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Contents

1 CDA Overview

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2 Introduction to CDA Technical Artifacts

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3 CDA Document Exchange in HL7 Messages

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4 CDA Templating

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5 CDA Design

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5.1 Clinical Document

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5.2 Header

The purpose of the CDA header is to enable clinical document exchange across and within institutions; facilitate clinical document management; and facilitate compilation of an individual patient's clinical documents into a lifetime electronic patient record. The CDA header sets the context for the document as a whole and the context for understanding the content contained in the document.

5.2.1 ClinicalDocument

The CDA schema was produced by serialization of the CDA model. The starting point for this serialization was the ClinicalDocument class. The ClinicalDocument is the root element in a CDA document instance.

Authenicator

5.2.1.1 ClinicalDocument Attributes

This section describes attributes defined in the ClinicalDocument class.

The table below identifies the attributes of ClinicalDocument. For each item, the name is provided, along with the data type, wire cardinality*, code bindings, and binding type or strength. The links allow will access to the item's definition, data type definition, and when appropriate, the concept domain or value set used with the item.

Table X: ClinicalDocument Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] DOCCLIN Fixed
moodCode CS [0..1] EVN Fixed
typeId II [1..1]
templateId II [0..*]
id II [1..1]
code CE [1..1] D:DocumentType Open
title ST [0..1]
effectiveTime TS [0..1]
confidentialityCode SET<CE> [0..*] V:x_BasicConfidentialityKind Open
languageCode CS [0..1] D:HumanLanguage Closed
setId II [0..1]
versionNumber ST [0..1]
copyTime (Deprecated) TS [0..1]

Note*: The wire cardinality represents is the effective cardinality of an element, taking into account 1.3.1 Recipient Responsibilities, relaxation of the requirement to exchange fixed and defaulted values. The logical cardinality expressed in the CDA Hierarchical Description is still present, but assumed by the recipient, not imposed on the wire format of an instance of a CDA document.


ClinicalDocument.classCode

The ClinicalDocument.classCode in the CDA model is fixed to "DOCCLIN". As a result, in the CDA R2.1 Schema, the ClinicalDocument/@classCode has been fixed to "DOCCLIN".

As noted in section 1.3.1 Recipient Responsibilities, fixed and default values asserted in this standard are not required to be present in CDA document instances. However, CDA Implementation Guides can still require them via conformance statements.

Table X: Fixed ClinicalDocument.classCode
Code Display Name
DOCCLIN clinical document
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

ClinicalDocument.moodCode

The ClinicalDocument.moodCode in the CDA model is fixed to "EVN" or event mood to indicate that this is documentation of a past service. In the CDA R2.1 Schema, the ClinicalDocument/@moodCode has been fixed to "EVN".

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

The ClinicalDocument class inherits various attributes from the InfrastructureRoot class of the RIM, including ClinicalDocument.templateId and ClinicalDocument.typeId which are discussed here. All CDA classes inherit from infrastructureRoot, which is discussed in Section (link here).

ClinicalDocument.typeId

ClinicalDocument.typeId is a technology-neutral explicit reference to this CDA, Release Two specification, and must be valued as follows: ClinicalDocument.typeId.root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId.extension = "POCD_HD000040UV20" (which is the unique identifier for the CDA, Release Two Hierarchical Description).

ClinicalDocument.templateId

When a templateId is present in a CDA element, it signals the imposition of a set of template-defined constraints for that element. The templateId is one of the infrastructure attributes added to all CDA classes. It has only been displayed for ClinicalDocument, but is present in all CDA classes, where it can be used to identify constraints defined in an external Implementation Guide template. See 4.3.2 Template Versioning.

ClinicalDocument.id

Represents the unique instance identifier of a clinical document.

ClinicalDocument.code

The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note). The value set is drawn from LOINC, and has a CWE coding strength.

Within the LOINC database, beginning with version 2.09, May 2003, document type codes are those that have a value of "DOC" in the Scale component. This subset of LOINC is described in the appendix (see LOINC Document Codes).

ClinicalDocument.title

Represents the title of the document. It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of ClinicalDocument.code (e.g. a "consultation" or "progress note"). Where these display names are rendered to the clinician, or where the document has a unique title, the ClinicalDocument.title component should be used. In the example document in the appendix (see Sample Document), the value of ClinicalDocument.title = "Good Health Clinic Consultation Note".

ClinicalDocument.effectiveTime

Signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document was created. The time when the transform occurred is not currently represented in CDA.

ClinicalDocument.ConfidentialityCode

Confidentiality is a required contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value (as further described in CDA Context). A best practice for clinical documents is to assert the highest level of confidentiality present within a document at the header level.

Table X: Value set for ClinicalDocument.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.

ClinicalDocument.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 a nested value (as further described in CDA Context).

ClinicalDocument.setId

Represents an identifier that is common across all document revisions.

ClinicalDocument.versionNumber

A string used to represent the version of the document. For CDA R2.1 we use the ST data type as defined in the HL7 Version 3 Standard: XML Implementation Technology Specification - Wire Format Compatible Release 1 Data Types, Release 1 (XML ITS R2B). We have adopted, for all versionNumber references in CDA R2.1, this data type because it supports an @value attribute, and can support wire format compatibility with the versionNumber in CDA R2.0.

ClinicalDocument.copyTime (Deprecated)

Represents the time a document is released (i.e. copied or sent to a display device) from a document management system that maintains revision control over the document. Once valued, it cannot be changed. The intent is to give the viewer of the document some notion as to how long the document has been out of the safe context of its document management system.

Included for backwards compatibility with CDA, Release One. ClinicalDocument.copyTime has been deprecated because it is not part of the document at the time it is authenticated, but instead represents metadata about the document, applied at some variable time after authentication. Further use is discouraged.

5.2.2 Header Participants

This section describes classes related to the root ClinicalDocument class via a Participation.

5.2.2.1 authenticator

authenicator

Represents a participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document. An example would be a resident physician who sees a patient and dictates a note, then later signs it. (See also legalAuthenticator (§ 5.2.2.8))

A clinical document can have zero to many authenticators. Both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual.

Table X: Authenicator
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] AUTHEN Fixed
time TS [1..1]
signatureCode CV [0..1] S Fixed
signatureText ED [0..1]

authenticator.typeCode

The authenticator.typeCode is fixed to "AUTHEN" to indicate that a participant has attested his participation through a signature.

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

authenticator.time

Authenticator has a required authenticator.time indicating the time of authentication.

authenticator.signatureCode

Authenticator has a required authenticator.signatureCode, indicating that a signature has been obtained and is on file.

Table X: Fixed authenticator.signatureCode
Code Display Name
S (Fixed) signed
Code System: ParticipationSignature (HL7) Code System OID: 2.16.840.1.113883.5.89

Note: CDA Release One represented either an intended ("X") or actual ("S") authenticator. CDA Release 2 and 2.1 only represents an actual authenticator, so usage of "X" and "I" are deprecated.

authenticator.signatureText

A new attribute, SignatureText has been added to authenticator. The signature can be represented either inline or by reference according to the ED data type. Typical cases are:

  1. Paper-based signatures: the ED data type may refer to a document or other resource that can be retrieved through an electronic interface to a hardcopy archive.
  2. Electronic signature: this attribute can represent virtually any electronic signature scheme.
  3. Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.
5.2.2.1.1 AssignedEntity

An authenticator is a person in the role of an assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a person (Person class). The entity scoping the role is an organization (Organization class). (See here for a description of "player" and "scoper" role associations.)

Table X: AssignedEntity
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] ASSIGNED Fixed
id SET<II> [1..*]
code CE [0..1] D:RoleCode Open
addr SET<AD> [0..*]
telecom SET<TEL> [0..*]

AssignedEntity.classCode

The classCode is fixed to "ASSIGNED", which is used in this context to indicate that a person in the employ of an organization was acting as their agent.

Table X: Fixed AssignedEntity.classCode
Code Display Name
ASSIGNED assigned entity
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

AssignedEntity.id

In this context, it is a unique identifier for the person in this Role.

AssignedEntity.code

Identifies the specific kind of Role to which an Role-instance belongs. The AssignedEntity.code is bound to D:RoleCode, which enables any code from the HL7 RoleCode vocabulary.

AssignedEntity.addr

A postal address for the Entity while in the Role.

AssignedEntity.telecom

A telecommunication address for the Entity while in the Role.

5.2.2.1.2 Person

Refer to Person (§ 5.2.2.2.2) as defined for Author participation.

5.2.2.1.3 Organization
Table X: Organization
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] ORG Fixed
determinerCode CS [0..1] INSTANCE Fixed
id SET<II> [0..*]
name SET<ON> [0..1]
telecom SET<TEL> [0..*]
addr SET<AD> [0..*]
standardIndustryClassCode CE [0..1] D:OrganizationIndustryClass

Organization.classCode With the code fixed to "ORG", it indicates we are referencing an Organization.

Table X: Fixed Organization.classCode
Code Display Name
ORG organization
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

Organization.determinerCode

The determinerCode is fixed to "INSTANCE", which indicates that the scoping organization referenced, is a specific instance of an organization.

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

Organization.id

A unique identifier for the Organization.

Organization.name

A non-unique textual identifier or moniker for the organization.

Organization.telecom

A telecommunication address for the Organization.

Organization.addr

The postal or residential address of an organization.

Organization.standardIndustryClassCode

A code which identifies the industrial category of an organization. In the US Realm, it has been bound to the Code System: North American Industry Classification System [2.16.840.1.113883.6.85] (NAICS). The binding type is Open, so other code system and values sets may be used in the US and other realms. D:OrganizationIndustryClass

5.2.2.1.4 OrganizationPartOf

A scoping organization can be part of a larger organization. Where there is a need to include whole-part relationships, the OrganizationPartOf role can be used. OrganizationPartOf.statusCode indicates the state of the whole-part relationship (e.g. "active", "terminated").

Table X: OrganizationPartOf
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] PART Fixed
id SET<II> [1..*]
code CE [0..1] D:RoleCode Open
statusCode CS [0..1] V:RoleStatus Closed
effectiveTime IVL<TS > [0..1]


OrganizationPartOf.classCode

Table X: Fixed OrganizationPartOf.classCode
Code Display Name
PART part
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

OrganizationPartOf.id

A unique identifier for the player organization in this Role.

OrganizationPartOf.code

The specific kind of Role to which an Role-instance belongs.

OrganizationPartOf.statusCode

The state of this Role as defined in the state-transition model.

Table X: Value set for OrganizationPartOf.statusCode
V:RoleStatus [2.16.840.1.113883.5.1068] (CLOSED)
Code Display Name Code Display Name
normal normal active active
cancelled cancelled pending pending
suspended suspended terminated terminated
nullified nullified
Code System: RoleStatus (HL7) Code System OID: 2.16.840.1.113883.5.1068

OrganizationPartOf.effectiveTime

The OrganizationPartOf.effectiveTime is an interval of time specifying the period during which the whole-part relationhship is in effect, if such time limit is applicable and known.

5.2.2.2 author

author

Represents the humans and/or machines that authored the document.

Table X: author
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] AUT Fixed
functionCode CE [0..1] D:ParticipationFunction Open
contextControlCode CS [0..1] OP Fixed
time TS [1..1]

author.typeCode

The author.typeCode is fixed to "AUT", used to indicate the party that originates the document and is responsible for the information in the document.

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

author.functionCode


The author.functionCode is bound to the concept domain ParticipationFunction, which is used to specify the exact function an actor had in a service in all necessary detail. This domain may include local extensions (Open).

In some cases, the role or function of the author is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is "Medical Student Progress Note". The role of the author can also be recorded in the Author.functionCode or AssignedAuthor.code attribute. If either of these attributes is included, they should be equivalent to or further specialize the role inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply "Physician Progress Note" and the value of Author.functionCode is "rounding physician"), and shall not conflict with the role inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

author.contextControlCode

The author.contextControlCode is fixed to "OP". It means that the author will replace the set of author participations that have propagated from ancestor Acts, and will itself be the only author to propagate to any child Acts that allow context to be propagated.

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

author.time

The author.time is used to capture the time this specific author contributed content to the document.

5.2.2.2.1 AssignedAuthor

An author is a person in the role of an assigned author (AssignedAuthor class). The entity playing the role is a person (Person class) or a device (AuthoringDevice class). The entity scoping the role is an organization (Organization class), and is the organization from which the document originates.

Table X: AssignedAuthor
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] ASSIGNED Fixed
id SET<II> [1..*]
code CE [0..1] D:RoleCode Open
addr SET<AD> [0..*]
telecom SET<TEL> [0..*]

AssignedAuthor.classCode

The classCode is fixed to "ASSIGNED", which is used in this context to indicate that a person in the employ of an organization was acting as their agent.

Table X: Fixed AssignedAuthor.classCode
Code Display Name
ASSIGNED assigned entity
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

AssignedAuthor.id

In this context, it is a unique identifier for the person in this Role.

AssignedAuthor.code

Identifies the specific kind of Role to which an Role-instance belongs. The AssignedEntity.code is bound to D:RoleCode, which enables any code from the HL7 RoleCode vocabulary.

AssignedAuthor.addr

A postal address for the Entity while in the Role.

AssignedAuthor.telecom

A telecommunication address for the Entity while in the Role.

5.2.2.2.2 Person

A human being.

Table X: Person
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] PSN Fixed
determinerCode CS [0..1] INSTANCE Fixed
name SET<PN> [0..*]
desc ED [0..1]
birthTime TS [0..1]

Person.classCode

With the code fixed to "PSN", it indicates we are referencing a Person.

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

Person.determinerCode

The determinerCode is fixed to "INSTANCE", which indicates that we are dealing with a specific person.

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

Person.name

The person'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.

Person.desc

A textual or multimedia depiction of the person.

Person.birthTime

The date and time of a person's birth.

5.2.2.2.3 AuthoringDevice
Table X: AuthoringDevice
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] DEV Fixed
determinerCode CS [0..1] INSTANCE Fixed
code CE [0..1] D:EntityCode
manufacturerModelName SC [0..1] D:ManufacturerModelName
softwareName SC [0..1] D:SoftwareName

AuthoringDevice.classCode

The AuthoringDevice.classCode is fixed to "DEV" indicating that a device was used to generate content in the document.

Table X: Fixed AuthoringDevice.classCode
Code Display Name
DEV role
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

AuthoringDevice.determinerCode

The determinerCode is fixed to "INSTANCE", which indicates we are referencing a specific device.

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

AuthoringDevice.code

The AuthoringDevice.code is bound to the EntityCode domain.

AuthoringDevice.manufacturerModelName

Is used to convey a coded name for the device.

AuthoringDevice.softwareName

Is used to convey a coded name for the software used to author content.

5.2.2.2.4 MaintainedEntity (Deprecated)
NOTE: In CDA, Release One, it was possible to specify those individuals responsible for the device. This functionality has been deprecated in CDA, Release Two. The MaintainedEntity class is present for backwards compatibility, and its use is discouraged, except where needed to support the transformation of CDA, Release One documents.
Table X: MaintainedEntity
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] MNT Fixed
effectiveTime IVL<TS> [0..1]

MaintainedEntity.classCode

With the classCode fixed to "MNT", it indicates that AuthoringDevice is maintained by person assuming responsibility for proper operation, quality, and safety.

Table X: Fixed MaintainedEntity.classCode
Code Display Name
MNT maintained entity
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

MaintainedEntity.effectiveTime

An interval of time specifying the period during which the Role is in effect.

5.2.2.3 custodian

custodian

Represents the organization that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian.

The custodian participation satisfies the CDA definition of Stewardship (see What is the CDA (§ 1.1)). Because CDA is an exchange standard and may not represent the original form of the authenticated document, the custodian represents the steward of the original source document.

Table X: custodian
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] CST Fixed

custodian.typeCode

The custodian.typeCode is fixed to "CST", which indicates in this instance an organization that is in charge of maintaining this document. Examples: Medical Records Dept in hospital, Health Information Management Dept., etc.

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

A custodian is a scoping organization in the role of an assigned custodian (AssignedCustodian class). The steward organization (CustodianOrganization class) is an entity scoping the role of AssignedCustodian, and has a required CustodianOrganization.id.

5.2.2.3.1 AssignedCustodian
Table X: AssignedCustodian
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] ASSIGNED Fixed

AssignedCustodian.classCode

Table X: Fixed AssignedCustodian.classCode
Code Display Name
ASSIGNED assigned entity
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110
5.2.2.3.2 CustodianOrganization
Table X: CustodianOrganization
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] ORG Fixed
determinerCode CS [0..1] INSTANCE Fixed
id SET<II> [1..*]
name SET<ON> [0..1]
telecom SET<TEL> [0..*]
addr SET<AD> [0..*]

CustodianOrganization.classCode With the code fixed to "ORG", it indicates we are referencing an Organization.

Table X: Fixed CustodianOrganization.classCode
Code Display Name
ORG organization
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

CustodianOrganization.determinerCode

The determinerCode is fixed to "INSTANCE", which indicates that the scoping organization referenced, is a specific instance of an organization.

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

CustodianOrganization.id

A unique identifier for the Organization.

CustodianOrganization.name

A non-unique textual identifier or moniker for the organization.

CustodianOrganization.telecom

A telecommunication address for the Organization.

CustodianOrganization.addr

The postal or residential address of an organization.

5.2.2.4 dataEnterer (Transcriptionist)

dataEnterer

Represents the participant who has transformed a dictated note into text.

Table X: dataEnterer
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] ENT Fixed
contextControlCode CS [0..1] OP Fixed
time TS [1..1]

dataEnterer.typeCode

The dataEnterer.typeCode is fixed to "ENT".

Table X: Fixed dataEnterer.typeCode
Code Display Name
ENT data entry person
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

dataEnterer.contextControlCode

The dataEnterer.contextControlCode is fixed to "OP".

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

dataEnterer.time

The date and time the data was entered into the originating system.

5.2.2.4.1 AssignedEntity

Refer to AssignedEntity (§ 5.2.2.1.1) as defined for authenticator participation.

5.2.2.5 encounterParticipant

See EncompassingEncounter (§ 5.2.3.5) for a description of the encounterParticipant participant.

5.2.2.6 informant

informant

An informant (or source of information) is a person that provides relevant information, such as the parent of a comatose patient who describes the patient's behavior prior to the onset of coma.

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

informant.typeCode The informant.typeCode is fixed to "INF", which indicates the source of reported information (e.g., a next of kin who answers questions about the patient's history).

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

informant.contextControlCode

The informant.contextControlCode is fixed to "OP". It means that the informant will replace the set of informant participations that have propagated from ancestor Acts, and will itself be the only informant to propagate to any child Acts that allow context to be propagated.

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

An informant can be a person in one of two roles RelatedEntity or AssignedEntity.

5.2.2.6.1 RelatedEntity

The RelatedEntity role is used to represent an informant without a role.id (e.g. a parent or guy on the street). The informant in this case bears some formal or personal relationship to the patient. The role is unscoped, with the assumption that the patient is always the implied scoper. RelatedEntity.code can be used to specify the nature of the relationship.

Table X: RelatedEntity
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] v:RoleClassMutualRelationship Closed
code CE [0..1] D:PersonalRelationshipRoleType Open
addr SET<AD> [0..*]
telecom SET<TEL> [0..*]
effectiveTime IVL<TS> [0..1]

RelatedEntity.classCode

Table X: Value set for RelatedEntity.classCode
v:RoleClassMutualRelationship [2.16.840.1.113883.1.11.19316] (CLOSED)
Code Display Name Code Display Name
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, GuarantorRole
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 coverage sponsor
STD student UNDWRT underwriter
CAREGIVER caregiver PRS personal relationship
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

RelatedEntity.code

The RelatedEntity.code is bound to the PersonalRelationshipRoleType concept domain.

RelatedEntity.addr

The RelatedEntity.addr is used to convey the postal address for the informant.

RelatedEntity.telecom

The RelatedEntity.telecom is used to convey the phone number for the informant.

RelatedEntity.effectiveTime

The RelatedEntity.effectiveTime is used to convey the time period that the role is/was in effect.

5.2.2.6.2 AssignedEntity

The AssignedEntity role is used for an identified informant, and is scoped by an Organization.

Refer to AssignedEntity (§ 5.2.2.1.1) as defined for authenticator participation.

5.2.2.7 informationRecipient

informationRecipient


Represents a recipient who should receive a copy of the document.

NOTE: The information recipient is an entity to whom a copy of a document is directed, at the time of document authorship. It is not the same as the cumulative set of persons to whom the document has subsequently been disclosed, over the life-time of the patient. Such a disclosure list would not be contained within the document, and it is outside the scope of CDA.
Table X: informationRecipient
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [1..1] V:x_InformationRecipient Closed


informationRecipient.typeCode

Two values are available for the informationRecipient.typeCode, the default value is primary information recipient an alternative value is tracker.

Table X: Value set for informationRecipient.typeCode
v:x_InformationRecipient [2.16.840.1.113883.1.11.19366] (CLOSED)
Code Display Name Code Display Name
PRCP (Default) primary information recipient TRC tracker
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90
5.2.2.7.1 IntendedRecipient

Identifies the person(s), organization or health chart to receive the document.

Table X: IntendedRecipient
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [1..1] V:x_InformationRecipientRole Closed
id SET<II> [1..*]
addr SET<AD> [0..*]
telecom SET<TEL> [0..*]

IntendedRecipient.classCode

Where a person is the intended recipient (IntendedRecipient class), the IntendedRecipient.classCode is valued with "ASSIGNED", and the playing entity is a person (Person class), optionally scoped by an organization (Organization class). Where the intended recipient is an organization, the IntendedRecipient.classCode is valued with "ASSIGNED", and the recipient is reflected by the presence of a scoping Organization, without a playing entity. Where a health chart is the intended recipient, the IntendedRecipient.classCode is valued with "HLTHCHRT" (health chart). In this case there is no playing entity, and an optional scoping organization (Organization class).

Table X: Value set for IntendedRecipient.classCode
V:x_InformationRecipientRole [2.16.840.1.113883.1.11.16772] (CLOSED)
Code Display Name Code Display Name
ASSIGNED (Default) assigned entity HLTHCHRT health chart
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110


IntendedRecipient.id

Optional identifier of the intended recipient.

IntendedRecipient.addr

Optional postal address of the intended recipient.

IntendedRecipient.telecom

Optional phone number for the intended recipient.

5.2.2.7.2 Person

Refer to Person (§ 5.2.2.2.2) as defined for Author participation.

5.2.2.7.3 Organization

Refer to organization (§ 5.2.2.1.3) as defined for authenticator participation.

5.2.2.8 legalAuthenticator

Represents the participant(s) who has legally authenticated the document.

authenicator

CDA R2.1, now supports [0..*] legal authentications. This enhancement was put into CDA to support the sharing of medical documents needing to take more than one legal authentication signature.

The CDA is a standard that specifies the structure of exchanged clinical documents. In the case where a local document is transformed into a CDA document for exchange, authentication occurs on the local document, and that fact is reflected in the exchanged CDA document. A CDA document can reflect the unauthenticated, authenticated, or legally authenticated state. The unauthenticated state exists when no authentication information has been recorded (i.e., it is the absence of being either authenticated or legally authenticated).

Both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual. A legalAuthenticator has a required legalAuthenticator.time indicating the time of authentication, and a required legalAuthenticator.signatureCode, indicating that a signature has been obtained and is on file.

Table X: legalAuthenticator[0..*]
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] LA Fixed
contextControlCode CS [0..1] OP Fixed
time TS [1..1]
signatureCode CV [0..1] S Fixed
signatureText ED [0..1]

legalAuthenticator.typeCode

The ClinicalDocument.typeCode is fixed to "LA" to indicate that a participant has legally attested his participation through a signature.

Table X: Fixed legalAuthenticator.typeCode
Code Display Name
AUTHEN authenticator
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

legalAuthenticator.contextControlCode


The legalAuthenticator.contextControlCode is fixed to "OP". It means that the legalAuthenticator will propagate to any child Acts that allow context to be propagated.

legalAuthenticator.time

legalAuthenticatorhas a required legalAuthenticator.time indicating the time of authentication.

legalAuthenticator.signatureCode

legalAuthenticatorhas a required legalAuthenticator.signatureCode, indicating that a signature has been obtained and is on file.

Table X: Fixed legalAuthenticator.signatureCode
Code Display Name
S (Fixed) signed
Code System: ParticipationSignature (HL7) Code System OID: 2.16.840.1.113883.5.89

Note: CDA Release One represented either an intended ("X") or actual ("S") legalAuthenticator. CDA Release 2 and 2.1 only represents an actual legalAuthenticator, so only S / Signed can be indicated for the signatureCode.

legalAuthenticator.signatureText

A new attribute, SignatureText has been added to legalAuthenticator. The signature can be represented either inline or by reference according to the ED data type. Typical cases are:

  1. Paper-based signatures: the ED data type may refer to a document or other resource that can be retrieved through an electronic interface to a hardcopy archive.
  2. Electronic signature: this attribute can represent virtually any electronic signature scheme.
  3. Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.
Table X: Fixed legalAuthenticator.contextControlCode
Code Display Name
OP overriding, propagating
Code System: ContextControl (HL7) Code System OID: 2.16.840.1.113883.5.1057

A legalAuthenticator is a person in the role of an assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a person (Person class). The entity scoping the role is an organization (Organization class).

5.2.2.8.1 AssignedEntity

Refer to AssignedEntity (§ 5.2.2.1.1) as defined for authenticator participation.

5.2.2.8.2 Person

Refer to Person (§ 5.2.2.2.2) as defined for Author participation.

5.2.2.8.3 Organization

Refer to Organization (§ 5.2.2.1.3) as defined for authenticator participation.

5.2.2.8.4 OrganizationPartOf

Refer to OrganizationPartOf (§ 5.2.2.1.4) as defined for authenticator participation.

5.2.2.9 participant

participant
Table X: participant
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] ParticipationType Fixed
functionCode CE [0..1] D:ParticipationFunction Open
contextControlCode CS [0..1] OP Fixed
time TS [1..1]

participant.typeCode

The participant.typeCode is can be any code defined in the ParticipationType domain. Which can be used to represent other participants not explicitly mentioned by other classes, that were somehow involved in the documented acts.

Table X: Value set for participant.typeCode
v:ParticipationType [2.16.840.1.113883.1.11.10901] (CLOSED)
Code Display Name Code Display Name
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 PART Participation
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

participant.functionCode

The participant.functionCode is bound to the concept domain ParticipationFunction, which is used to specify the exact function an actor had in a service in all necessary detail. This domain may include local extensions (Open).

participant.contextControlCode

The participant.contextControlCode is fixed to "OP". It means that the participantType code specified in participant.typeCode will replace the set of author participations that have propagated from ancestor Acts, and will itself be the only author to propagate to any child Acts that allow context to be propagated.

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

participant.typeCode.time

The participant.typeCode.time is the date and time the specific participation occurred.

5.2.2.9.1 AssociatedEntity

A participant is a person or organization in the role of a participating entity (AssociatedEntity class). The entity playing the role is a person (Person class). The entity scoping the role is an organization (Organization class).

Table X: AssociatedEntity
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [1..1] V:RoleClassAssociative Closed
id SET<II> [0..*]
code CE [0..1] D:RoleCode Open
addr SET<AD> [0..*]
telecom SET<TEL> [0..*]

AssociatedEntity.classCode

When the participating entity is an organization, this is reflected by the presence of a scoping Organization, without a playing entity. Otherwise, the participating entity is considered a person with or without a scoping Organization.

Table X: Value set for ParticipatingEntity.classCode
V:RoleClassAssociative [2.16.840.1.113883.1.11.19313] (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
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

AssociatedEntity.id

An identifier for the associate person (when present) or the organization.

AssociatedEntity.code

An optional role code taken from the RoleCode concept domain. This binding is open so other code systems can be used.

AssociatedEntity.addr

The postal address for the associate person (when present) or the organization.

AssociatedEntity.telecom

The phone number for the associated person (when present) or the organization.

5.2.2.9.2 Person

Refer to Person (§ 5.2.2.2.2) as defined for Author participation.

5.2.2.9.3 Organization

Refer to Organization (§ 5.2.2.1.3) as defined for authenticator participation.

5.2.2.10 performer

See ServiceEvent (§ 5.2.3.2.2) for a description of the performer participant.

5.2.2.11 recordTarget

recordTarget

The recordTarget identifies the specified patient's medical record that the document belongs to.

A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participant can be stated.

Note: The recordTarget(s) of a document are stated in the header and propagate to nested content, where they cannot be overridden. However, the patient(s) specified by the recordTarget are assumed to be the default subjects of the clinical document. Unlike the recordTarget, which can not be overridden, the patients or subjects propagate to nested components, and can be overridden at the section or entry level. (see See CDA Context).

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

recordTarget.typeCode

The recordTarget.typeCode is fixed to "RCT" and indicates that this is a record target participation.

Table X: Fixed recordTarget.typeCode
Code Display Name
RCT record target
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

recordTarget.contextControlCode

The recordTarget.contextControlCode is fixed to "OP". It means that the recordTarget identified in the header will propagate to any child Acts that allow context to be propagated.

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

A recordTarget is represented as a relationship between a person and an organization, where the person is in a patient role (PatientRole class). The entity playing the role is a patient (Patient class). The entity scoping the role is an organization (Organization class). A patient is uniquely identified via the PatientRole.id attribute.

5.2.2.11.1 PatientRole
Table X: PatientRole
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] PAT Fixed
id SET<II> [1..*]
addr SET<AD> [0..*]
telecom SET<TEL> [0..*]

PatientRole.classCode

The PatientRole.classCode is fixed to "PAT" to indicate a person (Patient) as a recipient of health care services from a healthcare provider.

Table X: Fixed PatientRole.classCode
Code Display Name
PAT patient
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

PatientRole.id

A unique identifier for the person in this patient role.

PatientRole.addr

The postal address for the Patient.

PatientRole.telecom

The phone number for the Patient.

5.2.2.11.2 Patient
Table X: Patient
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] PSN Fixed
determinerCode CS [0..1] INSTANCE Fixed
id (Deprecated) 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

Note: Not all Patient elements defined in the RIM have been added to CDA's Patient class. Only those originally defined, or added using extensions within actual implementation guides have been included in CDA R2.1. Implementers are free to use extensions with CDA R2.1 or model missing information using the Observation class within the CDA body.

Patient.classCode

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

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

Patient.determinerCode

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

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

Patient.id (Deprecated)

CDA Release 1.0 allowed for additional person identifiers, corresponding to the Patient.id attribute in CDA Release 2.1. This attribute is included for backwards compatibility and has been deprecated because having two different ways to identify a patient can result in inconsistent usage. Further use of Patient.id is discouraged.

Patient.name

The patient'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.

Patient.desc

A textual or multimedia depiction of the patient.

Patient.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.

Patient.birthTime

The date and time of the patient's birth.

Patient.deceasedInd

An indication that the subject is dead.

Patient.deceasedTime

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

Note: If the deceasedTime is valued, then the deceasedInd SHALL be set true. If deceasedInd is set true, the deceasedTime should be valued, if known.

Patient.multipleBirthInd

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

Patient.multipleBirthOrderNumber

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

Patient.maritalStatusCode

The domestic partnership status of the patient.

Patient.religiousAffiliationCode

The primary religious preference of the patient.

Patient.raceCode

The race of the patient.

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

Patient.ethnicGroupCode

The ethnic group of the patient.

Note: More than one ethnic group is now supported in CDA R2.1.

Note: See 2.7 Backwards and Forwards Compatibility, for discussion on sdtc: extensions defined for CDA R2.0 and CDA R2.1.

5.2.2.11.3 Organization

The optional Organization in recordTarget identifies the Patient's healthcare organization. Refer to Organization as defined for authenticator participation for details.

5.2.2.11.4 LanguageCommunication

A patient's language communication skills can be expressed in the associated LanguageCommunication class.

Table X: LanguageCommunication
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
languageCode CS [0..1] D:HumanLanguage Open
modeCode CE [0..1] D:LanguageAbilityMode Open
proficiencyLevelCode CE [0..1] D:LanguageAbilityProficiency Open
preferenceInd BL [0..1]

LanguageCommunication.languageCode

A language for which the patient has some level of proficiency for communication.
Note: Providing a language reference with the LanguageCommunication.languageCode is recommended, when using this class.

LanguageCommunication.modeCode

The method of expression of the language, e.g. expressed spoken, expressed written, expressed signed, received spoken, received written, received signed

LanguageCommunication.proficiencyLevelCode

The level of proficiency the patient has in a particular language, e.g. excellent, good, fair, poor

LanguageCommunication.preferenceInd

An indicator specifying whether the language is preferred by the patient for the associated mode.

5.2.2.11.5 Birthplace

A Patient's birthplace is represented as a relationship between a patient and a place. The Birthplace class is played by a place (Place class), and scoped by the patient (Patient class).

Table X: Birthplace
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] BIRTHPL Fixed

Birthplace.classCode

The Birthplace.classCode it fixed to "BIRTHPL" indicating in this context, that the Place referenced is the birth place of the patient.

Table X: Fixed Birthplace.classCode
Code Display Name
BIRTHPL birthplace
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110
5.2.2.11.6 Place
Table X: Place
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] PLC Fixed
determinerCode CS [0..1] INSTANCE Fixed
name SET<ON> [0..1]
addr SET<AD> [0..*]

Place.classCode

A physical place or site with its containing structure. May be natural or man-made. The geographic position of a place may or may not be constant.

Table X: Fixed Place.classCode
Code Display Name
PLC place
Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41

Place.determinerCode


The determinerCode is fixed to "INSTANCE", which indicates a specific place is being identified.

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

Place.name

The name of place of birth (E.g. Queen Mary)

Place.addr

The postal address for the patient's birthplace.

5.2.2.11.7 Guardian

A patient's guardian is a person or organization in the role of guardian (Guardian class). The entity playing the role of guardian is a person (Person class) or organization (Organization class). The entity scoping the role is the patient (Patient class).

Where a guardian is not explicitly stated, the value should default to local business practice (e.g. the patient makes their own health care decisions unless incapacitated in which case healthcare decisions are made by the patient's spouse).

Table X: Guardian
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [1..1] GUARD Fixed
id SET<II> [0..*]
code CE [0..1] D:RoleCode Open
addr SET<AD> [0..*]
telecom SET<TEL> [0..*]

Guardian.classCode

The Guardian.classCode is fixed to "GUARD", indicating that the associated person or institution are legally empowered with responsibility for the care of a ward.

Table X: Fixed Guardian.classCode
Code Display Name
GUARD guardian
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

Guardian.code

An optional role code taken from the RoleCode concept domain. This binding is open so other code systems can be used.

Guardian.addr

The guardian's postal address.

Guardian.telecom

The guardian's phone number.

5.2.2.11.8 Person

Refer to Person as defined for Author participation.

5.2.2.11.9 Organization

Refer to organization as defined for authenticator participation.

5.2.2.12 responsibleParty

See EncompassingEncounter for a description of the responsibleParty participant.

5.2.2.13 Participant Scenarios

Several CDA Header participations can be played by the same person. In such cases, the person should be identified as the player for each appropriate participation. For instance, if a person is both the author and the authenticator of a document, the CDA Header should identify that person as both the author participant and the authenticator participant.

On other occasions, CDA Header participants are played by different people. The following table shows a number of scenarios and the values for various participants.

Table X: CDA participation scenarios
1. StaffPhysicianOne sees a patient as a consultant, dictates a note, and later signs it.
  • Author — StaffPhysicianOne
  • Encounter Participant — StaffPhysicianOne (typeCode="CONS")
  • Legal Authenticator — StaffPhysicianOne
2. StaffPhysicianOne sees a patient and dictates a note. StaffPhysicianTwo later signs the note.†
  • Author — StaffPhysicianOne
  • Legal Authenticator — StaffPhysicianTwo
3. ResidentOne sees a patient with StaffPhysicianOne. ResidentOne dictates a note and later signs it. The note is co-signed by StaffPhysicianOne.†
  • Author — ResidentOne
  • Authenticator — ResidentOne
  • Encounter Participant — StaffPhysicianOne (typeCode="ATND")
  • Legal Authenticator — StaffPhysicianOne
4. ResidentOne sees a patient with StaffPhysicianOne. ResidentOne dictates a note and later signs it. The note is co-signed by StaffPhysicianTwo.†
  • Author — ResidentOne
  • Authenticator — ResidentOne
  • Encounter Participant — StaffPhysicianOne (typeCode="ATND")
  • Legal Authenticator — StaffPhysicianTwo
5. ResidentOne sees a patient with StaffPhysicianOne. ResidentOne dictates a note, and goes off on vacation. The note is signed by ResidentTwo and by StaffPhysicianOne.†
  • Author — ResidentOne
  • Authenticator — ResidentTwo
  • Encounter Participant — StaffPhysicianOne (typeCode="ATND")
  • Legal Authenticator — StaffPhysicianOne
6. ResidentOne sees a patient with StaffPhysicianOne. ResidentOne dictates a note, which is later signed by ResidentTwo and StaffPhysicianTwo.†
  • Author — ResidentOne
  • Authenticator — ResidentTwo
  • Encounter Participant — StaffPhysicianOne (typeCode="ATND")
  • Legal Authenticator — StaffPhysicianTwo
7. StaffPhysicianOne receives an abnormal laboratory result, attempts to contact patient but can't, and writes and signs a progress note.
  • Author — StaffPhysicianOne
  • Legal Authenticator — StaffPhysicianOne
8. ResidentSurgeonOne is operating on a patient with StaffSurgeonOne. StaffSurgeonOne dictates an operative report and later signs it.
  • Author — StaffSurgeonOne
  • Authenticator — null (need not be included)
  • Legal Authenticator — StaffSurgeonOne
  • Performer — StaffSurgeonOne (typeCode="PPRF")
  • Performer — ResidentSurgeonOne (typeCode="SPRF")
9. In Austria, a PET-CT report, is authored and legally authenticated by a radiologist together with a nuclear medicine specialist. The two specialists are working for different medical institutes. Their work and expertise are equal in importance.
  • Author — Radiologist
  • Author — Nuclear Medicine Specialist
  • Legal Authenticator — Radiologist
  • Legal Authenticator — Nuclear Medicine Specialist

† Note that the ability of one clinician to co-sign or to sign on behalf of another clinician is subject to regulatory and local practice constraints.

5.2.3 Header Relationships

This section describes classes related to the root ClinicalDocument class via an ActRelationship.

5.2.3.1 ParentDocument

ParentDocument

The ParentDocument represents the source of a document revision, addenda, or transformation.

5.2.3.1.1 relatedDocument

The optional relatedDocument class is used to associate a ClinicalDocument to a ParentDocument.

Table X: relatedDocument Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [1..1] x_ActRelationshipDocument Closed
inversionInd BL [0..1]

relatedDocument.typeCode

Allowable values for the intervening relatedDocument.typeCode are shown in the following table.

Table X: Value set for relatedDocument.typeCode
v:x_ActRelationshipDocument [2.16.840.1.113883.1.11.11610] (CLOSED)
Code Display Name Code Display Name
APND is appendage RPLC replaces
XFRM transformation
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

A conformant CDA document can have a single relatedDocument with typeCode "APND"; a single relatedDocument with typeCode "RPLC"; a single relatedDocument with typeCode "XFRM"; a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; or a combination of two relatedDocuments with typeCodes "XFRM" and "APND". No other combinations are allowed.

relatedDocument.inversionInd

Technical note: CDA R2.0 design assumes that ClinicalDocument was the source for all typecodes found in relatedDocument, ("APND", "RPLC" and "XFRM"). For "APND" and "RPLC" this is correct, however for "XFRM", the RIM definition indicates that "it is used when the target Act is a transformation of the source Act...". This technically is an error in CDA R2.0's design, which normally should have required the use of inversionInd to establish the ClinicalDocument as the target and the ParentDocument as the source for the "XFRM" relation.

As a result, in CDA R2.1 when "XFRM" is assigned to the relatedDocument.typeCode, the associated inversionInd will be assumed to be fixed to true, but will not be required to be present in the instance document. In all other cases, "APND", "RPLC" the associated inversionInd will not be present and will be assumed to be false. This enables wire format compatibility between CDA R2.0 and CDA R2.1, and ensures proper interpretation of the "XFRM" ActRelationshipType code.

5.2.3.1.2 ParentDocument

The ParentDocument identifies and optionally provides a reference to the original document serving as the source for the current document revision, addendum or transformation.

Table X: ParentDocument Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] DOCCLIN Fixed
moodCode CS [0..1] EVN Fixed
typeId II [1..1]
id II [1..*]
code CE [1..1] D:DocumentType Open
text ED [0..1]
setId II [0..1]
versionNumber ST [0..1]

ParentDocument.classCode

The ParentDocument.classCode is fixed to "DOCCLIN".

Table X: Fixed ParentDocument.classCode
Code Display Name
DOCCLIN clinical document
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

ParentDocument.moodCode

The ParentDocument.moodCode is fixed to "EVN".

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

ParentDocument.id

The ParentDocument.id is a required identifier, which uniquely identifies the parent document.

ParentDocument.code

The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note). The value set is drawn from LOINC, and has a CWE coding strength.

ParentDocument.text

ParentDocument.text is modeled as an ED data type - allowing for the expression of the MIME type of the parent document. It is not to be used to embed the related document, and thus ParentDocument.text.BIN is precluded from use.

ParentDocument.setId

Optional setID for the parent document.

ParentDocument.versionNumber

Optional versionNumber of the parent document.

Additional Information on Document Identification, Revisions, and Addenda

A clinical document can be replaced by a new document and/or appended with an addendum.

A replacement document is a new version of the parent document. The parent document is considered superseded, but a system may retain it for historical or auditing purposes. The parent document being replaced is referenced via act relationship relatedDocument, where relatedDocument.typeCode is set to equal "RPLC" (for "replaces"). An example is a report found to contain an error that is subsequently replaced by the corrected report.

An addendum is a separate document that references the parent document, and may extend or alter the observations in the prior document. The parent document remains a current component of the patient record, and the addendum and its parent are both read by report recipients. The parent report (represented by the ParentDocument class) being appended is referenced via act relationship relatedDocument, where relatedDocument.typeCode is set to equal "APND" (for "appends").

Every CDA document must have a unique ClinicalDocument.id, and thus the replacement or addendum documents each have ClinicalDocument.id that is different from that of the parent document.

CDA documents may also contain a ClinicalDocument.setId and a ClinicalDocument.versionNumber, which together support a document identification and versioning scheme used in some document management systems. In this scheme, all documents in a chain of replacements have the same ClinicalDocument.setId and are distinguished by an incrementing ClinicalDocument.versionNumber. The initial version of a document gets, in addition to a new unique value for ClinicalDocument.id, a new value for ClinicalDocument.setId, and has the value of ClinicalDocument.versionNumber set to equal "1". A replacement document gets a new globally unique ClinicalDocument.id value, and uses the same value for ClinicalDocument.setId as the parent report being replaced, and increments the value of ClinicalDocument.versionNumber by 1. (Note that version number must be incremented by one when a report is replaced, but can also be incremented more often to meet local requirements.)

These relationships are illustrated in the following exhibit "Document Identification, Revisions, and Addenda Scenarios". Typical scenarios are:

  • A simple relacement (e.g. ClinicalDocument.id "1.2.345.6789.266" replacing ClinicalDocument.id "1.2.345.6789.123")
  • A simple append (e.g. ClinicalDocument.id "1.2.345.6789.456" appends ClinicalDocument.id "1.2.345.6789.123").

More complex scenarios that might be anticipated include:

[1] replacement of an addendum (e.g. ClinicalDocument.id "1.2.345.6789.224" replaces ClinicalDocument.id "1.2.345.6789.456", which itself is an addendum to ClinicalDocument.id "1.2.345.6789.123") - expected behavior would be to render the replacement as the addendum (e.g. render ClinicalDocument.id "1.2.345.6789.224" as the addendum to ClinicalDocument.id "1.2.345.6789.123");

[2] addendum to a replaced document (e.g. ClinicalDocument.id "1.2.345.6789.456" appends ClinicalDocument.id "1.2.345.6789.123", which has been replaced by ClinicalDocument.id "1.2.345.6789.266") - expected behavior would be to render the addendum along with the replacement (e.g. render ClinicalDocument.id "1.2.345.6789.456" as an addendum to ClinicalDocument.id "1.2.345.6789.266").

Document transformations

A CDA document can be a transformation from some other format, meaning that it has undergone a machine translation from some other format (such as DICOM SR). In this case, relatedDocument.typeCode should be set to "XFRM".

A proper transformation must ensure that the human readable clinical content of the report is not impacted. Local business rules determine whether or not a transformed report replaces the source, but typically this would not be the case. If it is, an additional relationship of type "RPLC" is to be used. The "XFRM" relationship can also be used when translating a document in a local format into CDA for the purpose of exchange. In this case, the target of the "XFRM" relationship is the local document identifier.

Transformation

5.2.3.2 ServiceEvent

ServiceEvent

The ServiceEvent is used to represent the main activity being documented. It may used to represent a specific procedure, such as a colonoscopy, an appendectomy, or other clinical activity. When the ClinicalDocument represents a summary of care, the ServiceEvent.code can be set to "PCPR" to indicate the service is care provisioning.

5.2.3.2.1 documentationOf

The optional documentationOf class is used to associate a ClinicalDocument to a ServiceEvent.

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

documentationOf.typeCode

The documentationOf.typeCode is fixed to "DOC" which indicates that the ClinicalDocument provides documentation is about ServiceEvent.

Table X: Fixed documentationOf.typeCode
Code Display Name
DOC documents
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002
5.2.3.2.2 ServiceEvent

In some cases, the ServiceEvent is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is "History and Physical Report" and the procedure being documented is a "History and Physical". A ServiceEvent can further specialize the act inherent in the ClinicalDocument.code, such as where the ClinicalDocument.code is simply "Procedure Report" and the procedure was a "colonoscopy". If ServiceEvent is included, it must be equivalent to or further specialize the value inherent in the ClinicalDocument.code, and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

Table X: ServiceEvent Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] V:ActClassRoot Fixed
moodCode CS [0..1] EVN Fixed
id II [0..*]
code CD [0..1] D:ActCode Open
statusCode CS [0..1] D:ActStatus Closed
effectiveTime IVL<TS> [0..1]

ServiceEvent.classCode

The ServiceEvent.classCode identifies the RIM Act class code of the service event instance.

Table X: Value set for ServiceEvent.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
DOCSECT 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

ServiceEvent.moodCode

The ServiceEvent.moodCode is fixed to "EVN", which indicates documentation of a past service.

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

ServiceEvent.id

The optional unique identifier for the ServiceEvent.

ServiceEvent.code

The particular kind of service event that the this instance represents within its class code. The ServiceEvent.code is bound to the D:ActCode concept domain.

ServiceEvent.statusCode

The ServiceEvent.statusCode can take on any of the values defined in the D:ActStatus domain.

ServiceEvent.effectiveTime

ServiceEvent.effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place.

5.2.3.2.3 performer

The performer participant represents clinicians who actually and principally carry out the ServiceEvent.

Table X: performer
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [1..1] x_ServiceEventPerformer Closed
functionCode CE [0..1] D:ParticipationFunction Open
time TS [1..1]

performer.typeCode

Allows for the optional identification of performers, primary performers and secondary performers.

Table X: Value set for performer.typeCode
v:x_ServiceEventPerformer [2.16.840.1.113883.1.11.19601] (CLOSED)
Code Display Name Code Display Name
PRF performer PPRF primary performer
SPRF secondary performer
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

performer.functionCode

Performer.functionCode can be used to specify addition detail about the function of the performer (e.g. scrub nurse, third assistant). The functionCode is bound to the D:ParticipationFunction concept domain.

performer.time

Performer.time can be used to specify the time during which the performer is involved in the activity.

5.2.3.2.4 AssignedEntity

A performer is an entity in the role of assigned entity (AssignedEntity class).

5.2.3.2.5 Person

An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a person (Person] class).

5.2.3.2.6 Organization

The entity scoping the role is an organization (Organization class).

5.2.3.3 Order

Order

This class represents those requests that are fulfilled by this document. For instance, a provider orders an X-Ray. The X-Ray is performed. A radiologist reads the X-Ray and generates a report. The X-Ray order identifier is transmitted in the Order class, the performed X-Ray procedure is transmitted in the ServiceEvent class, and the ClinicalDocument.code would be valued with "Diagnostic Imaging Report".

5.2.3.3.1 inFullfillmentOf

The optional inFullfillmentOf class is used to associate a ClinicalDocument to an Order.

Table X: Fixed InFulfillmentOf.typeCode
Code Display Name
FLFS fulfills
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002
5.2.3.3.2 Order

A reference to the fulfilled order.

Table X: Order Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] V:ActClassRoot Closed
moodCode CS [0..1] RQO Fixed
id II [1..*]
code CD [0..1] D:ActCode Open
priorityCode CS [0..1] V:ActPriority Open

Order.classCode

The Order.classCode identifies the RIM Act class code of the order instance.

Table X: Value set for Order.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

Order.moodCode

The Order.moodCode is fixed to "RQO", which indicates we are referencing the actual order instance.

Table X: Fixed Order.moodCode
Code Display Name
RQO request
Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001

Order.id

The Order.id is a unique identifier for the order that was fulfilled.

Order.code

The particular kind of order that the this instance represents within its class code. The optional Order.code is bound to the D:ActCode concept domain.

Order.priorityCode

The optional Order.priorityCode, identifies the priority requested when the order was placed. It is bound to the D:ActPriority concept domain.

5.2.3.4 Consent

Consent

Provides references to consents on file.

5.2.3.4.1 authorization

The optional authorization class is used to associate a ClinicalDocument to a Consent.

Table X: authorization Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] AUTH Fixed

authorization.typeCode

Table X: Fixed authorization.typeCode
Code Display Name
AUTH authorized by
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002
5.2.3.4.2 Consent

This class references the consents associated with this document.

Table X: Consent Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] CONS Fixed
moodCode CS [0..1] EVN Fixed
id II [0..*]
code CD [0..1] D:ActCode Open
statusCode CS [1..1] completed Fixed

Consent.classCode

The Consent.classCode is fixed to "CONS" to represent a consent. The Consent class represents informed consents and all similar medico-legal transactions between the patient (or his legal guardian) and the provider.

Table X: Fixed Consent.classCode
Code Display Name
CONS consent
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

Consent.moodCode

The Consent.moodCode is fixed to "EVN" (event) which indicates the consent has already been captured and is assumed to be on file.

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

Consent.id

Optional identifier for the consent.

Consent.code

The Consent.code is bound to the D:ActCode concept domain. It is used to optionally identify the type of consent (e.g. a consent to perform the related ServiceEvent, a consent for the information contained in the document to be released to a third party).

Consent.statusCode

Consents referenced in the CDA Header have been finalized (Consent.statusCode must equal "completed") and should be on file.

Table X: Fixed Consent.statusCode
Code Display Name
completed completed
Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14

5.2.3.5 EncompassingEncounter

EncompassingEncounter

This optional class represents the setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal laboratory result, attempts to contact the patient but can't, and writes a Progress Note: in such a case, the encompassingEncounter could be omitted.

5.2.3.5.1 componentOf

The optional componentOf class is used to associate the ClinicalDocument to an EncompassingEncounter.

Table X: componentOf Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [0..1] COMP Fixed

componentOf.typeCode

The componentOf.typeCode is fixed to "COMP", which indicates that the ClinicalDocument was created within the context of an encounter (encompassingEncounter).

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

The EncompassingEncounter represents an interaction between a patient and care provider(s) for the purpose of providing healthcare-related service(s).

Table X: EncompassingEncounter Attributes
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] ENC Fixed
moodCode CS [0..1] EVN Fixed
id II [0..*]
code CD [0..1] V:ActEncounterCode Open
effectiveTime IVL<TS> [0..1]
admissionReferralSourceCode CE [0..1] D:EncounterReferralSourceCode Open
dischargeDispositionCode CE [0..1] D:EncounterDischargeDisposition Open

EncompassingEncounter.classCode

The EncompassingEncounter.classCode is fixed to "ENC" to represent a 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 EncompassingEncounter.classCode
Code Display Name
ENC encounter
Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6

EncompassingEncounter.moodCode

The EncompassingEncounter.moodCode is fixed to "EVN" (event) which indicates that the encounter is on-going or completed.

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

EncompassingEncounter.id

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

EncompassingEncounter.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

EncompassingEncounter.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 SHALL be omitted to indicate the encounter is on-going. This is preferred over using a nullFlavor.

EncompassingEncounter.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.

EncompassingEncounter.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.).

5.2.3.5.3 location

The location participant (location class) relates a healthcare facility (HealthCareFacility class) to the encounter to indicate where the encounter took place.

Table X: location
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [1..1] LOC Fixed

location.typeCode

Table X: Fixed participant.typeCode
Code Display Name
LOC location
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90
5.2.3.5.4 HealthCareFacility

The HealthCareFacility class supports the identification of the service delivery location. The location may be the setting (place) with an optional organizational reference, or a reference to the healthcare organization.

Table X: HealthCareFacility
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
classCode CS [0..1] V:RoleClassServiceDeliveryLocation Closed
id SET<II> [0..*]
code CE [0..1] V:ServiceDeliveryLocation Open

HealthCareFacility.classCode

The HealthCareFacility.classCode is bound to the ServiceDeliveryLocation value set and defaulted to the "SDLOC" to indicate the service delivery location.

Table X: Value set for HealthCareFacility.classCode
v:RoleClassServiceDeliveryLocation [2.16.840.1.113883.1.11.16927] (CLOSED)
Code Display Name Code Display Name
SDLOC (Default) service delivery location DSDLOC dedicated service delivery location, health care facility
ISDLOC incidental service delivery location
Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110

HealthCareFacility.id

An optional HealthCareFacility.id can be sent to uniquely identify the health care facility.

HealthCareFacility.code

The setting of an encounter (e.g. cardiology clinic, primary care clinic, rehabilitation hospital, skilled nursing facility) can be expressed in HealthCareFacility.code. A value set ServiceDeliveryLocationRoleType is provided for the this field.

Note: In some cases, the setting of the encounter is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is "Diabetes Clinic Progress Note". The setting of an encounter can also be transmitted in the HealthCareFacility.code attribute. If HealthCareFacility.code is sent, it should be equivalent to or further specialize the value inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply "Clinic Progress Note" and the value of HealthCareFacility.code is "cardiology clinic"), and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

5.2.3.5.5 Place

The entity playing the role of HealthCareFacility is a place (Place class).

The setting (place) and physical location are not the same. There is a many-to-many relationship between setting and the physical location where care is delivered. Thus, a particular room can provide the setting for cardiology clinic one day, and for primary care clinic another day; and cardiology clinic today might be held in one physical location, but in another physical location tomorrow.

5.2.3.5.6 Organization

The entity scoping the HealthCareFacility role is an organization (Organization class). When the location is an organization, this is indicated by the presence of a scoping Organization, without a playing Place.

5.2.3.5.7 responsibleParty

The responsibleParty participant represents the participant having primary legal responsibility for the encounter. This differs from the legalAuthenticator participant in that the legalAuthenticator may or may not be the responsible party, and is serving a medical records function by signing off on the document, moving it into a completed state.

responsibleParty.typeCode

The responsibleParty.typeCode is fixed to "RESP" to indicate the responsible party i.e. The person or organization that has primary responsibility for the encounter. The responsible party is not necessarily present in an action, but is accountable for the action through the power to delegate, and the duty to review actions with the performing actor after the fact. This responsibility may be ethical, legal, contractual, fiscal, or fiduciary in nature.

Table X: Fixed responsibleParty.typeCode
Code Display Name
RESP responsible party
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

A responsibleParty is a person or organization in the role of an assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a person (Person class). The entity scoping the role is an organization (Organization class).

When the responsible party is an organization, the value for AssignedEntity.classCode is "ASSIGNED", and the responsible party is reflected by the presence of a scoping Organization, without a playing entity.

5.2.3.5.8 AssignedEntity

A performer is an entity in the role of assigned entity (AssignedEntity class).

5.2.3.5.9 Person

An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a Person class.

5.2.3.5.10 Organization

The entity scoping the role is an organization (Organization class).

5.2.3.5.11 encounterParticipant

The encounterParticipant participant represents clinicians directly associated with the encounter (e.g. by initiating, terminating, or overseeing it).

Table X: performer
Attribute Name Data Type Wire Cardinality Code Binding Binding Type
typeCode CS [1..1] V:x_EncounterParticipant Closed
time TS [0..1]

encounterParticipant.typeCode

The encounterParticipant typeCode is bound to the x_EncounterParticipant value set. It supports for the following participation: admitter, attender, consultant, discharger, and referrer.

Table X: Value set for encounterParticipant.typeCode
V:x_EncounterParticipant [2.16.840.1.113883.1.11.19600] (CLOSED)
Code Display Name Code Display Name
ADM admitter ATND attender
CON consultant DIS discharger
REF
Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90

encounterParticipant.time

An encounterParticipant is an entity in the role of assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a person (Person class). The entity scoping the role is an organization (Organization class).

5.2.3.5.12 AssignedEntity

A performer is an entity in the role of assigned entity (AssignedEntity class).

5.2.3.5.13 Person

An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a Person class.

5.2.3.5.14 Organization

The entity scoping the role is an organization (Organization class).

5.3 Body

(content on separate page)

6 CDA Hierarchical Description

(content on separate page)

7 CDA XML Implementation

(content on separate page)

8 Appendix

(content on separate page)

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