply.code

Supply.actionNegationInd

Supply.text

Supply.statusCode

Supply.effectiveTime

Supply.activityTime

Supply.availabilityTime

Supply.priorityCode

Supply.confidentialityCode

Supply.repeatNumber

Supply.independentInd

Supply.languageCode

Supply.isCriterionInd

Supply.quantity

Supply.expectedUseTime

5.2.6.9.1 Product

The dispensed product is associated with the Supply act via a product participant, which connects to the same ManufacturedProduct role used for SubstanceAdministration.

The Supply class represents dispensing, whereas the SubstanceAdministration class represents administration. Prescriptions are complex activities that involve both an administration request to the patient (e.g. take digoxin 0.125mg by mouth once per day) and a supply request to the pharmacy (e.g. dispense 30 tablets, with 5 refills). This should be represented in CDA by a SubstanceAdministration entry that has a component Supply entry. The nested Supply entry can have Supply.independentInd set to "false" to signal that the Supply cannot stand alone, without it's containing SubstanceAdministration. The following example illustrates a prescription representation in CDA.

Product.typeCode

Table X: Fixed product.typeCode
Code	Display Name
PRD	product
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

5.2.6.9.2 ManufacturedProduct

See ManufacturedProduct above.

Example X

<section>
   <text>Digoxin 0.125mg, 1 PO qDay, #30, 5 refills.</text>
   <entry>
      <substanceAdministration classCode="SBADM" moodCode="RQO">
         <effectiveTime xsi:type="PIVL_TS">
            <period value="24" unit="h"/>
         </effectiveTime>
         <routeCode code="PO" 
          codeSystem="2.16.840.1.113883.5.112" 
          codeSystemName="RouteOfAdministration"/>
         <doseQuantity value="1"/>
         <consumable>
            <manufacturedProduct>
               <manufacturedLabeledDrug>
                  <code code="317896006" 
                   codeSystem="2.16.840.1.113883.6.96" 
                   codeSystemName="SNOMED CT" 
                   displayName="Digoxin 125micrograms tablet"/>
               </manufacturedLabeledDrug>
            </manufacturedProduct>
         </consumable>
         <entryRelationship typeCode="COMP">
            <supply classCode="SPLY" moodCode="RQO">
               <repeatNumber>
                  <low value="0"/>
                  <high value="5"/>
               </repeatNumber>
               <independentInd value="false"/>
               <quantity value="30"/>
            </supply>
         </entryRelationship>
      </substanceAdministration>
   </entry>
</section>

5.2.7 Entry Participants

CDA structures and entries can have various participants, some of which are also defined in the CDA header. As described in the discussion of CDA context (see CDA Context), participants propagated from the header can be overridden within the body.

5.2.7.1 author

The author participant (described above, see author), can be ascribed to a CDA section where it overrides the value(s) propagated from the CDA header, or can be ascribed to a CDA entry, where it overrides the value(s) propagated from a CDA section and propagates to nested entries.

5.2.7.2 consumable

The consumable participant is described above (see Entry Acts).

5.2.7.3 informant

The informant participant (described above, see informant), can be ascribed to a CDA section where it overrides the value(s) propagated from the CDA header, or can be ascribed to a CDA entry, where it overrides the value(s) propagated from a CDA section and propagates to nested entries.

5.2.7.4 participant

Can be used to represent any other participant that cannot be represented with one of the more specific participants. The participant can be ascribed to a CDA entry, and propagates to nested CDA entries, unless overridden.

Table X: Value set for participant.typeCode
v:ParticipationType [2.16.840.1.113883.1.11.10901] (CLOSED)
Code	Display Name	Code	Display Name
PART	Participation	ADM	admitter
ATND	attender	ADM	admitter
CALLBCK	callback contact	CON	consultant
DIS	discharger	ESC	escort
REF	referrer	TRANS	Transcriber
ENT	data entry person	WIT	witness
CST	custodian	DIR	direct target
BBY	baby	DEV	device
NRD	non-reuseable device	RDV	reusable device
EXPAGNT	ExposureAgent	EXPART	ExposureParticipation
EXPTRGT	ExposureTarget	EXSRC	ExposureSource
IND	indirect target	BEN	beneficiary
CAGNT	causative agent	COV	coverage target
GUAR	guarantor party	HLD	holder
DON	donor	RCV	receiver
IRCP	information recipient	NOT	ugent notification contact
PRCP	primary information recipient	REFB	Referred By
REFT	Referred to	TRC	tracker
LOC	location	DST	destination
ELOC	entry location	ORG	origin
RML	remote	VIA	via
RESP	responsible party	VRF	verifier
AUTHEN	authenticator
Use the following participations, only if the other participations provided in CDA will not work
RCT	record target	AUT	author (originator)
INF	informant	CSM	consumable
PRD	product	SBJ	subject
SPC	specimen	PRF	performer
DIST	distributor	PPRF	primary performer
SPRF	secondary performer	LA	legal authenticator
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

Table X: Fixed participant.contextControlCode
Code	Display Name
OP	overriding, propagating
Code System: ContextControl (HL7) Code System OID: 2.16.840.1.113883.5.1057

A participant is an entity playing one of several possible roles (ParticipantRole class). The entity playing the role is a device (Device class) or other entity (PlayingEntity class). The scoper is any entity (Entity class).

Table X: Value set for ParticipantRole.classCode
V:RoleClassRoot [2.16.840.1.113883.1.11.13940] (CLOSED)
Code	Display Name	Code	Display Name
ROL (Default)	role	AFFL	affiliate
AGNT	agent	ASSIGNED	assigned entity
COMPAR	commissioning party	SGNOFF	signing authority or officer
CON	contact	ECON	emergency contact
NOK	next of kin	GUARD	guardian
CIT	citizen	COVPTY	covered party
CLAIM	claimant	NAMED	named insured
DEPEN	dependent	INDIV	individual
SUBSCR	subscriber	PROG	program eligible
CRINV	clinical research investigator	CRSPNSR	clinical research sponsor
EMP	employee	MIL	military person
GUAR	guarantor	INVSBJ	Investigation Subject
CASEBJ	Case Subject	RESBJ	research subject
LIC	licensed entity	NOT	notary public
PROV	healthcare provider	PAT	patient
PAYEE	payee	PAYOR	invoice payor
POLHOLD	policy holder	QUAL	qualified entity
SPNSR	underwriter	STD	student
UNDWRT	coverage sponsor	CAREGIVER	caregiver
PRS	personal relationship	ACCESS	access
ADMM	Administerable Material	BIRTHPL	birthplace
DEATHPLC	place of death	DST	distributed material
RET	retailed material	EXPR	exposed entity
HLD	held entity	HLTHCHRT	health chart
IDENT	identified entity	MANU	manufactured product
THER	therapeutic agent	MNT	maintained entity
OWN	owned entity	RGPR	regulated product
SDLOC	service delivery location	DSDLOC	dedicated service delivery location, health care facility
ISDLOC	incidental service delivery location	TERR	territory of authority
USED	used entity	WRTE	warranted product
EQUIV	equivalent entity	SAME	same
SUBY	subsumed by	GEN	has generalization
GRIC	has generic	INST	instance
SUBS	subsumer	CONT	content
EXPAGTCAR	exposure agent carrier	EXPVECTOR	exposure vector
FOMITE	fomite	INGR	ingredient
ACTI	active ingredient	ACTIB	active ingredient - basis of strength
ACTIM	active ingredient - moiety is basis of strength	ACTIR	active ingredient - reference substance is basis of strength
ADTV	additive	BASE	base
IACT	inactive ingredient	COLR	color additive, color
FLVR	flavor additive, flavor	PRSV	preservative
STBL	stabilizer	LOCE	located entity
STOR	stored entity	MBR	member
PART	part	ACTM	active moiety
SPEC	specimen	ALQT	aliquot
ISLT	isolate
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

Table X: Value set for Device.classCode
V:EntityClassDevice [2.16.840.1.113883.1.11.11623] (CLOSED)
Code	Display Name	Code	Display Name
DEV (Default)	role	CER	certificate representation
MODDV	imaging modality, ImagingModalityEntity
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

Table X: Fixed Device.determinerCode
Code	Display Name
INSTANCE	specific
Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30

Table X: Value set for PlayingEntity.classCode
V:EntityClassRoot [2.16.840.1.113883.1.11.13922] (CLOSED)
Code	Display Name	Code	Display Name
ENT (Default)	entity	HCE	health chart entity
LIV	living subject	NLIV	non-person living subject
ANM	animal	MIC	microorganism
PLNT	plant	PSN	person
MAT	material	CHEM	chemical substance
FOOD	food	MMAT	manufactured material
CONT	container	HOLD	holder
DEV	device	CER	certificate representation
MODDV	imaging modality, ImagingModalityEntity	ORG	organization
PUB	public institution	STATE	state
NAT	Nation	PLC	place
CITY	city or town	COUNTRY	country
COUNTY	county or parish	PROVINCE	state or province
RGRP	group
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

Table X: Fixed PlayingEntity.determinerCode
Code	Display Name
INSTANCE	specific
Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30

Table X: Value set for Entity.classCode
V:EntityClassRoot [2.16.840.1.113883.1.11.13922] (CLOSED)
Code	Display Name	Code	Display Name
ENT (Default)	entity	HCE	health chart entity
LIV	living subject	NLIV	non-person living subject
ANM	animal	MIC	microorganism
PLNT	plant	PSN	person
MAT	material	CHEM	chemical substance
FOOD	food	MMAT	manufactured material
CONT	container	HOLD	holder
DEV	device	CER	certificate representation
MODDV	imaging modality, ImagingModalityEntity	ORG	organization
PUB	public institution	STATE	state
NAT	Nation	PLC	place
CITY	city or town	COUNTRY	country
COUNTY	county or parish	PROVINCE	state or province
RGRP	group
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

Table X: Fixed Entity.determinerCode
Code	Display Name
INSTANCE	specific
Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30

5.2.7.5 performer

The performer is a person who carries out or will carry out a particular act. The performer need not be the principal responsible participant, e.g. a surgery resident operating under supervision of attending surgeon is a performer.

Table X: Value set for performer.typeCode
v:ParticipationPhysicalPerformer [2.16.840.1.113883.1.11.10248] (CLOSED)
Code	Display Name	Code	Display Name
PRF (Default)	performer	DIST	distributor
PPRF	primary performer	SPRF	secondary performer
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

5.2.7.6 product

The product participant is described above (see Entry Acts).

5.2.7.7 specimen

A specimen is a part of some entity, typically the subject, that is the target of focused laboratory, radiology or other observations. In many clinical observations, such as physical examination of a patient, the patient is the subject of the observation, and there is no specimen. The specimen participant is only used when observations are made against some substance or object that is taken or derived from the subject.

Table X: Fixed specimen.typeCode
Code	Display Name
SPC	specimen
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

Table X: Fixed SpecimenRole.classCode
Code	Display Name
SPEC	specimen
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

5.2.7.8 subject

The subject participant (described above, see subject), can be ascribed to a CDA section, or it can be ascribed to a CDA entry, where it overrides the value(s) propagated from a CDA section and propagates to nested entries.

5.2.8 Entry Relationships

5.2.8.1 component

The component relationship has a source of Organizer (see Organizer, and a target that is another CDA entry, and is used to create groupings of CDA entries within an Organizer.

Table X: Fixed component.typeCode
Code	Display Name
COMP (FIXED)	has component
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

5.2.8.2 precondition

The precondition class, derived from the ActRelationship class, is used along with the Criterion class to express a condition that must hold true before some over activity occurs.

Table X: Fixed precondition.typeCode
Code	Display Name
PRCN	has pre-condition
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

Table X: Value set for Criterion.classCode
V:ActClassObservation [2.16.840.1.113883.1.11.11529] (CLOSED)
Code	Display Name	Code	Display Name
OBS (Default)	Observation	ALRT	detected issue
BATTERY	battery	CLNTRL	clinical trial
CONC	concern	COND	Condition
CASE	public health case	OUTB	outbreak
DGIMG	diagnostic image	GEN	genomic observation
DETPOL	determinant peptide	EXP	expression level
LOC	locus	PHN	phenotype
POL	polypeptide	SEQ	bio sequence
SEQVAR	bio sequence variation	INVSTG	investigation
OBSSER	observation series	OBSCOR	correlated observation sequences
POS	position	POSACC	position accuracy
POSCOORD	position coordinate	SPCOBS	specimen observation
VERIF	Verification	ROIBND	bounded ROI
ROIOVL	overlay ROI	LLD (Deprecated)	left lateral decubitus
PRN (Deprecated)	prone	RLD (Deprecated)	right lateral decubitus
SFWL (Deprecated)	Semi-Fowler's	SIT (Deprecated)	sitting
STN (Deprecated)	standing	SUP (Deprecated)	supine
RTRD (Deprecated)	reverse trendelenburg	TRD (Deprecated)	trendelenburg
CNOD (Deprecated)	Condition Node
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Table X: Fixed Criterion.moodCode
Code	Display Name
EVN.CRT	event criterion
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

5.2.8.3 referenceRange

The referenceRange relationship (described above, see Observation), has a source of Observation, and a target of ObservationRange.

5.2.8.4 entryRelationship

CDA has identified and modeled various link and reference scenarios. These scenarios enable CDA entries to be semantically linked to entries that exist within the same document (by traversing the entryRelationship class) or to objects external to it (by traversing the reference class).

In CDA R2.0, the following entryRelationships scenarios were provided as informative content:

Table X: Examples of typical entryRelationships
ActRelationship Type	Reasonable Source and Target entries	Comments
CAUS (is etiology for)	(Act \| Observation \| Procedure \| SubstanceAdministration) CAUS (Observation)	Used to show that the source caused the target observation (for instance, source "diabetes mellitus" is the cause of target "kidney disease").
COMP (has component)	(Act \| Observation \| Procedure \| SubstanceAdministration \| Supply) COMP (Act \| Observation \| Procedure \| SubstanceAdministration \| Suppply)	Used to show that the target is a component of the source (for instance "hemoglobin measurement" is a component of a "complete blood count").
GEVL (evaluates (goal))	(Observation) GEVL (Observation)	Used to link an observation (intent or actual) to a goal to indicate that the observation evaluates the goal (for instance, a source observation of "walking distance" evaluates a target goal of "adequate walking distance").
MFST (is manifestation of)	(Observation) MFST (Observation)	Used to say that the source is a manifestation of the target (for instance, source "hives" is a manifestation of target "penicillin allergy").
REFR (refers to)	(Act \| Observation \| Procedure \| SubstanceAdministration \| Supply) REFR (Act \| Observation \| ObservationMedia \| Procedure \| RegionOfInterest \| SubstanceAdministration \| Supply)	Used to show a general relationship between the source and the target, when the more specific semantics of the relationship isn't known.
RSON (has reason)	(Act \| Encounter \| Observation \| Procedure \| SubstanceAdministration \| Supply) RSON (Act \| Encounter \| Observation \| Procedure \| SubstanceAdministration \| Supply)	Used to show the reason or rational for a service (for instance source "treadmill test" has reason "chest pain").
SAS (starts after start)	(Act \| Encounter \| Observation \| Procedure \| SubstanceAdministration \| Supply) SAS (Act \| Encounter \| Observation \| Procedure \| SubstanceAdministration \| Supply)	The source Act starts after the start of the target Act (for instance source "diaphoresis" starts after the start of target "chest pain").
SPRT (has support)	(Observation) SPRT (Observation \| ObservationMedia \| RegionOfInterest)	Used to show that the target provides supporting evidence for the source (for instance source "possible lung tumor" has support target "mass seen on chest-x-ray").
SUBJ (has subject)	(Observation \| RegionOfInterest) SUBJ (Observation \| ObservationMedia)	Used to relate a source region of interest to a target image, or to relate an observation to its subject observation (for instance, source "moderate severity" has subject target "chest pain").

NOTE: The preceding table provides examples of reasonable relationships between CDA entries, but does not represent a conformance constraint.

The ActRelationshipType "has subject" is similar to the ParticipationType "subject". Entries that primarily operate on physical subjects use the Participation, whereas entries that primarily operate on other entries use the ActRelationship.

XCRPT (is excerpt of) (Act | Observation) XCRPT (Act | Observation | Procedure | SubstanceAdministration | Supply) Used to show that the source is excerpted from the target (for instance source "hemoglobin value of 12" is an excerpt of target "complete blood count").

The distinction between an excerpt and an informant participant can be blurry — such as in the case of recording a patient's medication history where the clinician may obtain the information from an informant or may excerpt the information from another computer system. An informant (or source of information) is a person who provides relevant information. An informant class is in the header, and can be overridden in the body. An excerpt is a sub portion of some other act.

In CDA R2.1 any entry (excluding Organizer), may be related to another entry, using the entryRelationship class. In the entryRelationship class, the typeCode attribute is used to define the semantic relationship that exists between the source or parent entry and the destination or child entry. The valueset binding on typeCode was been significantly enhanced in CDA R2.1, and now any code present in the HL7 entryRelationship code system (RIM 2.35) may be used.

Table X: Value set for entryRelationship.typeCode
V:ActRelationshipType [2.16.840.1.113883.1.11.10317] (CLOSED)
Code	Display Name	Code	Display Name
CIND	has contra-indication	PRCN	has pre-condition
RSON	has reason	BLOCK	Blocks
CURE	curative indication	CURE.ADJ	adjunct curative indication
DIAG	diagnosis	MITGT	mitigates
RCVY	Recovery	MTGT.ADJ	adjunct mitigation
SYMP	symptomatic relief	TRIG	has trigger
COMP	has component	ARR	arrival
CTRLV	has control variable	DEP	departure
OUTC	has outcome	OBJC	has continuing objective
OBJF	has final objective	GOAL	has goal
RISK	has risk	PERT	has pertinent information
SAE	starts after end of	SAS	starts after start of
CHRG	has charge	COST	has cost
CREDIT	has credit	DEBIT	has debit
AUTH	authorized by	CAUS	is etiology for
COVBY	covered by	DRIV	is derived from
ELNK	episodeLink	EVID	provides evidence for
EXACBY	exacerbated by	EXPL	has explanation
ITEMSLOC	items located	LIMIT	limited by
MFST	is manifestation of	NAME	assigns name
PREV	has previous instance	REFR	refers to
REFV	has reference values	RELVBY	relieved by
SPRT	has support	SPRTBND	has bounded support
SUBJ	has subject	SUMM	summarized by
SEQL	is sequel	APND	is appendage
COMPLY	Update	DOC	documents
FLFS	fulfills	OCCR	occurrence
OREF	references order	SCH	schedules request
GEN	has generalization	GEVL	evaluates (goal)
INST	instantiates (master)	MOD	modifies
MTCH	matches (trigger)	OPTN	has option
RCHAL	re-challenge	REV	reverses
RPLC	replaces	SUCC	succeeds
UPDT	updates (condition)	XCRPT	Excerpts
VRXCRPT	Excerpt verbatim	XFRM	transformation
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

Note: Implementation Guide ("IG") authors will need to exercise caution and ensure they fully understand the semantics of the relationship defined by the term they have selected. In addition, IG authors will need to understand the impact of both inversionInd and negationInd flags, as these attributes can materially impact those semantics when machine processing.

The entryRelationship.inversionInd can be set to "true" to indicate that the relationship should be interpreted as if the roles of the source and target entries were reversed. As in the example provided in CDA R2.0, "treadmill test" RSON (has reason) "chest pain". Inverted, this would have "chest pain" as the source and "treadmill test" as the target: "chest pain" RSON (inverted) "treadmill test". Inversion can be useful when the current context is describing the target of an act relationship that needs to be related back to the source.

The entryRelationship.negationInd can be set to "true" to indicate that the meaning of the link is negated. Examples where this might be useful:

If the relationship without negation specifies that Act A has Act B as a component, then the negation indicator specifies that Act A does not have Act B as a component.
If B is a reason for A, then negation means that B is not a reason for A.
If B is a pre-condition for A, then negation means that B is not a precondition for A.

The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute (see CDA Context) in that in all other cases where this attribute is used, the value is fixed at "true", whereas here the value is defaulted to "true", and can be changed to "false" when referencing an entry in the same document. Setting the context conduction to false when referencing an entry in the same document keeps clear the fact that the referenced object retains its original context.

5.2.8.5 reference

CDA entries can reference external objects such as external images and prior reports. These external objects are not part of the authenticated document content. They contain sufficient attributes to enable an explicit reference rather than duplicating the entire referenced object. The CDA entry that wraps the external reference can be used to encode the specific portions of the external reference that are addressed in the narrative block.

Each object allows for an identifier and a code, and contains the RIM Act.text attribute, which can be used to store the URL and MIME type of the object. External objects always have a fixed moodCode of "EVN".

The reference class contains the attribute reference.seperatableInd, which indicates whether or not the source is intended to be interpreted independently of the target. The indicator cannot prevent an individual or application from separating the source and target, but indicates the author's desire and willingness to attest to the content of the source if separated from the target. Typically, where seperatableInd is "false", the exchanged package should include the target of the reference so that the recipient can render it.

A description of allowable reference.typeCode values are shown in the following table.

Table X: Value set for reference.typeCode
V:ActRelationshipType [2.16.840.1.113883.1.11.10317] (CLOSED)
Code	Display Name	Code	Display Name
ELNK	episodeLink	REFR	refers to
SPRT	has support	RPLC	replaces
XCRPT	Excerpts
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

As in the table above (CDA entryRelationship Types), the following table is a guideline for reasonable relationships between CDA entries and external objects, and is not a conformance constraint.

Table X: CDA reference Types
ActRelationship Type	Reasonable Source and Target classes	Comments
ELNK (episode link)	(Observation) ELNK (ExternalObservation)	Used to show that the source and the target are part of the same episode (for instance, a diagnosis of "pneumonia" can be linked to an external problem list entry of "pneumonia" to show that the current diagnosis is part of the ongoing episode of pneumonia).
REFR (refers to)	(Act \| Observation \| Procedure \| SubstanceAdministration \| Supply) REFR (ExternalAct \| ExternalDocument \| ExternalObservation \| ExternalProcedure)	Used to show a general relationship between the source and the target, when the more specific semantics of the relationship isn't known.
RPLC (replace)	(Act \| Encounter \| Observation \| ObservationMedia \| Organizer \| Procedure \| SubstanceAdministration \| Supply) RPLC (ExternalAct \| ExternalDocument \| ExternalObservation \| ExternalProcedure)	Used to indicate that the source entry is a replacement for the target external act.
SPRT (has support)	(Observation) SPRT (ExternalDocument \| ExternalObservation)	Used to show that the target provides supporting evidence for the source.
SUBJ (has subject)	(Observation \| RegionOfInterest) SUBJ (ExternalObservation)	Used to relate a source region of interest to a target image, or to relate an observation to its subject observation.
XCRPT (is excerpt of)	(Act \| Observation) XCRPT (ExternalAct \| ExternalDocument \| ExternalObservation \| ExternalProcedure)	Used to show that the source is excerpted from the target (for instance "the hemoglobin is 10.7" is an excerpt of an externally referenced "complete blood count").

Target classes of the reference relationship include ExternalAct, ExternalDocument, ExternalObservation, and External Procedure.

ExternalAct is a derivative of the RIM Act class, to be used when the other more specific classes are not appropriate.

Table X: Value set for ExternalAct.classCode
V:ActClassRoot [2.16.840.1.113883.1.11.13856] (CLOSED)
Code	Display Name	Code	Display Name
ACT (Default)	act	COMPOSITION	composition, Attestable unit
DOC	document	DOCCLIN	clinical document
CDALVLONE	CDA Level One clinical document	CONTAINER	record container
CATEGORY	category	DOCBODY	document body
CATEGORY	document section, Section	TOPIC	topic
EXTRACT	extract	EHR	electronic health record
FOLDER	folder	GROUPER	grouper
CLUSTER	Cluster	ACCM	accommodation
ACCT	account	ACSN	accession
ADJUD	financial adjudication, financial adjudication results	CACT	control act
ACTN	action	INFO	information
STC	state transition control	CNTRCT	contract
FCNTRCT	financial contract	COV	coverage
CONS	consent	CONTREG	container registration
CTTEVENT	clinical trial timepoint event	DISPACT	disciplinary action
EXPOS	exposure	AEXPOS	acquisition exposure
TEXPOS	transmission exposure	INC	incident
INFRM	inform	INVE	invoice element
LIST	working list	MPROT	monitoring program
OBS	Observation	ALRT	detected issue
BATTERY	battery	CLNTRL	clinical trial
CONC	concern	COND	Condition
CASE	public health case	OUTB	outbreak
DGIMG	diagnostic image	GEN	genomic observation
DETPOL	determinant peptide	EXP	expression level
LOC	locus	PHN	phenotype
POL	polypeptide	SEQ	bio sequence
SEQVAR	bio sequence variation	INVSTG	investigation
OBSSER	observation series	OBSCOR	correlated observation sequences
POS	position	POSACC	position accuracy
POSCOORD	position coordinate	SPCOBS	specimen observation
VERIF	Verification	ROIBND	bounded ROI
ROIOVL	overlay ROI	PCPR	care provision
ENC	encounter	POLICY	policy
JURISPOL	jurisdictional policy	ORGPOL	organizational policy
SCOPOL	scope of practice policy	STDPOL	standard of practice policy
PROC	procedure	SBEXT	Substance Extraction
SPECCOLLECT	Specimen Collection	SBADM	substance administration
REG	registration	REV	review
SPCTRT	specimen treatment	SPLY	supply
DIET	diet	STORE	storage
SUBST	Substitution	TRFR	transfer
TRNS	transportation	XACT	financial transaction
CNOD (Deprecated)	Condition Node	LLD (Deprecated)	left lateral decubitus
PRN (Deprecated)	prone	RLD (Deprecated)	right lateral decubitus
SFWL (Deprecated)	Semi-Fowler's	SIT (Deprecated)	sitting
STN (Deprecated)	standing	SUP (Deprecated)	supine
RTRD (Deprecated)	reverse trendelenburg	TRD (Deprecated)	trendelenburg
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Table X: Fixed ExternalAct.moodCode
Code	Display Name
EVN	event
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

ExternalDocument is a derivative of the RIM Document class, used for representing external documents. ExternalDocument.text is modeled as an ED data type - allowing for the expression of the MIME type of the external document.

Table X: Value set for ExternalDocument.classCode
V:ActClassDocument [2.16.840.1.113883.1.11.18938] (CLOSED)
Code	Display Name	Code	Display Name
DOC (Default)	document	DOCCLIN	clinical document
CDALVLONE	CDA Level One clinical document
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Table X: Fixed ExternalDocument.moodCode
Code	Display Name
EVN	event
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

ExternalObservation is a derivative of the RIM Observation class, used for representing external coded and other observations.

Table X: Value set for ExternalObservation.classCode
V:ActClassObservation [2.16.840.1.113883.1.11.11529] (CLOSED)
Code	Display Name	Code	Display Name
OBS (Default)	Observation	ALRT	detected issue
BATTERY	battery	CLNTRL	clinical trial
CONC	concern	COND	Condition
CASE	public health case	OUTB	outbreak
DGIMG	diagnostic image	GEN	genomic observation
DETPOL	determinant peptide	EXP	expression level
LOC	locus	PHN	phenotype
POL	polypeptide	SEQ	bio sequence
SEQVAR	bio sequence variation	INVSTG	investigation
OBSSER	observation series	OBSCOR	correlated observation sequences
POS	position	POSACC	position accuracy
POSCOORD	position coordinate	SPCOBS	specimen observation
VERIF	Verification	ROIBND	bounded ROI
ROIOVL	overlay ROI	LLD (Deprecated)	left lateral decubitus
PRN (Deprecated)	prone	RLD (Deprecated)	right lateral decubitus
SFWL (Deprecated)	Semi-Fowler's	SIT (Deprecated)	sitting
STN (Deprecated)	standing	SUP (Deprecated)	supine
RTRD (Deprecated)	reverse trendelenburg	TRD (Deprecated)	trendelenburg
CNOD (Deprecated)	Condition Node
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Table X: Fixed ExternalObservation.moodCode
Code	Display Name
EVN	event
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

ExternalProcedure is a derivative of the RIM Procedure class, used for representing external procedures.

Table X: Fixed ExternalProcedure.classCode
Code	Display Name
PROC	procedure
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Table X: Fixed ExternalProcedure.moodCode
Code	Display Name
EVN	event
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

6 CDA Hierarchical Description

(content on separate page)

7 CDA XML Implementation

(content on separate page)

8 Appendix

(content on separate page)

Body

Contents

1 CDA Overview

2 Introduction to CDA Technical Artifacts

3 CDA Document Exchange in HL7 Messages

4 CDA Templating

5 CDA R-MIM

5.1 Header

5.2 Body

5.2.1 Body Choice

5.2.1.1 component

5.2.1.2 NonXMLBody

5.2.1.3 StructuredBody

5.2.1.3.1 component

5.2.2 Section Attributes

5.2.3 Section Participants

5.2.3.1 author

5.2.3.2 informant

5.2.3.3 subject

5.2.3.3.1 RelatedSubject

5.2.3.3.2 SubjectPerson

5.2.4 Section Relationships

5.2.4.1 component

5.2.4.2 entry

5.2.5 Section Narrative Block

5.2.5.1 <content>

5.2.5.2 <linkHtml>

5.2.5.3 <sub> and <sup>

5.2.5.4 <br>

5.2.5.5 <footnote> and <footnoteRef>

5.2.5.6 <renderMultiMedia>

5.2.5.7 <paragraph>

5.2.5.8 <list>

5.2.5.9 <table>

5.2.5.10 <caption>

5.2.5.11 styleCode attribute

5.2.5.12 Referencing in and out of the narrative block

5.2.6 Entry Acts

5.2.6.1 Act

5.2.6.2 Encounter

5.2.6.3 Observation

5.2.6.3.1 Reference Range

5.2.6.3.2 ObservationRange

5.2.6.4 ObservationMedia

5.2.6.5 Organizer

5.2.6.6 Procedure

5.2.6.7 RegionOfInterest

5.2.6.8 SubstanceAdministration

5.2.6.8.1 consumable

5.2.6.8.2 ManufacturedProduct

5.2.6.8.3 LabeledDrug

5.2.6.8.4 Material

5.2.6.9 Supply

5.2.6.9.1 Product

5.2.6.9.2 ManufacturedProduct

5.2.7 Entry Participants

5.2.7.1 author

5.2.7.2 consumable

5.2.7.3 informant

5.2.7.4 participant

5.2.7.5 performer

5.2.7.6 product

5.2.7.7 specimen

5.2.7.8 subject

5.2.8 Entry Relationships

5.2.8.1 component

5.2.8.2 precondition

5.2.8.3 referenceRange

5.2.8.4 entryRelationship

5.2.8.5 reference

6 CDA Hierarchical Description

7 CDA XML Implementation

8 Appendix

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