Difference between revisions of "Body"

From HL7 Publishing Wiki
Jump to navigation Jump to search
(→‎Observation: %N% added documentation on negation value and action)
 
(719 intermediate revisions by 2 users not shown)
Line 7: Line 7:
 
=[[CDA Document Exchange in HL7 Messages]]=
 
=[[CDA Document Exchange in HL7 Messages]]=
 
(content on separate page)
 
(content on separate page)
−
=[[CDA R-MIM]]=
+
=[[CDA Templating]]=
 +
(content on separate page)
 +
=[[CDA Design]]=
 +
==[[Clinical Document]]==
 
(remaining content on separate page)
 
(remaining content on separate page)
 
==[[Header]]==
 
==[[Header]]==
Line 14: Line 17:
 
==Body==
 
==Body==
  
−
===Body Choice===
+
===<big>Body Choice</big>===
  
−
The CDA body can be either an unstructured blob, or can be comprised of structured markup. Every CDA document has exactly one body, associated with the ClinicalDocument class through the component relationship.
+
[[Image:BodyChoice.png|800px|border|center|Body Choice]]
  
−
{| class='wikitable' 
+
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.  
−
|+Table {{AUTOTABLENUM}}: Value set for component.typeCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|COMP (component) ['''default''']||The associated document body is a component of the document.
 
−
|}
 
  
−
====NonXMLBody====
+
<div id="div-component"></div>
 +
=====<big>component</big>=====
  
−
The NonXMLBody class represents a document body that is in some format other than XML. NonXMLBody.text is used to reference data that is stored externally to the CDA document or to encode the data directly inline.
+
The component class relates the ClinicalDocument header to the body choice; NonXMLBody or StructuredBody.
−
 
 
−
Rendering a referenced non-XML body requires a software tool that recognizes the particular MIME media type of the blob.
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for NonXMLBody.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: documentationOf Attributes
−
!Code!!Definition
+
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-typeCode-att typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActRelationshipType.htm#ActRelationshipDocuments DOC]||Fixed
 
|-
 
|-
−
|DOCBODY (document body) ['''default''']||A context that distinguishes the body of a document from the document header.
+
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-contextConductionInd-att contextConductionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 
|}
 
|}
  
−
{| class='wikitable'
+
'''component.typeCode'''
−
|+Table {{AUTOTABLENUM}}: Value set for NonXMLBody.moodCode (CNE)
+
 
−
!Code!!Definition
+
The component.typeCode is fixed to "COMP", which indicates that the body is a component part of the StructuredDocument.
−
|-
 
−
|EVN (event) ['''default''']||An actual occurrence of the event.
 
−
|}
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for NonXMLBody.confidentialityCode (CWE)
+
|+Table {{AUTOTABLENUM}}: Fixed component.typeCode
−
!Code *!!Definition
+
!Code!!Display Name
 
|-
 
|-
−
|N (normal) (codeSystem 2.16.840.1.113883.5.25)||Normal confidentiality rules (according to good health care practice) apply. That is, only authorized individuals with a legitimate medical or business need may access this item.
+
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COMP COMP]||has component
 
|-
 
|-
−
|R (restricted) (codeSystem 2.16.840.1.113883.5.25)||Restricted access, e.g. only to providers having a current care relationship to the patient.
+
!style="text-align:left;"  colspan="2" | <small> Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002</small>
−
|-
 
−
|V (very restricted) (codeSystem 2.16.840.1.113883.5.25)||Very restricted access as declared by the Privacy Officer of the record holder.
 
 
|}
 
|}
−
<nowiki>*</nowiki> The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.
 
  
−
====StructuredBody====
+
'''component.contextConductionInd'''
  
−
The StructuredBody class represents a CDA document body that is comprised of one or more document sections.
+
The component.contextConductionInd indicator is fixed to "true". Ancestor elements () which propagate, will conduct through this component class to the associated child element.
 +
 
 +
====<big>NonXMLBody</big>====
  
−
{| class='wikitable'  
+
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 {{AUTOTABLENUM}}: Value set for StructuredBody.classCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|DOCBODY (document body) ['''default''']||A context that distinguishes the body of a document from the document header.
 
−
|}
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for StructuredBody.moodCode (CNE)
+
|+Table {{AUTOTABLENUM}}: NonXMLBody Attributes
−
!Code!!Definition
+
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 
|-
 
|-
−
|EVN (event) ['''default''']||An actual occurrence of an event.
+
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att    classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#DOCCLIN DOCCLIN]||Fixed
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for StructuredBody.confidentialityCode (CWE)
 
−
!Code *!!Definition
 
 
|-
 
|-
−
|N (normal) (codeSystem 2.16.840.1.113883.5.25)||Normal confidentiality rules (according to good health care practice) apply. That is, only authorized individuals with a legitimate medical or business need may access this item.
+
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att    moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 
|-
 
|-
−
|R (restricted) (codeSystem 2.16.840.1.113883.5.25)||Restricted access, e.g. only to providers having a current care relationship to the patient.
+
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[1..1]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/vs_Confidentiality.htm#x_BasicConfidentialityKind V:x_BasicConfidentialityKind]||Open
 
|-
 
|-
−
|V (very restricted) (codeSystem 2.16.840.1.113883.5.25)||Very restricted access as declared by the Privacy Officer of the record holder.
+
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 
|}
 
|}
  
−
<nowiki>*</nowiki> The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.
+
'''NonXMLBody.typeCode'''
  
−
The StructuredBody class is associated with one or more Section classes through a component relationship.||
+
The ClinicalDocument.classCode in the CDA model is fixed to "DOCCLIN".
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for component.typeCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Fixed NonXMLBody.classCode
−
!Code!!Definition
+
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DOCBODY DOCBODY]||document body
 
|-
 
|-
−
|COMP (component) ['''default''']||The associated section is a component of the document body.
+
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 
|}
 
|}
  
−
===Section Attributes===
+
'''NonXMLBody.moodCode'''
  
−
Document sections can nest, can override context propagated from the header (see [[#CDA_Context|CDA Context]], and can contain narrative and CDA entries.
+
The NonXMLBody.moodCode is fixed to "EVN" or event mood to indicate that this is documentation of a past service.
−
 
 
−
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|reference]]). All values of attributes of type XML ID must be unique within the document (per the [http://www.w3.org/TR/2004/REC-xml-20040204/#id W3C XML specification]).
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for Section.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Fixed NonXMLBody.moodCode
−
!Code!!Definition
+
!Code!!Display Name
 
|-
 
|-
−
|DOCSECT (document section) ['''default''']||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.
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for Section.moodCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|EVN (event) ['''default''']||An actual occurrence of an event.
+
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 
|}
 
|}
  
−
====Section.id====
+
'''NonXMLBody.text'''
  
−
The unique instance identifier of a particular document section.
+
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.
  
−
====Section.code====
+
'''NonXMLBody.confidentialityCode'''
  
−
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.
+
Confidentiality is a required contextual component of CDA, where the value expressed in the ClinicalDocument can be overridden for the NonXMLBody of the document.  
  
−
====Section.title====
+
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for NonXMLBody.confidentialityCode
 +
! style="text-align:left;"  colspan="5" |  X_BasicConfidentialityKind <small>[2.16.840.1.113883.1.11.16926] (OPEN) </small>
 +
|-
 +
!Code !!Display Name!! !!Code !!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/Confidentiality.htm#N  N]||normal || ||[http://cda/infrastructure/vocabulary/Confidentiality.htm#R  R]||restricted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/Confidentiality.htm#V  V]||very restricted|| || ||
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: Confidentiality (HL7) Code System OID: 2.16.840.1.113883.5.25</small>
 +
|}
 +
&Dagger; The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.
  
−
Represents the label of a section. If valued, it is to be rendered as part of the narrative content of the clinical document body.
+
'''NonXMLBody.languageCode'''
  
−
====Section.text====
+
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 (see [[#CDA_Context|CDA Context]] (&sect; 5.4)).
  
−
Used to store narrative to be rendered. Also referred to as the CDA Narrative Block. See [[#Section_Narrative_Block|Section Narrative Block]] for details.
+
====<big>StructuredBody</big>====
  
−
====Section.confidentialityCode====
+
The StructuredBody class represents a CDA document body that is comprised of one or more document sections.
−
 
 
−
A value for Section.confidentialityCode overrides the value propagated from StructuredBody. See [[#CDA_Context|CDA Context]] for more details.
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for Section.confidentialityCode (CWE)
+
|+Table {{AUTOTABLENUM}}: StructuredBody Attributes
−
!Code*!!Definition
+
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att    classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#DOCCLIN DOCCLIN]||Fixed
 
|-
 
|-
−
|N (normal) (codeSystem 2.16.840.1.113883.5.25)||Normal confidentiality rules (according to good health care practice) apply. That is, only authorized individuals with a legitimate medical or business need may access this item.
+
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att    moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 
|-
 
|-
−
|R (restricted) (codeSystem 2.16.840.1.113883.5.25)||Restricted access, e.g. only to providers having a current care relationship to the patient.
+
|[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/vs_Confidentiality.htm#x_BasicConfidentialityKind V:x_BasicConfidentialityKind]||Open
 
|-
 
|-
−
|V (very restricted) (codeSystem 2.16.840.1.113883.5.25)||Very restricted access as declared by the Privacy Officer of the record holder.
+
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 
|}
 
|}
−
<nowiki>*</nowiki> The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.
 
  
−
====Section.languageCode====
+
'''StructuredBody.classCode'''
  
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed StructuredBody.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DOCBODY DOCBODY]||document body
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
  
−
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".
+
'''StructuredBody.moodCode'''
  
−
A value for Section.languageCode overrides the value propagated from StructuredBody. See [[#CDA_Context|CDA Context]] for more details.
+
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed StructuredBody.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
  
−
===Section Participants===
+
'''StructuredBody.confidentialityCode'''
  
−
====author====
+
{| class='wikitable' 
−
 
+
|+Table {{AUTOTABLENUM}}: Value set for StructuredBody.confidentialityCode
−
The author participant (described above, see [[#author|author]]), can be ascribed to a CDA section, where it overrides the value(s) propagated from the CDA header.
+
! style="text-align:left;"  colspan="5" |  X_BasicConfidentialityKind <small>[2.16.840.1.113883.1.11.16926] (OPEN) </small>
 +
|-
 +
!Code !!Display Name!! !!Code !!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/Confidentiality.htm#N  N]||normal || ||[http://cda/infrastructure/vocabulary/Confidentiality.htm#R  R]||restricted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/Confidentiality.htm#V  V]||very restricted|| || ||
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: Confidentiality (HL7) Code System OID: 2.16.840.1.113883.5.25</small>
 +
|}
 +
&Dagger; The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.
 +
 
 +
'''StructuredBody.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 StructuredBody.languageCode overrides the value propagated from the header (see [[#CDA_Context|CDA Context]] (&sect; 5.4) for more details).
  
−
====informant====
+
=====<big>component @a@</big>=====
  
−
The informant participant (described above, see [[#informant|informant]]), can be ascribed to a CDA section where it overrides the value(s) propagated from the CDA header.
+
A component class is used to relate the body choice (NonXMLBody, StructuredBody) to it's component Section(s) (see [[#div-component|component]] (&sect; 5.3.1.1) for modeling).
  
−
====subject====
+
===<big>Section Attributes</big>===
  
−
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|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.
+
[[Image:Section.png|800px|border|center|Section]]
  
−
A subject is a person playing one of several possible roles (RelatedSubject class). The entity playing the role is a person (SubjectPerson class).
+
Document sections can nest, can override context propagated from the header, and can contain narrative and CDA entries (see [[#CDA_Context|CDA Context]] (&sect; 5.4)).
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for subject.typeCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Section Attributes
−
!Code!!Definition
+
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att    classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#DOCSECT DOCSECT]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[1..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#DocumentSectionType D:DocumentSectionType]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-title-att title]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ST ST]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED].[[#Section_Narrative_Block|STRUCTURED_TEXT]]||[0..1]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/vs_Confidentiality.htm#x_BasicConfidentialityKind V:x_BasicConfidentialityKind]||Open
 
|-
 
|-
−
|SBJ (subject) ['''default''']||The principle target that the service acts on.
+
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 
|}
 
|}
  
−
{| class='wikitable'  
+
NOTE: XML ID Attribute added.  For more information, see ID/IDREF discussion in [[#Section_Narrative_Block|Section Narrative Block]] (&sect; 5.3.5). 
−
|+Table {{AUTOTABLENUM}}: Value set for subject.contextControlCode (CNE)
+
 
−
!Code!!Definition
+
'''Section.classCode'''
−
|-
+
 
−
|OP (overriding propagating) ['''default''']||The participant overrides associations with the same typeCode. This overriding association will propagate to any descendant Acts reached by conducting ActRelationships. (See section "CDA Context" below.)
+
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.  
−
|}
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for RelatedSubject.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Fixed Section.classCode  
−
!Code!!Definition
+
!Code!!Display Name
 
|-
 
|-
−
|PRS (personal relationship) ['''default''']||The subject has a personal relationship to the patient. The type of personal relationship is stated in SubjectRole.code, with a value drawn from the extensible (CWE) PersonalRelationshipRoleType vocabulary domain. The scoper is always the patient, and is implied.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#DOCSECT DOCSECT]||document section
 
|-
 
|-
−
|PAT (patient)||The subject of an entry is the patient, who is identified in the recordTarget participant in the CDA header.
+
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 
|}
 
|}
 +
 +
'''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.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for SubjectPerson.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Fixed Section.moodCode
−
!Code!!Definition
+
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event
 
|-
 
|-
−
|PSN (person) ['''default''']||A living subject of the species homo sapiens.
+
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 
|}
 
|}
  
−
{| class='wikitable'
+
'''Section.id'''
−
|+Table {{AUTOTABLENUM}}: Value set for SubjectPerson.determinerCode (CNE)
+
 
−
!Code!!Definition
+
The unique instance identifier of a particular document section.
−
|-
+
 
−
|INSTANCE (instance) ['''default''']||The INSTANCE determiner indicates an actual occurrence of an entity, as opposed to the KIND determiner, which refers to the general description of a kind of entity. For example, one can refer to a specific car (a car instance), or one can refer to cars in general (a car kind).
+
'''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 in the US Realm, but has an OPEN binding to enable other coding systems in other realms.
 +
 
 +
'''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'''
  
−
===Section Relationships===
+
Used to store narrative to be rendered. Also referred to as the CDA Narrative Block (see [[#Section_Narrative_Block|Section Narrative Block]] (&sect; 5.3.5) for details).
  
−
====component====
+
'''Section.confidentialityCode'''
  
−
The "component" Act Relationship is used to nest a Section within a Section. Context propagates to nested sections (see [[#CDA_Context|CDA Context]]).
+
A value for Section.confidentialityCode overrides the value propagated from StructuredBody (see [[#CDA_Context|CDA Context]] (&sect; 5.4) for more details.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for component.typeCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Value set for Section.confidentialityCode
−
!Code!!Definition
+
! style="text-align:left;"  colspan="5" |  X_BasicConfidentialityKind <small>[2.16.840.1.113883.1.11.16926] (OPEN) </small>
 +
|-
 +
!Code !!Display Name!! !!Code !!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/Confidentiality.htm#N  N]||normal || ||[http://cda/infrastructure/vocabulary/Confidentiality.htm#R  R]||restricted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/Confidentiality.htm#V  V]||very restricted|| || ||
 
|-
 
|-
−
|COMP (component) ['''default''']||The nested section is a component of the outer section.
+
!style="text-align:left;"  colspan="5" |<small> Code System: Confidentiality (HL7) Code System OID: 2.16.840.1.113883.5.25</small>
 
|}
 
|}
 +
&Dagger; The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.
 +
 +
'''Section.languageCode'''
  
−
====entry====
+
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".
  
−
The relationship between a section and its entries is encoded in the intervening "entry" Act Relationship.
+
A value for Section.languageCode overrides the value propagated from StructuredBody (see [[#CDA_Context|CDA Context]] (&sect; 5.4) for more details).
  
−
:'''NOTE:''' See [[#Referencing_in_and_out_of_the_narrative_block|Referencing in and out of the narrative block]] for a discussion of referencing in and out of a section's narrative block.
+
===<big>Section Participants</big>===
  
 +
====<big>author @a@</big>====
  
−
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.
+
The author participant (see [[#author|author]] (&sect; 5.2.2.2)), can be ascribed to a CDA section, where it overrides the value(s) propagated from the CDA header.
  
−
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.
+
====<big>informant @a@</big>====
  
−
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|entryRelationship]].
+
The informant participant (see [[#informant|informant]] (&sect; 5.2.2.6)), can be ascribed to a CDA section where it overrides the value(s) propagated from the CDA header.
  
−
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".
+
====<big>subject</big>====
  
−
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 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|recordTarget]] (&sect; 5.2.2.11)), but need not be, for instance when the subject is a fetus observed in an obstetrical ultrasound.
  
−
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.
+
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.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for entry.typeCode (CNE)
+
|+Table {{AUTOTABLENUM}}: informant
−
!Code!!Definition
+
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-typeCode-att  typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ParticipationType.htm#INF INF]||Fixed
 
|-
 
|-
−
|COMP (component) ['''default''']||The associated entry is a component of the section. No semantic relationship is implied.
+
|[http://cda/infrastructure/rim/rim.htm#Participation-contextControlCode-att contextControlCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ContextControl.htm#_ContextControlPropagating OP]||Fixed
 
|-
 
|-
−
|DRIV (is derived from)||The narrative was rendered from the CDA Entries, and contains no clinical content not derived from the entries.
+
|[http://cda/infrastructure/rim/rim.htm#Participation-awarenessCode-att awarenessCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#TargetAwareness D:TargetAwareness]||Open
 
|}
 
|}
  
−
===Section Narrative Block===
+
'''subject.typeCode'''
  
−
The Section.text field is used to store narrative to be rendered, as described above in [[#CDA_Conformance|CDA Conformance]], and is therefore referred to as the CDA Narrative Block.
+
The subject.typeCode is fixed to "SBJ" to indicate that a participant that is the principle target (subject) of the service acts documented.  
  
−
{{ext|processable/coreschemas/NarrativeBlock.xsd|The CDA Narrative Block schema can be found here.}}
+
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed subject.typeCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#SBJ SBJ]||subject
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90</small>
 +
|}
  
−
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|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.
+
'''subject.contextControlCode'''
  
−
====<content>====
+
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.
  
−
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.
+
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed subject.contextControlCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ContextControl.htm#_ContextControlPropagating OP]||overriding, propagating
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System:  ContextControl (HL7) Code System OID: 2.16.840.1.113883.5.1057</small>
 +
|}
  
−
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 [http://www.w3.org/TR/2004/REC-xml-20040204/#id 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.
+
=====RelatedSubject=====
  
−
'''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.
+
A subject is a person playing one of several possible roles (RelatedSubject class).  
  
−
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
+
{| class='wikitable' 
−
<nowiki>
+
|+Table {{AUTOTABLENUM}}: RelatedSubject
−
<section>
+
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
−
  <code code="10153-2"  
+
|-
−
    codeSystem="2.16.840.1.113883.6.1"
+
|[http://cda/infrastructure/rim/rim.htm#Role-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_RoleClass.htm#x_DocumentSubject x_DocumentSubject]||Closed
−
    codeSystemName="LOINC"/>
+
|-
−
  <title>Past Medical History</title>
+
|[http://cda/infrastructure/rim/rim.htm#Role-code-att  code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#PersonalRelationshipRoleType D:PersonalRelationshipRoleType ]|| Open
−
  <text>
+
|-
−
    There is a history of <content ID="a1">Asthma</content>
+
|[http://cda/infrastructure/rim/rim.htm#Role-addr-att  addr ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-AD AD]>||[0..*]|| ||
−
  </text>
+
|-
−
  <entry>
+
|[http://cda/infrastructure/rim/rim.htm#Role-telecom-att  telecom ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TEL TEL]>||[0..*]|| ||
−
      <observation classCode="OBS" moodCode="EVN">
+
|}
−
        <code code="195967001"
+
 
−
          codeSystem="2.16.840.1.113883.6.96"
+
'''RelatedSubject.classCode'''
−
          codeSystemName="SNOMED CT"  
+
 
−
          displayName="Asthma">
+
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.
−
            <originalText>
+
 
−
              <reference value="#a1"/>
+
{| class='wikitable' 
−
            </originalText>
+
|+Table {{AUTOTABLENUM}}: Value set for RelatedSubject.classCode
−
        </code>
+
! style="text-align:left;" colspan="5" | v:x_DocumentSubject  <small>[2.16.840.1.113883.1.11.19368] (CLOSED)</small>
−
        <statusCode code="completed"/>
+
|-
−
      </observation>
+
!Code!!Display Name !!  !!Code!!Display Name
−
  </entry>
+
|-
−
</section>
+
|[http://cda/infrastructure/vocabulary/RoleClass.htm#PAT PAT] ('''Default''')||patient ||
−
</nowiki>
+
||[http://cda/infrastructure/vocabulary/RoleClass.htm#PRS PRS]||personal relationship
 +
|-
 +
!style="text-align:left;" colspan="5" | <small> Code System:  RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110</small>
 +
|}
 +
 
 +
'''RelatedSubject.code'''
 +
 
 +
The RelatedSubject.code is bound to the [http://cda/infrastructure/vocabulary/vs_RoleCode.htm#PersonalRelationshipRoleType PersonalRelationshipRoleType] concept domain
  
−
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.
+
'''RelatedSubject.addr'''
  
−
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.
+
An optional postal address for the subject.
  
−
====<linkHtml>====
+
'''RelatedSubject.telecom'''
  
−
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.
+
An optional phone number for the subject.
  
−
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 [[#.3CrenderMultiMedia.3E|<renderMultiMedia>]]). Multimedia that is simply referenced by the document and not an integral part of the document can use <linkHtml>.
+
=====SubjectPerson=====
  
−
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.
+
The entity playing in the role RelatedSubject, is a person (SubjectPerson class).
  
−
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
+
{| class='wikitable' 
−
  <nowiki>
+
|+Table {{AUTOTABLENUM}}: SubjectPerson
−
<section ID="SECT001">
+
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
−
  <code code="10164-2" codeSystem="2.16.840.1.113883.6.1"
+
|-
−
    codeSystemName="LOINC"/>
+
|[http://cda/infrastructure/rim/rim.htm#Entity-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityClass.htm#PSN PSN]||Fixed
−
  <title>History of Present Illness</title>
+
|-
−
  <text>Mr. Smith is a 57 year old male presenting with
+
|[http://cda/infrastructure/rim/rim.htm#Entity-determinerCode-att determinerCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE  INSTANCE]||Fixed
−
    chest pain. He sustained a myocardial infarction 3 years
+
|-
−
    ago, ...
+
|[http://cda/infrastructure/rim/rim.htm#Entity-id-att  id] ||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]|| ||
−
  </text>
+
|-
−
</section>
+
|[http://cda/infrastructure/rim/rim.htm#Entity-name-att name]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PN PN]>||[0..*]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-desc-att  desc ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#LivingSubject-administrativeGenderCode-att administrativeGenderCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/AdministrativeGender.htm D:administrativeGender]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#LivingSubject-birthTime-att birthTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]|| ||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#LivingSubject-deceasedInd-att deceasedInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#LivingSubject-deceasedTime-att deceasedTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]|| ||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#LivingSubject-multipleBirthInd-att multipleBirthInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#LivingSubject-multipleBirthOrderNumber-att multipleBirthOrderNumber]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-INT INT]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Person-maritalStatusCode-att maritalStatusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/vs_MaritalStatus.htm#MaritalStatus D:MaritalStatus]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Person-religiousAffiliationCode-att religiousAffiliationCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/ReligiousAffiliation.htm D:ReligousAffiliation]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Person-raceCode-att raceCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||<span class="change-highlight">[0..*]</span>||[http://cda/infrastructure/vocabulary/Race.htm D:Race]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Person-ethnicGroupCode-att ethnicGroupCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||<span class="change-highlight">[0..*]</span>||[http://cda/infrastructure/vocabulary/Ethnicity.htm D:Ethnicity]||Open
 +
|}
 +
 
 +
'''SubjectPerson.classCode'''
  
−
...
+
The SubjectPerson.classCode is fixed to "PSN", indicating that the entity is a person.
  
−
<section ID="SECT003">
+
{| class='wikitable' 
−
  <code code="10153-2" codeSystem="2.16.840.1.113883.6.1"  
+
|+Table {{AUTOTABLENUM}}: Fixed SubjectPerson.classCode
−
    codeSystemName="LOINC"/>
+
!Code!!Display Name
−
  <title>Past Medical History</title>
+
|-
−
  <text>History of coronary artery disease, as noted
+
|[http://cda/infrastructure/vocabulary/EntityClass.htm#PSN PSN]||person
−
    <linkHtml href="#SECT001">above</linkHtml>.</text>
+
|-
−
</section>
+
!style="text-align:left;" colspan="2" | <small> Code System:  EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41</small>
−
</nowiki>
+
|}
 +
 
 +
'''SubjectPerson.determinerCode'''
 +
 
 +
The determinerCode is fixed to "INSTANCE", which indicates a specific person is a SubjectPerson.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed SubjectPerson.determinerCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE INSTANCE]||specific
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System:  EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30</small>
 +
|}
 +
 
 +
'''SubjectPerson.id'''
 +
 
 +
Optional identifier for the SubjectPerson.
 +
 
 +
'''SubjectPerson.name'''
  
−
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.
+
The subject's name.
  
−
====<nowiki><sub> and <sup></nowiki>====
+
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.
  
−
The CDA &lt;sub> and &lt;sup> elements are used to indicate subscripts and superscripts, respectively.
+
'''SubjectPerson.desc'''
  
−
Receivers are required to interpret these elements when rendering by visually distinguishing subscripted and superscripted characters.
+
A textual or multimedia depiction of the subject.
  
−
====<nowiki><br></nowiki>====
+
'''SubjectPerson.administrativeGenderCode'''
  
−
The CDA &lt;br/> element is used to indicate a hard line break. It differs from the CDA <paragraph> element in that the &lt;br/> element has no content. Receivers are required to interpret this element when rendering so as to represent a line break.
+
The gender (i.e., the behavioral, cultural, or psychological traits typically associated with one sex) of a living subject as defined for administrative purposes.  
  
−
====<footnote> and <footnoteRef>====
+
'''SubjectPerson.birthTime'''
  
−
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 date and time of the subject's birth.
  
−
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.
+
'''<span class="change-highlight">SubjectPerson.deceasedInd</span>'''
  
−
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.
+
<span class="change-highlight">An indication that the subject is dead.</span>
  
−
====<renderMultiMedia>====
+
'''<span class="change-highlight">SubjectPerson.deceasedTime</span>'''
  
 +
<span class="change-highlight">The date and time that the Subject's death occurred.</span>
  
−
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.
+
'''<span class="change-highlight">SubjectPerson.multipleBirthInd</span>'''
  
−
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.
+
<span class="change-highlight">An indication as to whether the subject was part of a multiple birth.</span>
  
−
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
+
'''<span class="change-highlight">SubjectPerson.multipleBirthOrderNumber</span>'''
−
<nowiki>
+
 
−
<section>
+
<span class="change-highlight">The order within a multiple birth in which this subject was born.</span>
−
  <code code="8709-8" codeSystem="2.16.840.1.113883.6.1"
+
 
−
    codeSystemName="LOINC"/>
+
'''SubjectPerson.maritalStatusCode'''
−
  <title>Skin exam</title>
+
 
−
  <text>Erythematous rash, palmar surface, left index
+
The domestic partnership status of the subject.
−
    finger.<renderMultiMedia referencedObject="MM1"/>
+
 
−
  </text>
+
'''SubjectPerson.religiousAffiliationCode'''
−
  <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>
 
−
</nowiki>
 
  
−
Multimedia that is simply referenced by the document and not an integral part of the document must use <linkHtml>.
+
The primary religious preference of the subject.
  
−
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.
+
'''SubjectPerson.raceCode'''
  
−
====<paragraph>====
+
The race of the subject.
  
−
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.
+
<span class="change-highlight">'''Note:''' More than one race code is now supported in CDA R2.1.</span>
  
−
====<list>====
+
'''SubjectPerson.ethnicGroupCode'''
  
−
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.
+
The ethnic group of the subject.
  
−
====&lt;table>====
+
<span class="change-highlight">'''Note:''' More than one ethnic group is now supported in CDA R2.1.</span>
  
−
The CDA &lt;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 &lt;entry> element.
+
'''Note:''' See 2.7 Backwards and Forwards Compatibility, for discussion on sdtc: extensions defined for CDA R2.0 and CDA R2.1.
  
−
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 &lt;table> element within &lt;td> & &lt;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.
+
===<big>Section Relationships</big>===
  
−
The table.border, table.cellspacing, and table.cellpadding attributes are deprecated, because the styleCode attribute (see [[#styleCode_attribute|styleCode attribute]]) provides a more consistent way for senders to suggest rendering characteristics.
+
====<big>component @b@</big>====
  
−
====&lt;caption>====
+
The "component" Act Relationship is used to nest a Section within a Section. Context propagates to nested sections (see [[#CDA_Context|CDA Context]] (&sect; 5.4)).  Refer to [[#div-component|component]] (&sect; 5.3.1.1) above for more information.
  
−
The CDA &lt;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 &lt;caption> contains plain text and may contain links and footnotes.
+
====<big>entry</big>====
  
−
====styleCode attribute====
+
The relationship between a section and its entries is encoded in the intervening "entry" Act Relationship.
  
−
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 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.
  
−
The value set is drawn from the HL7 styleType vocabulary domain, and has a CWE coding strength.
+
:'''NOTE:''' See [[#Referencing_in_and_out_of_the_narrative_block|Referencing in and out of the narrative block]] (&sect; 5.3.5.12) for a discussion of referencing in and out of a section's narrative block.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for styleCode (CWE)
+
|+Table {{AUTOTABLENUM}}: entry Attributes
−
!Code!!Definition
+
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 
|-
 
|-
−
|colspan="2"|Font style (Defines font rendering characteristics.)
+
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-typeCode-att typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActRelationshipType.htm#x_ActRelationshipEntry V:x_ActRelationshipEntry]||Fixed
 
|-
 
|-
−
|Bold||Render with a bold font.
+
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-contextConductionInd-att contextConductionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL 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|entryRelationship]] (&sect; 5.3.8.4).
 +
 
 +
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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for entry.typeCode
 +
! style="text-align:left;"  colspan="5" | V:x_ActRelationshipEntry  <small>[2.16.840.1.113883.1.11.19446] (CLOSED)</small>
 
|-
 
|-
−
|Underline||Render with an underlines font.
+
!Code!!Display Name!! !!Code!!Display Name
 
|-
 
|-
−
|Italics||Render italicized.
+
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COMP COMP] ('''Default''')||has component ||
 +
||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#DRIV DRIV]||is derived from
 
|-
 
|-
−
|Emphasis||Render with some type of emphasis.
+
!style="text-align:left;"  colspan="5" | <small> Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002</small>
−
|-
+
|}
−
|colspan="2"|Table rule style (Defines table cell rendering characteristics.
+
 
−
|-
+
'''entry.contextConductionInd'''
−
|Lrule||Render cell with left-sided rule.
+
 
−
|-
+
The component.contextConductionInd indicator is fixed to "true". Ancestor elements () which propagate, will conduct through this component class to the associated child element.
−
|Rrule||Render cell with right-sided rule.
+
 
−
|-
+
===<big>Section Narrative Block</big>===
−
|Toprule||Render cell with rule on top.
+
 
−
|-
+
The Section.text field is used to store narrative to be rendered, as described above in [[#CDA_Conformance|CDA Conformance]] (&sect; 1.3), and is therefore referred to as the CDA Narrative Block.
−
|Botrule||Render cell with rule on bottom.
+
 
−
|-
+
[http://cda/processable/coreschemas/NarrativeBlock.xsd| The CDA Narrative Block schema can be found here].
−
|colspan="2"|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.
 
−
|-
 
−
|colspan="2"|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 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|Human Readability and Rendering CDA Documents]] (&sect; 1.2.3)). 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.
 +
 
 +
====<big><content></big>====
 +
 
 +
The CDA &lt;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 &lt;content> element can nest recursively, which enables wrapping a string of plain text down to as small a chunk as desired.
 +
 
 +
The &lt;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 [http://www.w3.org/TR/2004/REC-xml-20040204/#id 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.
  
−
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:
+
'''Note:''' The &lt;content&gt; element is not the only element which can serve as the target of a reference. All narrative elements (including &lt;text&gt;) contain an ID element which can be referenced by the originalText component in a CDA entry. &lt;content&gt; is simply a tool which can be used to reference only a portion of a longer string contained in another narrative element.
  
 
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
 
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
 
  <nowiki>
 
  <nowiki>
 
<section>
 
<section>
−
   <text><content styleCode="Bold">This is rendered bold,
+
   <code code="10153-2"
−
     <content styleCode="Italics">this is rendered bold and
+
    codeSystem="2.16.840.1.113883.6.1"  
−
    italicized,</content> this is rendered bold. </content>
+
     codeSystemName="LOINC"/>
−
     <content styleCode="Bold Italics">This is also rendered
+
  <title>Past Medical History</title>
−
    bold and italicized.</content>
+
  <text>
 +
     There is a history of <content ID="a1">Asthma</content>
 
   </text>
 
   </text>
−
</section>
+
  <entry>
−
</nowiki>
+
      <observation classCode="OBS" moodCode="EVN">
−
 
+
        <code code="195967001"
−
====Referencing in and out of the narrative block====
+
          codeSystem="2.16.840.1.113883.6.96"
−
 
+
          codeSystemName="SNOMED CT"
−
NOTE: See [[#entry|entry]] for a discussion of the relationships between a section and its contained entries.
+
          displayName="Asthma">
−
 
+
            <originalText>
−
To summarize the mechanisms for referencing in and out of the CDA Narrative Block:
+
              <reference value="#a1"/>
 +
            </originalText>
 +
        </code>
 +
        <statusCode code="completed"/>
 +
      </observation>
 +
  </entry>
 +
</section>
 +
</nowiki>
  
−
CDA entries can point in to the <content> element of the CDA Narrative Block (see [[#.3Ccontent.3E|<content>]]).
+
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 <linkHtml> element of the CDA Narrative Block can reference targets that are either internal or external to the document (see [[#.3ClinkHtml.3E|<linkHtml>]]).
+
The &lt;content&gt; 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.
  
−
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 [[#.3Cfootnote.3E_and_.3CfootnoteRef.3E|<footnote> and <footnoteRef>]]).
+
====<big><linkHtml></big>====
  
−
The <renderMultiMedia> element of the CDA Narrative Block can point out to CDA ObservationMedia and RegionOfInterest entries of the same document (see [[#.3CrenderMultiMedia.3E|<renderMultiMedia>]]).
+
The CDA &lt;linkHtml&gt; 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.
  
−
===Entry Acts===
+
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 &lt;renderMultiMedia&gt; element (see [[#.3CrenderMultiMedia.3E|&lt;renderMultiMedia&gt;]] (&sect; 5.3.5.6)). Multimedia that is simply referenced by the document and not an integral part of the document can use &lt;linkHtml>.
  
−
CDA entries represent the structured computer-processable components within a document section. Each section can contain zero to many entries.
+
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 &lt;section&gt;, &lt;ObservationMedia&gt;, or &lt;renderMultiMedia&gt; 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.
 +
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
 +
<nowiki><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>
  
−
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.
+
<section ID="SECT003">
−
 
+
  <code code="10153-2" codeSystem="2.16.840.1.113883.6.1"
−
====Act====
+
    codeSystemName="LOINC"/>
 +
  <title>Past Medical History</title>
 +
  <text>History of coronary artery disease, as noted
 +
    <linkHtml href="#SECT001">above</linkHtml>.</text>
 +
</section>
 +
</nowiki>
 +
 
 +
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.
 +
 
 +
====<big>&lt;sub&gt; and &lt;sup&gt;</big>====
 +
 
 +
The CDA &lt;sub&gt; and &lt;sup&gt; elements are used to indicate subscripts and superscripts, respectively.
  
−
A derivative of the RIM Act class, to be used when the other more specific classes aren't appropriate.
+
Receivers are required to interpret these elements when rendering by visually distinguishing subscripted and superscripted characters.
  
−
Act.negationInd, when set to "true", is a positive assertion that the Act as a whole is negated. 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. For instance, a negated "finding of wheezing on July 1" means that the author positively denies that there was wheezing on July 1, 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.
+
====<big>&lt;br&gt;</big>====
  
−
{| class='wikitable' 
+
The CDA &lt;br/> element is used to indicate a hard line break. It differs from the CDA &lt;paragraph> element in that the &lt;br/> element has no content. Receivers are required to interpret this element when rendering so as to represent a line break.
−
|+Table {{AUTOTABLENUM}}: Value set for Act.classCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|ACT (act)||A healthcare service.
 
−
|-
 
−
|ACCM (accommodation)||An accommodation is a service provided for a Person or other LivingSubject in which a place is provided for the subject to reside for a period of time.
 
−
|-
 
−
|CONS (consent)||Represents informed consents and other medico-legal transactions between the patient (or legal guardian) and the provider.
 
−
|-
 
−
|CTTEVENT (clinical trial timepoint event)||An identified point during a clinical trial at which one or more actions are scheduled to be performed (definition mood), or are actually performed (event mood).
 
−
|-
 
−
|INC (incident)||An event that occurred outside of the control of one or more of the parties involved. Includes the concept of an accident.
 
−
|-
 
−
|INFRM (inform)||The act of transmitting information and understanding about a topic (or requesting that such information be transmitted) to a subject.
 
−
|-
 
−
|PCPR (care provision)||A patient care provision is the taking on of the responsibility by a performer for the health care of a patient or group of patients.
 
−
|-
 
−
|REG (registration)||Represents the act of maintaining information about an entity or role in a registry.
 
−
|-
 
−
|SPCTRT (specimen treatment)||A procedure or treatment performed on a specimen to prepare it for analysis
 
−
|}
 
  
−
{| class='wikitable' 
+
====<big><footnote> and <footnoteRef></big>====
−
|+Table {{AUTOTABLENUM}}: Value set for Act.moodCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|EVN (event)||The entry defines an actual occurrence of an event.
 
−
|-
 
−
|INT (intent)||The entry is intended or planned.
 
−
|-
 
−
|APT (appointment)||The entry is planned for a specific time and place.
 
−
|-
 
−
|ARQ (appointment request)||The entry is a request for the booking of an appointment.
 
−
|-
 
−
|PRMS (promise)||A commitment to perform the stated entry.
 
−
|-
 
−
|PRP (proposal)||A proposal that the stated entry be performed.
 
−
|-
 
−
|RQO (request)||A request or order to perform the stated entry.
 
−
|-
 
−
|DEF (definition)||The entry defines a service (master).
 
−
|}
 
  
−
====Encounter====
+
The CDA &lt;footnote> element is used to indicate a footnote. The element contains the footnote, inline with the flow of text to which it is applied.
−
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|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.
+
The &lt;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.
  
−
{| class='wikitable' 
+
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.
−
|+Table {{AUTOTABLENUM}}: Value set for Encounter.classCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|ENC (encounter)||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.
 
−
|}
 
  
−
{| class='wikitable' 
+
====<big><renderMultiMedia></big>====
−
|+Table {{AUTOTABLENUM}}: Value set for Encounter.moodCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|INT (intent)||The entry is intended or planned.
 
−
|-
 
−
|EVN (event)||The entry defines an actual occurrence of an event.
 
−
|-
 
−
|APT (appointment)||The entry is planned for a specific time and place.
 
−
|-
 
−
|ARQ (appointment request)||The entry is a request for the booking of an appointment.
 
−
|-
 
−
|PRMS (promise)||A commitment to perform the stated entry.
 
−
|-
 
−
|PRP (proposal)||A proposal that the stated entry be performed.
 
−
|-
 
−
|RQO (request)||A request or order to perform the stated entry.
 
−
|}
 
  
−
====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.  
+
The CDA &lt;renderMultiMedia&gt; 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.
  
−
=====Observation Negation=====
+
The &lt;renderMultiMedia&gt; element has an optional &lt;caption&gt;, 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.
−
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.  
+
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
−
<br />
+
<nowiki><section>
−
 
+
  <code code="8709-8" codeSystem="2.16.840.1.113883.6.1"
−
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).  
+
    codeSystemName="LOINC"/>
−
<br />
+
  <title>Skin exam</title>
−
 
+
  <text>Erythematous rash, palmar surface, left index
−
Observation.negationInd, <b><I>is deprecated in CDA R2.1</i></b>, and is only retained for backwards compatibility. It was deprecated as the type of negation required knowledge of template documentation, I.e. value or action negation. It was used in CDA R2.0 to indicate that the Act statement is a negation of the Act as described by the descriptive attributes.
+
    finger.<renderMultiMedia referencedObject="MM1"/>
−
<br />
+
  </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>
 +
</nowiki>
 +
 
 +
Multimedia that is simply referenced by the document and not an integral part of the document must use <linkHtml>.
  
−
{| class='wikitable' 
+
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. &lt;renderMultiMedia> can either reference a single ObservationMedia, or one or more RegionOfInterest. If &lt;renderMultiMedia> references a single ObservationMedia, that ObservationMedia should be rendered or referenced at the point of reference. If &lt;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 &lt;renderMultiMedia> references more than one RegionOfInterest, each RegionOfInterest must be a region on the same multimedia.
−
|+Table {{AUTOTABLENUM}}: Value set for Observation.classCode (CNE)
+
 
−
!Code!!Definition
+
====<big><paragraph></big>====
−
|-
+
 
−
|OBS (Observation)||Observations are actions performed in order to determine an answer or result value.
+
A CDA &lt;paragraph> is similar to the HTML paragraph, which allows blocks of narrative to be broken up into logically consistent structures. A CDA &lt;paragraph> element contains an optional caption, which if present must come first before any other character data.
−
|-
 
−
|Any OBS subtype||See vocabulary domain "ActClassObservation" for allowable values.
 
−
|}
 
  
−
{| class='wikitable'   
+
====<big><list></big>====
−
|+Table {{AUTOTABLENUM}}: Value set for Observation.moodCode (CNE)
+
 
−
!Code!!Print Name!!Definition
+
A CDA &lt;list> is similar to the HTML list. A CDA &lt;list> has an optional caption, and contains one or more &lt;item> elements. A CDA &lt;item> element contains an optional caption, which if present must come first before any other character data. The required listType attribute specifies whether the &lt;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.
−
|-
+
 
−
|APT||appointment||A planned Act for a specific time and place.
+
====<big>&lt;table></big>====
−
|-
+
 
−
|ARQ||appointment request||A request for the booking of an appointment.
+
The CDA &lt;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 &lt;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. <span class="change-highlight">A notable enhancement to the CDA R2.1 standard is the support of the &lt;table> element within &lt;td> & &lt;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.</span> For definitions of the @align and @valign attributes see [http://www.w3.org/TR/html401/struct/tables.htm#h-11.3.2 the W3C HTML 4.01 Specification section 11.3.2].
 +
 
 +
The table.border, table.cellspacing, and table.cellpadding attributes are deprecated, because the styleCode attribute (see [[#styleCode_attribute|styleCode attribute]] (&sect; 5.3.5.11)) provides a more consistent way for senders to suggest rendering characteristics.
 +
 
 +
====<big>&lt;caption></big>====
 +
 
 +
The CDA &lt;caption> is a label for a paragraph, list, list item, table, or table cell. It can also be used within the &lt;renderMultiMedia> element to indicate a label for referenced ObservationMedia and RegionOfInterest entries. A &lt;caption> contains plain text and may contain links and footnotes.
 +
 
 +
====<big>styleCode attribute</big>====
 +
 
 +
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.
 +
 
 +
{| class='wikitable'   
 +
|+Table {{AUTOTABLENUM}}: Value set for styleCode (CWE)
 +
!Code!!Definition
 
|-
 
|-
−
|EVN||event||A service that actually happens, may be an ongoing service or a documentation of a past service.
+
|colspan="2"|Font style (Defines font rendering characteristics.)
 
|-
 
|-
−
|DEF||definition||A definition of a service (master).
+
|Bold||Render with a bold font.
 
|-
 
|-
−
|GOL||goal||An observation that is considered to be desirable to occur in the future. The essential feature of a goal is that if it occurs it would be considered as a marker of a positive outcome or of progress towards a positive outcome.  
+
|Underline||Render with an underlines font.
 
|-
 
|-
−
|INT||intent||An intention or plan to perform a service. Historical note: in previous RIM versions, the intent mood was captured as a separate class hierarchy, called Service_intent_or_order.  
+
|Italics||Render italicized.
 
|-
 
|-
−
|PRMS||promise||An intent to perform a service that has the strength of a commitment, i.e., other parties may rely on the originator of such promise that said originator will see to it that the promised act will be fulfilled. A promise can be either solicited or unsolicited.  
+
|Emphasis||Render with some type of emphasis.
 
|-
 
|-
−
|PRP||proposal||A non-mandated intent to perform an act. Used to record intents that are explicitly not Orders. Professional responsibility for the 'proposal' may or may not be present.  
+
|colspan="2"|Table rule style (Defines table cell rendering characteristics.
 
|-
 
|-
−
|RSK||risk||An act that may occur in the future and which is regarded as undesirable. The essential feature of a risk is that if it occurs this would be regarded as a marker of a negative outcome or of deterioration towards a negative outcome. Recording a risk indicates that it is seen as more likely to occur in the subject than in a general member of the population but does not mean it is expected to occur.  
+
|Lrule||Render cell with left-sided rule.
 
|-
 
|-
−
|RQO||request||A request or order for a service is an intent directed from a placer (request author) to a fulfiller (service performer).
+
|Rrule||Render cell with right-sided rule.
−
|}
 
−
|An Observation can have zero to many referenceRange relationships, which relate an Observation to the ObservationRange class, where the expected range of values for a particular observation can be specified.
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for referenceRange.typeCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|REFV (has reference values) ['''default''']||Reference ranges are essentially descriptors of a class of result values assumed to be "normal", "abnormal", or "critical". This link type can act as a trigger in case of alarms being triggered by critical results.
+
|Toprule||Render cell with rule on top.
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for ObservationRange.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|OBS (observation) ['''default''']||Observations are actions performed in order to determine an answer or result value.
+
|Botrule||Render cell with rule on bottom.
 
|-
 
|-
−
|Any OBS subtype||See vocabulary domain "ActClassObservation" for allowable values.
+
|colspan="2"|Ordered list style (Defines rendering characteristics for ordered lists.)
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for ObservationRange.moodCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|EVN.CRT (event criterion) ['''default''']||A criterion or condition over observations that must apply for an associated service to be considered.
+
|Arabic||List is ordered using Arabic numerals: 1, 2, 3.
−
|}
 
−
 
 
−
====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.
 
−
 
 
−
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 [[#.3CrenderMultiMedia.3E|<renderMultiMedia>]]). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).
 
−
 
 
−
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.
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for ObservationMedia.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|OBS (observation)||A multimedia observation.
+
|LittleRoman||List is ordered using little Roman numerals: i, ii, iii.
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for ObservationMedia.moodCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|EVN (event)||The entry defines an actual occurrence of an event.
+
|BigRoman||List is ordered using big Roman numerals: I, II, III.
−
|}
+
|-
−
 
+
|LittleAlpha||List is ordered using little alpha characters: a, b, c.
−
====Organizer====
+
|-
−
 
+
|BigAlpha||List is ordered using big alpha characters: A, B, C.
−
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.
+
|-
−
 
+
|colspan="2"|Unordered list style (Defines rendering characteristics for unordered lists.)
−
:'''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.
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for Organizer.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|BATTERY (battery)||A battery specifies a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are grouped together because of automation.
+
|Disc||List bullets are simple solid discs.
 
|-
 
|-
−
|CLUSTER (cluster)||A group of entries that have a logical association with one another. The Cluster class permits aggregation into a compound statement.
+
|Circle||List bullets are hollow discs.
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for Organizer.moodCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|EVN (event)||The entry defines an actual occurrence of an event
+
|Square||List bullets are solid squares.
 
|}
 
|}
  
−
====Procedure====
+
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).
  
−
A derivative of the RIM Procedure class, used for representing procedures.
+
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:
  
−
Procedure.negationInd, when set to "true", is a positive assertion that the Procedure as a whole is negated. Some properties such as Procedure.id, Procedure.moodCode, and the participations are not affected. These properties always have the same meaning: i.e., the author remains the author of the negative Procedure. A procedure statement with negationInd is still a statement about the specific fact described by the Procedure. 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.
+
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
−
 
+
<nowiki>
−
{| class='wikitable' 
+
<section>
−
|+Table {{AUTOTABLENUM}}: Value set for Procedure.classCode (CNE)
+
  <text><content styleCode="Bold">This is rendered bold,  
−
!Code!!Definition
+
    <content styleCode="Italics">this is rendered bold and  
−
|-
+
    italicized,</content> this is rendered bold. </content>
−
|PROC (procedure)||An act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject.
+
    <content styleCode="Bold Italics">This is also rendered
−
|}
+
    bold and italicized.</content>
 +
  </text>
 +
</section>
 +
</nowiki>
 +
 
 +
====<big>Referencing in and out of the narrative block</big>====
  
−
{| class='wikitable' 
+
NOTE: See [[#entry|entry]] (&sect; 5.3.4.2) for a discussion of the relationships between a section and its contained entries.
−
|+Table {{AUTOTABLENUM}}: Value set for Procedure.moodCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|EVN (event)||The entry defines an actual occurrence of an event.
 
−
|-
 
−
|INT (intent)||The entry is intended or planned.
 
−
|-
 
−
|APT (appointment)||The entry is planned for a specific time and place.
 
−
|-
 
−
|ARQ (appointment request)||The entry is a request for the booking of an appointment.
 
−
|-
 
−
|PRMS (promise)||A commitment to perform the stated entry.
 
−
|-
 
−
|PRP (proposal)||A proposal that the stated entry be performed.
 
−
|-
 
−
|RQO (request)||A request or order to perform the stated entry.
 
−
|-
 
−
|DEF (definition)||The entry defines a service (master).
 
−
|}
 
  
−
====RegionOfInterest====
+
To summarize the mechanisms for referencing in and out of the CDA Narrative Block:
  
 +
CDA entries can point in to the &lt;content> element of the CDA Narrative Block (see [[#.3Ccontent.3E|&lt;content>]] (&sect; 5.3.5.1)).
  
−
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.
+
The &lt;linkHtml> element of the CDA Narrative Block can reference targets that are either internal or external to the document (see [[#.3ClinkHtml.3E|&lt;linkHtml>]] (&sect; 5.3.5.2)).
  
−
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 [[#.3CrenderMultiMedia.3E|<renderMultiMedia>]]). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).
+
The &lt;footnoteRef> element of the CDA Narrative Block can reference a &lt;footnote> element in the same or different CDA Narrative Block of the same document (see [[#.3Cfootnote.3E_and_.3CfootnoteRef.3E|&lt;footnote> and &lt;footnoteRef>]] (&sect; 5.3.5.5)).
  
−
{| class='wikitable' 
+
The &lt;renderMultiMedia> element of the CDA Narrative Block can point out to CDA ObservationMedia and RegionOfInterest entries of the same document (see [[#.3CrenderMultiMedia.3E|&lt;renderMultiMedia>]] (&sect; 5.3.5.6)).
−
|+Table {{AUTOTABLENUM}}: Value set for RegionOfInterest.classCode (CNE)
+
 
−
!Code!!Definition
+
===<big>Entry Acts</big>===
−
|-
+
 
−
|ROIOVL (overlay region of interest)||A Region of Interest specified for an image using an overlay shape.
+
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.
 +
 
 +
====<big><big>Act</big></big>====
 +
[[Image:Act.png|500px|border|center|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.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for RegionOfInterest.moodCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Act Attributes
−
!Code!!Definition
+
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActClass.htm#x_ActClassDocumentEntryAct V:x_ActClassDocumentEntryAct]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActMood.htm#x_DocumentActMood V:x_DocumentActMood]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ActCode D:ActCode]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-actionNegationInd-att  actionNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-negationInd-att negationInd] ('''Deprecated''')||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-statusCode-att statusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActStatus.htm#ActStatus V:ActStatus]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-effectiveTime-att effectiveTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-activityTime-att activityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-availabilityTime-att availabilityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]||||
 
|-
 
|-
−
|EVN (event)||The entry defines an actual occurrence of an event.
+
|[http://cda/infrastructure/rim/rim.htm#Act-priorityCode-att priorityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority D:ActPriority]||Open
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for RegionOfInterest.code (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|CIRCLE (circle)||A circle defined by two (column,row) pairs. The first point is the center of the circle and the second point is a point on the perimeter of the circle.
+
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality D:Confidentiality]||Open
 
|-
 
|-
−
|ELLIPSE (ellipse)||An ellipse defined by four (column,row) pairs, the first two points specifying the endpoints of the major axis and the second two points specifying the endpoints of the minor axis.
+
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-uncertaintyCode-att uncertaintyCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActUncertainty D:ActUncertainty]||Open
 
|-
 
|-
−
|POINT (point)||A single point denoted by a single (column,row) pair, or multiple points each denoted by a (column,row) pair.
+
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-reasonCode-att reasonCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActReason D:ActReason]||Open
 
|-
 
|-
−
|POLY (polyline)||A series of connected line segments with ordered vertices denoted by (column,row) pairs; if the first and last vertices are the same, it is a closed polygon.
+
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 
|}
 
|}
  
−
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.
+
'''Act.classCode'''
  
−
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
+
The major class of Acts to which an Act-instance belongs.
−
<nowiki>
+
 
−
<section>
+
{| class='wikitable' 
−
  <code code="8709-8" codeSystem="2.16.840.1.113883.6.1"
+
|+Table {{AUTOTABLENUM}}: Value set for Act.classCode
−
    codeSystemName="LOINC"/>
+
! style="text-align:left;" colspan="5" |  x_ActClassDocumentEntryAct <small>[2.16.840.1.113883.1.11.19599] (CLOSED) </small>
−
  <title>Skin Exam</title>
+
|-
−
  <text>Erythematous rash, palmar surface, left index
+
!Code!!Display Name!!  !!Code!!Display Name
−
    finger.<renderMultiMedia referencedObject="MM2"/>
+
|-
−
  </text>
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#ACT ACT]||Act||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ACCM ACCM]||accommodation
−
  <entry>
+
|-
−
      <observation classCode="OBS" moodCode="EVN">
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONS CONS]||consent||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CTTEVENT CTTEVENT]||clinical trial timepoint event
−
        <code code="271807003"  
+
|-
−
          codeSystem="2.16.840.1.113883.6.96"
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#INC INC]||incident||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#INFRM INFRM]||inform
−
          codeSystemName="SNOMED CT"
+
|-
−
          displayName="Rash"/>
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#PCPR PCPR]||care provision||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#REG REG]||registration
−
        <statusCode code="completed"/>
+
|-
−
        <targetSiteCode code="48856004"  
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#SPCTRT SPCTRT]||specimen treatment||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#TRNS TRNS]||transportation
−
          codeSystem="2.16.840.1.113883.6.96"
+
|-
−
          codeSystemName="SNOMED CT"
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#ACSN ACSN]</span>||accession||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#CONTREG CONTREG]</span>||container registration
−
          displayName="Skin of palmer surface of index finger">
+
|-
−
            <qualifier>
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#DISPACT DISPACT]</span>||disciplinary action||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#EXPOS EXPOS]</span>||exposure
−
              <name code="78615007"  
+
|-
−
                codeSystem="2.16.840.1.113883.6.96"
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#AEXPOS AEXPOS]</span>||acquisition exposure||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#TEXPOS TEXPOS]</span>||transmission exposure
−
                displayName="with laterality"/>
+
|-
−
              <value code="7771000"
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#LIST LIST]</span>||working list||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#MPROT MPROT]</span>||monitoring program
−
                codeSystem="2.16.840.1.113883.6.96"
+
|-
−
                displayName="left"/>
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#REV REV]</span>||review||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#STORE STORE]</span>||storage
−
            </qualifier>
+
|-
−
        </targetSiteCode>
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActClass.htm#TRFR TRFR]</span>||transfer|| || ||
−
        <entryRelationship typeCode="SPRT">
+
|-
−
            <regionOfInterest classCode="ROIOVL" moodCode="EVN" ID="MM2">
+
!style="text-align:left;" colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
−
              <id root="2.16.840.1.113883.19.3.1"/>
+
|}
−
              <code code="ELLIPSE"/>
+
 
−
              <value value="3"/>
+
'''Act.moodCode'''
−
              <value value="1"/>
+
 
−
              <value value="3"/>
+
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.
−
              <value value="7"/>
+
 
−
              <value value="2"/>
+
{| class='wikitable' 
−
              <value value="4"/>
+
|+Table {{AUTOTABLENUM}}: Value set for Act.moodCode
−
              <value value="4"/>
+
! style="text-align:left;" colspan="5" | V:x_DocumentActMood <small>[2.16.840.1.113883.1.11.19458] (CLOSED) </small>
−
              <value value="4"/>
+
|-
−
              <entryRelationship typeCode="SUBJ">
+
!Code!!Display Name!!  !!Code!!Display Name
−
                  <observationMedia classCode="OBS" moodCode="EVN">
+
|-
−
                    <id root="2.16.840.1.113883.19.2.1"/>
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#APT APT]</span>||appointment||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#ARQ ARQ]</span>||appointment request
−
                    <value mediaType="image/jpeg">
+
|-
−
                        <reference value="lefthand.jpeg"/>
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event|| ||[http://cda/infrastructure/vocabulary/ActMood.htm#DEF DEF]||definition
−
                    </value>
+
|-
−
                  </observationMedia>
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#RQO RQO]||request||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#INT INT]||intent
−
              </entryRelationship>
+
|-
−
            </regionOfInterest>
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#PRMS PRMS]||promise||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#PRP PRP]||proposal
−
        </entryRelationship>
+
|-
−
      </observation>
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#RSK RSK]</span>||risk||  ||  ||
−
  </entry>
+
|-
−
</section>
+
!style="text-align:left;" colspan="5" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
−
</nowiki>
+
|}
−
 
+
 
−
====SubstanceAdministration====
+
'''Act.id'''
−
 
+
 
−
 
+
A unique identifier for the Act.
−
A derivative of the RIM SubstanceAdministration class, used for representing medication-related events such as medication history or planned medication administration orders.
+
 
−
 
+
'''Act.code'''
−
SubstanceAdministration.negationInd, when set to "true", is a positive assertion that the SubstanceAdministration as a whole is negated. 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 negative 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 positively denies that aspirin is being 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 negation.
+
 
 +
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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActCode ActCode] concept domain.
 +
 
 +
'''<span class="change-highlight">Act.actionNegationInd</span>'''
 +
 
 +
<span class="change-highlight">The Act.actionNegationInd works as a negative existence quantifier on the actual, intended or described Act event. In Event mood, it indicates the defined act did not occur. In Intent mood, it indicates the defined act is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.
 +
 
 +
The actionNegationInd negates the Act as described by the descriptive properties which are:  classCode, code, statusCode, effectiveTime, activityTime, priorityCode, reasonCode and any of their components.  
 +
 
 +
The remaining properties represent the document characteristics, E.g. Act.id, Act.moodCode, Act.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.
 +
</span>
 +
 
 +
'''Act.negationInd'''
 +
 
 +
<span class="change-highlight">Act.negationInd, <b><i>is deprecated in RIM 2.35</i></b>, and CDA R2.1 retains it for backwards compatibility.  CDA R2.1 compliant implementation guides should use actionNegationInd moving forward.</span>
 +
 
 +
'''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 [http://cda/infrastructure/rim/rim.htm#ActStatus  state machine diagram] depicts the allowable state transitions that an Act.StatusCodes can take on.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for SubstanceAdministration.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Value set for Act.statusCode
−
!Code!!Definition
+
! style="text-align:left;"  colspan="5" | V:ActStatus <small>[2.16.840.1.113883.1.11.15933] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 
|-
 
|-
−
|SBADM (substance administration)||The act of introducing or otherwise applying a substance to the subject.
+
|[http://cda/infrastructure/vocabulary/ActStatus.htm#normal normal]||normal|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#aborted aborted]||aborted
−
|}
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for SubstanceAdministration.moodCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|EVN (event)||The entry defines an actual occurrence of an event.
+
|[http://cda/infrastructure/vocabulary/ActStatus.htm#active active]||active|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#cancelled cancelled]||cancelled
 
|-
 
|-
−
|INT (intent)||The entry is intended or planned.
+
|[http://cda/infrastructure/vocabulary/ActStatus.htm#completed completed]||completed|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#held held]||held
 
|-
 
|-
−
|PRMS (promise)||A commitment to perform the stated entry.
+
|[http://cda/infrastructure/vocabulary/ActStatus.htm#new new]||new|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#suspended suspended]||suspended
 
|-
 
|-
−
|PRP (proposal)||A proposal that the stated entry be performed.
+
|[http://cda/infrastructure/vocabulary/ActStatus.htm#nullified nullified]||nullified|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#obsolete obsolete]||obsolete
 
|-
 
|-
−
|RQO (request)||A request or order to perform the stated entry.
+
!style="text-align:left;"  colspan="5" |<small> Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14</small>
 
|}
 
|}
  
−
SubstanceAdministration.priorityCode categorizes the priority of a substance administration. SubstanceAdministration.doseQuantity indicates how much medication is given per dose. 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.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.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.
+
'''Act.effectiveTime'''
  
−
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
+
Act.effectiveTime is used to indicate the clinically or operationally relevant time of an act, exclusive of administrative activity.
−
<nowiki>
+
 
−
<section>
+
'''<span class="change-highlight">Act.activityTime</span>'''
−
  <text>Take captopril 25mg PO every 12 hours, starting on  
+
 
−
    Jan 01, 2002, ending on Feb 01, 2002.
+
<span class="change-highlight">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. </span>
−
  </text>
+
 
−
  <entry>
+
'''<span class="change-highlight">Act.availabilityTime</span>'''
−
      <substanceAdministration classCode="SBADM" moodCode="RQO">
+
 
−
        <effectiveTime xsi:type="IVL_TS">
+
<span class="change-highlight">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.</span>
−
            <low value="20020101"/>
+
 
−
            <high value="20020201"/>
+
'''Act.priorityCode'''
−
        </effectiveTime>
+
 
−
        <effectiveTime xsi:type="PIVL_TS" operator="A">
+
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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority ActPriority] concept domain.
−
            <period value="12" unit="h"/>
+
 
−
        </effectiveTime>
+
'''<span class="change-highlight">Act.confidentialityCode</span>'''
−
        <routeCode code="PO"  
+
 
−
          codeSystem="2.16.840.1.113883.5.112"
+
<span class="change-highlight">Constraints around appropriate disclosure of information about this Act, regardless of mood. The Act.confidentialityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality Confidentiality] concept domain.</span>
−
          codeSystemName="RouteOfAdministration"/>
+
 
−
        <doseQuantity value="1"/>
+
'''<span class="change-highlight">Act.uncertaintyCode</span>'''
−
        <consumable>
+
 
−
            <manufacturedProduct>
+
<span class="change-highlight">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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActUncertainty ActUncertainty] concept domain.</span>
−
              <manufacturedLabeledDrug>
+
 
−
                  <code code="318821008"  
+
'''<span class="change-highlight">Act.reasonCode</span>'''
−
                  codeSystem="2.16.840.1.113883.6.96"
+
 
−
                  codeSystemName="SNOMED CT"
+
<span class="change-highlight">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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActReason ActReason] concept domain.</span>
−
                  displayName="Captopril 25mg tablet"/>
+
 
−
              </manufacturedLabeledDrug>
+
<span class="change-highlight">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.</span>
−
            </manufacturedProduct>
+
 
−
        </consumable>
+
<span class="change-highlight">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.</span>
−
      </substanceAdministration>
+
 
−
  </entry>
+
'''Act.languageCode'''
−
</section>
+
 
−
</nowiki>
+
The primary language in which this Act statement is specified, particularly the language of the Act.text.  The Act.languageCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage HumanLanguage] concept domain.
 +
 
 +
====<big><big>Encounter</big></big>====
 +
 
 +
[[Image:Encounter.png|800px|border|center|Encounter]]
 +
 
 +
A derivative of the RIM PatientEncounter class, used to represent related encounters, such as follow-up visits or referenced past encounters.
  
−
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.
+
:'''NOTE:''' The EncompassingEncounter class in the CDA Header (see [[#Header_Relationships|Header Relationships]] (&sect; 5.2.3)) 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.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for consumable.typeCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Encounter Attributes
−
!Code!!Definition
+
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 
|-
 
|-
−
|CSM (consumable) ['''default''']||A substance that is taken up or consumed as part of the substance administration.
+
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#ENC ENC] ||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActMood.htm#x_DocumentEncounterMood V:x_DocumentEncounterMood]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ActCode D:ActCode]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-actionNegationInd-att  actionNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-negationInd-att negationInd] ('''Deprecated''')||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-statusCode-att statusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActStatus.htm#ActStatus V:ActStatus]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-effectiveTime-att effectiveTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-activityTime-att activityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-availabilityTime-att availabilityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-priorityCode-att priorityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority D:ActPriority]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality D:Confidentiality]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-uncertaintyCode-att uncertaintyCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActUncertainty D:ActUncertainty]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-reasonCode-att reasonCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActReason D:ActReason]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#PatientEncounter-admissionReferralSourceCode-att admissionReferralSourceCode]</span>||<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#EncounterReferralSource D:EncounterReferralSource]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#PatientEncounter-lengthOfStayQuantity-att lengthOfStayQuantity]</span>||<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ]>.TIME||[0..1]||  ||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#PatientEncounter-dischargeDispositionCode-att dischargeDispositionCode]</span>||<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#EncounterDischargeDisposition D:EncounterDischargeDisposition]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#PatientEncounter-preAdmitTestInd-att  preAdmitTestInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#PatientEncounter-specialCourtesiesCode-att specialCourtesiesCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#EncounterSpecialCourtesy D:EncounterSpecialCourtesy]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#PatientEncounter-specialArrangementCode-att specialArrangementCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#SpecialArrangement 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.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for ManufacturedProduct.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Fixed Encounter.classCode  
−
!Code!!Definition
+
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ENC ENC] ('''Fixed''')||encounter
 
|-
 
|-
−
|MANU (manufactured) ['''default''']||A manufactured product
+
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 
|}
 
|}
 +
 +
'''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.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for LabeledDrug.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Value set for Encounter.moodCode
−
!Code!!Definition
+
! style="text-align:left;"  colspan="5" |  V:x_DocumentEncounterMood <small>[2.16.840.1.113883.1.11.19459] (CLOSED) </small>
 
|-
 
|-
−
|MMAT (manufactured) ['''default''']||A manufactured material.
+
!Code!!Display Name!!  !!Code!!Display Name
−
|}
+
|-
−
 
+
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#APT APT]</span>||appointment||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#ARQ ARQ]</span>||appointment request
−
{| class='wikitable'  
+
|-
−
|+Table {{AUTOTABLENUM}}: Value set for LabeledDrug.determinerCode (CNE)
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#DEF DEF]</span>||definition
−
!Code!!Definition
+
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#RQO RQO]||request|| ||[http://cda/infrastructure/vocabulary/ActMood.htm#INT INT]||intent
 
|-
 
|-
−
|KIND (kind) ['''default''']||The described determiner is used to indicate that the given Entity is taken as a general description of a kind of thing that can be taken in whole, in part, or in multiples.
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#PRMS PRMS]||promise||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#PRP PRP]||proposal
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Material.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|MMAT (manufactured) ['''default''']||A manufactured material.
+
!style="text-align:left;"  colspan="5" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 
|}
 
|}
  
−
{| class='wikitable'
+
'''Encounter.id'''
−
|+Table {{AUTOTABLENUM}}: Value set for Material.determinerCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|KIND (kind) ['''default''']||The described determiner is used to indicate that the given Entity is taken as a general description of a kind of thing that can be taken in whole, in part, or in multiples.
 
−
|}
 
  
−
====Supply====
+
The optional Encounter.id can be used to uniquely identify the encounter.
  
−
A derivative of the RIM Supply class, used for representing the provision of a material by one entity to another.
+
'''Encounter.code'''
  
 +
The optional Encounter.code is bound to the ActEncounterCode value set.
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for Supply.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Value set for EncompassingEncounter.code
−
!Code!!Definition
+
! style="text-align:left;"  colspan="5" | V:ActEncounterCode <small> [2.16.840.1.113883.1.11.13955] (OPEN)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 
|-
 
|-
−
|SPLY (supply)||The act of dispensing or delivering a product.
+
|[http://cda/infrastructure/vocabulary/ActCode.htm#AMB AMB]||ambulatory||  ||[http://cda/infrastructure/vocabulary/ActCode.htm#EMER EMER]||emergency
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Supply.moodCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|EVN (event)||The entry defines an actual occurrence of an event.
+
|[http://cda/infrastructure/vocabulary/ActCode.htm#FLD FLD]||field|| ||[http://cda/infrastructure/vocabulary/ActCode.htm#HH HH]||home health
 
|-
 
|-
−
|INT (intent)||The entry is intended or planned.
+
|[http://cda/infrastructure/vocabulary/ActCode.htm#IMP IMP]||inpatient encounter|| ||[http://cda/infrastructure/vocabulary/ActCode.htm#ACUTE ACUTE]||inpatient acute
 
|-
 
|-
−
|PRMS (promise)||A commitment to perform the stated entry.
+
|[http://cda/infrastructure/vocabulary/ActCode.htm#NONAC NONAC]||virtual|| ||[http://cda/infrastructure/vocabulary/ActCode.htm#SS SS]||short stay
 
|-
 
|-
−
|PRP (proposal)||A proposal that the stated entry be performed.
+
|[http://cda/infrastructure/vocabulary/ActCode.htm#VR VR]||inpatient non-acute||  || ||
 
|-
 
|-
−
|RQO (request)||A request or order to perform the stated entry.
+
!style="text-align:left;"  colspan="5" | <small> Code System: ActCode (HL7) Code System OID: 2.16.840.1.113883.5.4</small>
 
|}
 
|}
  
−
The dispensed product is associated with the Supply act via a product participant, which connects to the same ManufacturedProduct role used for SubstanceAdministration.
+
'''<span class="change-highlight">Encounter.actionNegationInd</span>'''
  
−
{| class='wikitable' 
+
<span class="change-highlight">The Encounter.actionNegationInd works as a negative existence quantifier on the actual, intended or described Encounter event. In Event mood, it indicates the defined encounter did not occur. In Intent mood, it indicates the defined encounter is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.  
−
|+Table {{AUTOTABLENUM}}: Value set for product.typeCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|PRD (product) ['''default''']||A material target that is brought forth (e.g. dispensed) in the service.
 
−
|}
 
  
−
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.
+
The actionNegationInd negates the Encounter as described by the descriptive properties which are:  classCode, code, statusCode, effectiveTime, activityTime, priorityCode, reasonCode, admissionReferralSourceCode, lengthOfStayQuantity, dischargeDispositionCode, preAdmitTestInd, specialCourtesiesCode, specialArrangementCode and any of their components.  
  
−
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
+
The remaining properties represent the document characteristics, E.g. Encounter.id, Encounter.moodCode, Encounter.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative encounter. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance. </span>
−
<nowiki>
+
 
−
<section>
+
'''Encounter.text'''
−
  <text>Digoxin 0.125mg, 1 PO qDay, #30, 5 refills.</text>
+
 
−
  <entry>
+
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.
−
      <substanceAdministration classCode="SBADM" moodCode="RQO">
+
 
−
        <effectiveTime xsi:type="PIVL_TS">
+
'''Encounter.statusCode'''
−
            <period value="24" unit="h"/>
+
 
−
        </effectiveTime>
+
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.
−
        <routeCode code="PO"  
+
 
−
          codeSystem="2.16.840.1.113883.5.112"
+
'''Encounter.effectiveTime'''
−
          codeSystemName="RouteOfAdministration"/>
+
 
−
        <doseQuantity value="1"/>
+
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.
−
        <consumable>
+
 
−
            <manufacturedProduct>
+
'''<span class="change-highlight">Encounter.activityTime</span>'''
−
              <manufacturedLabeledDrug>
+
 
−
                  <code code="317896006"
+
<span class="change-highlight">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.</span>
−
                  codeSystem="2.16.840.1.113883.6.96"
+
 
−
                  codeSystemName="SNOMED CT"
+
'''<span class="change-highlight">Encounter.availabilityTime</span>'''
−
                  displayName="Digoxin 125micrograms tablet"/>
+
 
−
              </manufacturedLabeledDrug>
+
<span class="change-highlight">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.</span>  
−
            </manufacturedProduct>
+
 
−
        </consumable>
+
'''Encounter.priorityCode'''
−
        <entryRelationship typeCode="COMP">
+
 
−
            <supply classCode="SPLY" moodCode="RQO">
+
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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority ActPriority] concept domain.
−
              <repeatNumber>
+
 
−
                  <low value="0"/>
+
'''<span class="change-highlight">Encounter.confidentialityCode</span>'''
−
                  <high value="5"/>
+
 
−
              </repeatNumber>
+
<span class="change-highlight">Constraints around appropriate disclosure of information about this Encounter, regardless of mood. The Encounter.confidentialityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality Confidentiality] concept domain.</span>
−
              <independentInd value="false"/>
+
 
−
              <quantity value="30"/>
+
'''<span class="change-highlight">Encounter.reasonCode</span>'''
−
            </supply>
+
 
−
        </entryRelationship>
+
<span class="change-highlight">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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActReason ActReason] concept domain.</span>
−
      </substanceAdministration>
 
−
  </entry>
 
−
</section>
 
−
</nowiki>
 
  
−
===Entry Participants===
+
'''Encounter.languageCode'''
  
−
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|CDA Context]]), participants propagated from the header can be overridden within the body.
+
The primary language in which this Encounter statement is specified, particularly the language of the Encounter.text.  The Encounter.languageCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage HumanLanguage] concept domain.
  
−
====author====
+
'''<span class="change-highlight">Encounter.admissionReferralSourceCode</span>'''
  
−
The author participant (described above, see [[#author|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.
+
<span class="change-highlight">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.</span>
  
−
====consumable====
+
'''<span class="change-highlight">Encounter.lengthOfStayQuantity</span>'''
  
−
The consumable participant is described above (see [[#Entry_Acts|Entry Acts]]).
+
<span class="change-highlight">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.</span>
  
−
====informant====
+
'''<span class="change-highlight">Encounter.dischargeDispositionCode</span>'''
  
−
The informant participant (described above, see [[#informant|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.
+
<span class="change-highlight">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.).</span>
  
−
====participant====
+
'''<span class="change-highlight">Encounter.preAdmitTestInd</span>'''
−
 
+
 
−
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.
+
<span class="change-highlight">An indication that pre-admission tests are required for this patient encounter.</span>
−
 
+
 
−
{| class='wikitable'   
+
'''<span class="change-highlight">Encounter.specialCourtesiesCode</span>'''
−
|+Table {{AUTOTABLENUM}}: Value set for participant.typeCode (CNE)
+
 
−
!Code!!Definition
+
<span class="change-highlight">Extraordinary considerations or services provided within the context of the Patient Encounter. Examples include: Professional courtesy, VIP courtesies, no courtesies</span>
 +
 
 +
'''<span class="change-highlight">Encounter.specialArrangementCode</span>'''
 +
 
 +
<span class="change-highlight">Extraordinary provisions required in the context of the patient encounter. For encounters in intention moods, this information can be used to identify special arrangements that will need to be made for the incoming patient.</span>
 +
 
 +
====<big><big>Observation</big></big>====
 +
 
 +
[[Image:Observation.png|800px|border|center|Observation]]
 +
 
 +
A derivative of the [http://cda/infrastructure/rim/rim.htm#Observation-cls Observation] (&sect; RIM 2.35) 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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Observation Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||  &lt;= OBS  is [http://cda/infrastructure/vocabulary/vs_ActClass.htm#ActClassObservation V:ActClassObservation]  ||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActMood.htm#x_ActMoodDocumentObservation V:x_ActMoodDocumentObservation]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ObservationType D:ObservationType]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-actionNegationInd-att  actionNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-negationInd-att negationInd] ('''Deprecated''')||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-derivationExpr-att derivationExpr]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ST ST]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-title-att title]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-statusCode-att statusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActStatus.htm#ActStatus V:ActStatus]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-effectiveTime-att effectiveTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-activityTime-att activityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-availabilityTime-att availabilityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-priorityCode-att priorityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority D:ActPriority]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality D:Confidentiality]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-repeatNumber-att repeatNumber]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-INT INT]>||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-uncertaintyCode-att uncertaintyCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActUncertainty D:ActUncertainty]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-isCriterionInd-att isCriterionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-value-att value]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ANY ANY]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ObservationValue D:ObservationValue]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Observation-valueNegationInd-att valueNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-interpretationCode-att interpretationCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ObservationInterpretation D:ObservationInterpretation]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-methodCode-att methodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ObservationMethod D:ObservationMethod]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-targetSiteCode-att targetSiteCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActSite D:ActSite]||Open
 +
|}
 +
 
 +
'''Observation.classCode'''
 +
 
 +
The defines a specific sub-type of a given Observation type. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Observation.classCode
 +
! style="text-align:left;"  colspan="5" | V:ActClassObservation <small> [2.16.840.1.113883.1.11.11529] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBS OBS]||Observation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ALRT ALRT]||detected issue
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#BATTERY BATTERY]||battery||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CLNTRL CLNTRL]||clinical trial
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONC CONC]||concern||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#COND COND]||Condition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CASE CASE]||public health case||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OUTB OUTB]||outbreak
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DGIMG DGIMG]||diagnostic image||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#GEN GEN]||genomic observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DETPOL DETPOL]||determinant peptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#EXP EXP]||expression level
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#LOC LOC]||locus||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#PHN PHN]||phenotype
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POL POL]||polypeptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SEQ SEQ]||bio sequence
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SEQVAR SEQVAR]||bio sequence variation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#INVSTG INVSTG]||investigation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBSSER OBSSER]||observation series||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OBSCOR OBSCOR]||correlated observation sequences
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POS POS]||position||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#POSACC POSACC]||position accuracy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POSCOORD POSCOORD]||position coordinate||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SPCOBS SPCOBS]||specimen observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#VERIF VERIF]||Verification||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ROIBND ROIBND]||bounded ROI
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ROIOVL ROIOVL]||overlay ROI||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#LLD LLD] ('''Deprecated''')||left lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#PRN PRN] ('''Deprecated''')||prone ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#RLD RLD] ('''Deprecated''')||right lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SFWL SFWL] ('''Deprecated''')||Semi-Fowler's ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SIT SIT] ('''Deprecated''')||sitting
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#STN STN] ('''Deprecated''')||standing ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SUP SUP] ('''Deprecated''')||supine
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#RTRD RTRD] ('''Deprecated''')|| reverse trendelenburg ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#TRD TRD] ('''Deprecated''')||trendelenburg
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CNOD CNOD] ('''Deprecated''')||Condition Node ||  ||  || 
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Observation.moodCode
 +
! style="text-align:left;"  colspan="5" | V:x_ActMoodDocumentObservation <small>[2.16.840.1.113883.1.11.19644] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#APT APT]</span>||appointment||  ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#ARQ ARQ]</span>||appointment request
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event|| ||[http://cda/infrastructure/vocabulary/ActMood.htm#DEF DEF]||definition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#GOL GOL]||goal||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#INT INT]||intent
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#PRMS PRMS]||promise||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#PRP PRP]||proposal
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#RSK RSK]</span>||risk||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#RQO RQO]||request
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''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.
 +
 
 +
'''<span class="change-highlight">Observation.actionNegationInd</span>'''
 +
 
 +
<span class="change-highlight">The Observation.actionNegationInd works as a negative existence quantifier on the actual, intended or described observation event. In Event mood, it indicates the defined observation did not occur. In Intent mood, it indicates the defined observation is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.
 +
 
 +
The actionNegationInd negates the Observation as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, derivationExpr, repeatNumber, isCriterionInd, value, valueNegationInd,  interpretationCode, methodCode, targetSiteCode,  and any of their components.
 +
 
 +
The remaining properties represent the document characteristics, E.g. Observatoin.id, Observation.moodCode, Observation.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.</span>
 +
 
 +
'''Observation.negationInd'''
 +
 
 +
<span class="change-highlight">Observation.negationInd, <b><I>is deprecated in RIM 2.35</i></b>, 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.</span>
 +
 
 +
'''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.
 +
 
 +
'''<span class="change-highlight">Observation.title</span>'''
 +
 
 +
<span class="change-highlight">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.)</span>
 +
 
 +
'''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.  In the case of an Observation, this is the status of the activity of observing (e.g., "new," "complete," "cancelled"), not the status of what is being observed (e.g., disease status, "Active" allergy to penicillin). To convey the status of the subject being observed, consider coordinating it into the code or value attribute of the Observation or using a related Observation.  The RIM based [http://cda/infrastructure/rim/rim.htm#ActStatus  state machine diagram] depicts the allowable state transitions that an Observation.StatusCode can take on. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Observation.statusCode
 +
! style="text-align:left;"  colspan="5" | V:ActStatus <small>[2.16.840.1.113883.1.11.15933] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#normal normal]||normal|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#aborted aborted]||aborted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#active active]||active|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#cancelled cancelled]||cancelled
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#completed completed]||completed|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#held held]||held
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#new new]||new|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#suspended suspended]||suspended
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#nullified nullified]||nullified|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#obsolete obsolete]||obsolete
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14</small>
 +
|}
 +
 
 +
'''Observation.effectiveTime'''
 +
 
 +
<span class="change-highlight">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.</span>
 +
 
 +
'''<span class="change-highlight">Observation.activityTime</span>'''
 +
 
 +
<span class="change-highlight">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.</span>
 +
 
 +
'''<span class="change-highlight">Observation.availabilityTime</span>'''
 +
 
 +
<span class="change-highlight">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.</span>
 +
 
 +
'''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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority ActPriority] concept domain.
 +
 
 +
'''<span class="change-highlight">Observation.confidentialityCode</span>'''
 +
 
 +
<span class="change-highlight">Constraints around appropriate disclosure of information about this Observation, regardless of mood. The Observation.confidentialityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality Confidentiality] concept domain.</span>
 +
 
 +
'''Observation.repeatNumber'''
 +
 
 +
An interval of integer numbers stating the minimal and maximal number of repetitions of the Observation.
 +
 
 +
'''<span class="change-highlight">Observation.uncertaintyCode</span>'''
 +
 
 +
<span class="change-highlight">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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActUncertainty ActUncertainty] concept domain. Note: Implementation Guides will need to provide explicit guidance on the proper evaluation and interpretation, as well as provide a default value assignment.</span>
 +
 
 +
'''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 [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage HumanLanguage] concept domain.
 +
 
 +
'''Observation.isCriterionInd'''
 +
 
 +
Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.
 +
 
 +
'''Observation.value'''
 +
 
 +
The result of the observation action. Extensive usage notes are available in the RIM, reference [http://cda/infrastructure/rim/rim.htm#Observation-value-att Value UsageNotes]
 +
 
 +
'''<span class="change-highlight">Observation.valueNegationInd</span>'''
 +
 
 +
<span class="change-highlight">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: The RIM indicates that this attribute should only be used when the terminology used for Observation.value is not itself capable of expressing negated findings. (E.g. ICD9).  Implementation experience may override the RIM definition and it's important to review template definitions and Value Set content and binding for consistent negation implementation. Existing CDA R2.0 implementations use negationInd in many C-CDA templates.</span>
 +
 
 +
'''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.
 +
 
 +
The following is an example of how an author can record a patient that has no known allergies. It uses the new valueNegationInd with an "Allergy to substance" code in the value element.
 +
 
 +
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
 +
<nowiki>
 +
<section>
 +
    <templateId .../>
 +
    <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
 +
    <title>ALLERGIES AND ADVERSE REACTIONS</title>
 +
    <text>No Known Allergies</text>
 +
    <entry typeCode="DRIV">
 +
        <!-- Allergy Concern Act -->
 +
        <act classCode="ACT" moodCode="EVN">
 +
            <templateId ... />
 +
            <id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
 +
            <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
 +
            <statusCode code="active"/>
 +
            <effectiveTime>
 +
                <low value="20100103"/>
 +
            </effectiveTime>
 +
            <author> ... </author>
 +
            <entryRelationship typeCode="SUBJ">
 +
                <!-- No Known Allergies -->
 +
                <!-- The <valueNegationInd value="true" /> negates the observation/value -->
 +
                <observation classCode="OBS" moodCode="EVN">
 +
                    <!-- allergy - intolerance observation template -->
 +
                    <templateId ... />
 +
                    <templateId ... />
 +
                    <id ... />
 +
                    <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
 +
                    <statusCode code="completed"/>
 +
                    <effectiveTime>
 +
                        <low nullFlavor="NA"/>
 +
                    </effectiveTime>
 +
                    <value xsi:type="CD" code="419199007"
 +
                        displayName="Allergy to substance (disorder)"
 +
                        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
 +
                    <valueNegationInd value="true"/>
 +
                    <author> ... </author>
 +
                    <participant typeCode="CSM">
 +
                        <participantRole classCode="MANU">
 +
                            <playingEntity classCode="MMAT">
 +
                                <code nullFlavor="NA"/>
 +
                            </playingEntity>
 +
                        </participantRole>
 +
                    </participant>
 +
                </observation>
 +
            </entryRelationship>
 +
        </act>
 +
    </entry>
 +
</section>
 +
</nowiki>
 +
 
 +
 
 +
=====Reference Range=====
 +
 
 +
An Observation can have zero to many referenceRange relationships, which relate an Observation to the ObservationRange class.
 +
 
 +
'''referenceRange.typeCode'''
 +
 
 +
The referenceRange.typeCode has been fixed to "REFV", which indicates an association to a reference range.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed referenceRange.typeCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#REFV REFV]||has reference values
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002</small>
 +
|}
 +
 
 +
=====ObservationRange=====
 +
 
 +
ObservationRange or 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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: ObservationRange Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||  <= OBS  is [http://cda/infrastructure/vocabulary/vs_ActClass.htm#ActClassObservation V:ActClassObservation]||Closed w/ Default
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS] ||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN.CRT ENV.CRT] ||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[1..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActCode D:ActCode]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-isCriterionInd-att isCriterionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-value-att value]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ANY ANY]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ObservationValue D:ObservationValue]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Observation-valueNegationInd-att valueNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-interpretationCode-att interpretationCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ObservationInterpretation D:ObservationInterpretation]||Open
 +
|}
 +
 
 +
'''ObservationRange.classCode'''
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for ObservationRange.classCode
 +
! style="text-align:left;"  colspan="5" | V:ActClassObservation <small>[2.16.840.1.113883.1.11.11529] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBS OBS] (<b>Default</b>)||Observation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ALRT ALRT]||detected issue
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#BATTERY BATTERY]||battery||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CLNTRL CLNTRL]||clinical trial
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONC CONC]||concern||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#COND COND]||Condition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CASE CASE]||public health case||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OUTB OUTB]||outbreak
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DGIMG DGIMG]||diagnostic image||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#GEN GEN]||genomic observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DETPOL DETPOL]||determinant peptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#EXP EXP]||expression level
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#LOC LOC]||locus||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#PHN PHN]||phenotype
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POL POL]||polypeptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SEQ SEQ]||bio sequence
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SEQVAR SEQVAR]||bio sequence variation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#INVSTG INVSTG]||investigation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBSSER OBSSER]||observation series||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OBSCOR OBSCOR]||correlated observation sequences
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POS POS]||position||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#POSACC POSACC]||position accuracy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POSCOORD POSCOORD]||position coordinate||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SPCOBS SPCOBS]||specimen observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#VERIF VERIF]||Verification||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ROIBND ROIBND]||bounded ROI
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ROIOVL ROIOVL]||overlay ROI||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#LLD LLD] (<b>Deprecated</b>)||left lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#PRN PRN] (<b>Deprecated</b>)||prone ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#RLD RLD] (<b>Deprecated</b>)||right lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SFWL SFWL] (<b>Deprecated</b>)||Semi-Fowler's ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SIT SIT] (<b>Deprecated</b>)||sitting
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#STN STN] (<b>Deprecated</b>)||standing ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SUP SUP] (<b>Deprecated</b>)||supine
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#RTRD RTRD] (<b>Deprecated</b>)|| reverse trendelenburg ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#TRD TRD] (<b>Deprecated</b>)||trendelenburg
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CNOD CNOD] (<b>Deprecated</b>)||Condition Node ||  ||  || 
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''ObservationRange.moodCode'''
 +
 
 +
The ObservationRange.moodCode is fixed to the "EVN.CRT" (event criterion).  The "EVN.CRT" is a criterion or condition over service events that must apply for an associated service to be considered.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed ObservationRange.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN.CRT EVN.CRT]||event criterion
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''ObservationRange.code'''
 +
 
 +
The particular kind of Observation that the ObservationRange-instance represents within its class. ObservationRange.code, if used, SHALL be a specialization of the ObservationRange.classCode. This attribute defines a specific sub-type of a given Observation type (determined by the "classCode" attribute). The ObservationRange.code is bound to the ActCode concept domain.
 +
 
 +
'''ObservationRange.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 ObservationRange. The ObservationRange.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.
 +
 
 +
'''ObservationRange.isCriterionInd'''
 +
 
 +
Is set to true to indicate that the data conveyed by the ObservationRange, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.
 +
 
 +
'''ObservationRange.value'''
 +
 
 +
The result of the ObservationRange action. Extensive usage notes are available in the RIM, reference [http://cda/infrastructure/rim/rim.htm#Observation-value-att Value UsageNotes]
 +
 
 +
'''<span class="change-highlight">ObservationRange.valueNegationInd</span>'''
 +
 
 +
<span class="change-highlight">ObservationRange.valueNegationInd, indicates that when the ObservationRange event occurred, the finding communicated by the value attribute was NOT found.  Note: This attribute should only be used when the terminology used for ObservationRange.value is not itself capable of expressing negated findings. (E.g. ICD9).</span>
 +
 
 +
'''ObservationRange.interprerationCode'''
 +
 
 +
A qualitative interpretation of the ObservationRange. 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."
 +
 
 +
====<big><big>ObservationMedia</big></big>====
 +
 
 +
[[Image:ObservationMedia.png|800px|border|center|Observation Media]]
 +
 
 +
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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: ObservationMedia Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]|| <= OBS is [http://cda/infrastructure/vocabulary/vs_ActClass.htm#ActClassObservation V:ActClassObservation]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-value-att value]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED 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 &lt;renderMultiMedia> reference (see [[#.3CrenderMultiMedia.3E|&lt;renderMultiMedia>]] (&sect; 5.3.5.6)). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).
 +
 
 +
'''ObservationMedia.classCode'''
 +
 
 +
The ObservationMedia.classCode is defaulted to "OBS" for Observation, but can be set to any sub-type of Observation that may more accurately characterize the multi-media referenced via the ObservationMedia class.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for ObservationMedia.classCode
 +
! style="text-align:left;"  colspan="5" | V:ActClassObservation <small> [2.16.840.1.113883.1.11.11529] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBS OBS] ('''Default''')||Observation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ALRT ALRT]||detected issue
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#BATTERY BATTERY]||battery||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CLNTRL CLNTRL]||clinical trial
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONC CONC]||concern||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#COND COND]||Condition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CASE CASE]||public health case||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OUTB OUTB]||outbreak
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DGIMG DGIMG]||diagnostic image||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#GEN GEN]||genomic observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DETPOL DETPOL]||determinant peptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#EXP EXP]||expression level
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#LOC LOC]||locus||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#PHN PHN]||phenotype
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POL POL]||polypeptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SEQ SEQ]||bio sequence
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SEQVAR SEQVAR]||bio sequence variation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#INVSTG INVSTG]||investigation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBSSER OBSSER]||observation series||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OBSCOR OBSCOR]||correlated observation sequences
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POS POS]||position||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#POSACC POSACC]||position accuracy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POSCOORD POSCOORD]||position coordinate||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SPCOBS SPCOBS]||specimen observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#VERIF VERIF]||Verification||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ROIBND ROIBND]||bounded ROI
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ROIOVL ROIOVL]||overlay ROI||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#LLD LLD] ('''Deprecated''')||left lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#PRN PRN] ('''Deprecated''')||prone ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#RLD RLD] ('''Deprecated''')||right lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SFWL SFWL] ('''Deprecated''')||Semi-Fowler's ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SIT SIT] ('''Deprecated''')||sitting
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#STN STN] ('''Deprecated''')||standing ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SUP SUP] ('''Deprecated''')||supine
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#RTRD RTRD] ('''Deprecated''')|| reverse trendelenburg ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#TRD TRD] ('''Deprecated''')||trendelenburg
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CNOD CNOD] ('''Deprecated''')||Condition Node ||  ||  || 
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''ObservationMedia.moodCode'''
 +
 
 +
The ObservationMedia.moodCode is fixed to "EVN" or event mood to indicate that this is ObservationMedia is from a past service.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed ObservationMedia.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event (occurrence)
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''ObservationMedia.id'''
 +
 
 +
An optional identifier for the ObservationMedia instance.
 +
 
 +
'''ObservationMedia.languageCode'''
 +
 
 +
Specifies the human language of character data (whether they be in contents or attribute values).
 +
 
 +
'''ObservationMedia.value'''
 +
 
 +
The ObservationMedia.value is set to the xsi:type="ED" which enables the referencing of the multi-media object.  Review the [http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED] data type for more information about linking to files.
 +
 
 +
====<big><big>Organizer</big></big>====
 +
 
 +
[[Image:Organizer.png|800px|border|center|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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Organizer Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActClass.htm#x_ActClassDocumentEntryOrganizer V:x_ActClassDocumentEntryOrganizer ]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#ENV EVN]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ActCode D:ActCode]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-statusCode-att statusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActStatus.htm#ActStatus V:ActStatus]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-effectiveTime-att effectiveTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-activityTime-att activityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-availabilityTime-att availabilityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-priorityCode-att priorityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority D:ActPriority]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality D:Confidentiality]||Open
 +
|}
 +
 
 +
'''Organizer.classCode'''
 +
 
 +
The Organizer.classCode can take on one of two values, BATTERY or CLUSTER. 
 +
 
 +
#CLUSTER is an ACT that organizes a set of component acts into a semantic grouping that have a shared subject. The subject may be either a subject participation (SBJ), subject act relationship (SUBJ), or child participation/act relationship types. 
 +
#The BATTERY is an observation that is composed of a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are run together because of automation. A battery can define required and optional component observations and, in some cases, will define complex rules that determine whether or not a particular observation is made. BATTERY is a constraint on the Observation class in that it is understood to always be composed of component observations.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Organizer.classCode
 +
! style="text-align:left;"  colspan="5" | V:x_ActClassDocumentEntryOrganizer  <small> [2.16.840.1.113883.1.11.19598] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#BATTERY BATTERY]||battery||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CLUSTER CLUSTER]||Cluster
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''Organizer.moodCode'''
 +
 
 +
The Organizer.moodCode is fixed to the "EVN" or event mood to indicate that the Organizer has been created with the contents specified.
 +
 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed Organizer.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event (occurrence)
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''Organizer.id'''
 +
 
 +
An optional identifier for the Organizer instance.
 +
 
 +
'''Organizer.code'''
 +
 
 +
The particular kind of Organizer that the Organizer-instance represents within its class. Organizer.code, if used, SHALL be a specialization of the Organizer.classCode. This attribute defines a specific sub-type of a given Organizer type (BATTERY or CLUSTER). The Organizer.code is bound to the ActCode concept domain.
 +
 
 +
'''Organizer.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 Organizer. The Organizer.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.
 +
 
 +
'''Organizer.statusCode'''
 +
 
 +
The status reflects the state of the activity.  The RIM based [http://cda/infrastructure/rim/rim.htm#ActStatus  state machine diagram] depicts the allowable state transitions that an Organizer.StatusCode can take on. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Organizer.statusCode
 +
! style="text-align:left;"  colspan="5" | V:ActStatus <small>[2.16.840.1.113883.1.11.15933] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#normal normal]||normal|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#aborted aborted]||aborted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#active active]||active|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#cancelled cancelled]||cancelled
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#completed completed]||completed|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#held held]||held
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#new new]||new|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#suspended suspended]||suspended
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#nullified nullified]||nullified|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#obsolete obsolete]||obsolete
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14</small>
 +
|}
 +
 
 +
'''Organizer.effectiveTime'''
 +
 
 +
<span class="change-highlight">The optional Organizer.effectiveTime is used to indicate the clinically or operationally relevant time of an Organizer's component items, 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. </span>
 +
 
 +
'''<span class="change-highlight">Organizer.activityTime</span>'''
 +
 
 +
<span class="change-highlight">The optional Organizer.activityTime is a time expression specifying when the activityTime of the Organizer's component items occurred, 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 component Acts occurred, is supposed to occur, is scheduled to occur, etc. </span>
 +
 
 +
'''<span class="change-highlight">Organizer.availabilityTime</span>'''
 +
 
 +
<span class="change-highlight">The optional Observation.availabilityTime is the point in time at which information about the component Acts regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the Organizer's component activities themselves. </span>
 +
 
 +
'''Organizer.priorityCode'''
 +
 
 +
The optional priorityCode identifies the urgency under which the component Act's happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. The Organizer.priorityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority ActPriority] concept domain.
 +
 
 +
'''<span class="change-highlight">Organizer.confidentialityCode</span>'''
 +
 
 +
<span class="change-highlight">The optional confidentialityCode identifies any constraints around appropriate disclosure of information about this Organizer and it's component Acts, regardless of mood. The Organizer.confidentialityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality Confidentiality] concept domain.</span>
 +
 
 +
====<big><big>Procedure</big></big>====
 +
 
 +
[[Image:Procedure.png|800px|border|center|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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Procedure Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]|| <= PROC is [http://cda/infrastructure/vocabulary/vs_ActClass.htm#ActClassProcedure V:ActClassProcedure]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActMood.htm#x_DocumentProcedureMood V:x_DocumentProcedureMood]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActProcedureCode D:ActProcedureCode]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-actionNegationInd-att  actonNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-negationInd-att negationInd] ('''Deprecated''')||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-statusCode-att statusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActStatus.htm#ActStatus V:ActStatus]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-effectiveTime-att effectiveTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-activityTime-att activityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-availabilityTime-att availabilityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-priorityCode-att priorityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority D:ActPriority]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality D:Confidentiality]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-uncertaintyCode-att uncertaintyCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActUncertainty D:ActUncertainty]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-isCriterionInd-att isCriterionInd]</span> ||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Procedure-methodCode-att methodCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ProcedureMethod D:ProcedureMethod]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Procedure-approachSiteCode-att approachSiteCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActSite D:ActSite]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Procedure-targetSiteCode-att targetSiteCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActSite D:ActSite]||Open
 +
|}
 +
 
 +
'''Procedure.classCode'''
 +
 
 +
The defines a specific sub-type of a given Procedure type. The Procedure.classCode is bound to the V:ActClassProcedure value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Procedure.classCode
 +
! style="text-align:left;"  colspan="5" |  V:ActClassProcedure <small>[2.16.840.1.113883.1.11.19665] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!! !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#PROC PROC] ('''Default''')||procedure||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#SBEXT SBEXT]||Substance Extraction
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SPECCOLLECT SPECCOLLECT]||Specimen Collection||
 +
|| ||
 +
|-
 +
!colspan="5" |  Note: Although SBADM is technically allowed, is best used with the SubstanceAdministration Entry Class
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SBADM SBADM]||substance administration||
 +
|| ||
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''Procedure.moodCode'''
 +
 
 +
The intended use of the Procedure statement: as a procedure report, a command, a possibility, a goal, etc. Since the mood code is a determining factor for the meaning of an entire Procedure object, the mood must always be known. This means that whenever an Procedure is instantiated, the mood attribute SHALL be assigned to a valid code, and the mood assignment SHALL NOT change throughout the lifetime of the Procedure.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Procedure.moodCode
 +
! style="text-align:left;"  colspan="5" |  V:x_DocumentProcedureMood <small>[2.16.840.1.113883.1.11.19460] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#APT APT]||appointment|| ||[http://cda/infrastructure/vocabulary/ActMood.htm#ARQ ARQ]||appointment request
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event|| ||[http://cda/infrastructure/vocabulary/ActMood.htm#DEF DEF]||definition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#RQO RQO]||request||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#INT INT]||intent
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#PRMS PRMS]||promise||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#PRP PRP]||proposal
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''Procedure.id'''
 +
 
 +
A unique identifier for the Procedure.
 +
 
 +
'''Procedure.code'''
 +
 
 +
The particular kind of Procedure that the Procedure-instance represents within its class. Procedure.code, if used, SHALL be a specialization of the Procedure.classCode. This attribute defines a specific sub-type of a given Procedure type (determined by the "classCode" attribute). The Procedure.code is bound to the ActProcedureCode concept domain.
 +
 
 +
'''<span class="change-highlight">Procedure.actionNegationInd</span>'''
 +
 
 +
<span class="change-highlight">The Procedure.actionNegationInd works as a negative existence quantifier on the actual, intended or described Procedure event. In Event mood, it indicates the defined procedure did not occur. In Intent mood, it indicates the defined procedure is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.
 +
 
 +
The actionNegationInd negates the Act as described by the descriptive properties which are:  classCode, code, statusCode, effectiveTime, activityTime, priorityCode, isCriterionInd, methodCode, approachSiteCode, targetSiteCode and any of their components.
 +
 
 +
The remaining properties represent the document characteristics, E.g. Procedure.id, Procedure.moodCode, Procedure.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.  </span>
 +
 
 +
'''Procedure.negationInd'''
 +
 
 +
Procedure.negationInd, <b><i>is deprecated in RIM 2.35</i></b>, and CDA R2.1 retains it for backwards compatibility.  CDA R2.1 compliant implementation guides should use actionNegationInd moving forward.
 +
 
 +
'''Procedure.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 Procedure. The Procedure.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.
 +
 
 +
'''Procedure.statusCode'''
 +
 
 +
The status reflects the state of the activity.  The RIM based [http://cda/infrastructure/rim/rim.htm#ActStatus  state machine diagram] depicts the allowable state transitions that an Procedure.statusCode can take on. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Procedure.statusCode
 +
! style="text-align:left;"  colspan="5" | V:ActStatus <small>[2.16.840.1.113883.1.11.15933] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#normal normal]||normal|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#aborted aborted]||aborted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#active active]||active|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#cancelled cancelled]||cancelled
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#completed completed]||completed|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#held held]||held
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#new new]||new|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#suspended suspended]||suspended
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#nullified nullified]||nullified|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#obsolete obsolete]||obsolete
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14</small>
 +
|}
 +
 
 +
 
 +
'''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.
 +
 
 +
'''<span class="change-highlight">Procedure.activityTime</span>'''
 +
 
 +
<span class="change-highlight">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.</span>
 +
 
 +
'''<span class="change-highlight">Procedure.availabilityTime</span>'''
 +
 
 +
<span class="change-highlight">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. </span>
 +
 
 +
'''Procedure.priorityCode'''
 +
 
 +
The urgency under which the Act happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. The Procedure.priorityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority ActPriority] concept domain.
 +
 
 +
'''<span class="change-highlight">Procedure.confidentialityCode</span>'''
 +
 
 +
<span class="change-highlight">Constraints around appropriate disclosure of information about this Procedure, regardless of mood. The Procedure.confidentialityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality Confidentiality] concept domain.</span>
 +
 
 +
'''<span class="change-highlight">Procedure.uncertaintyCode</span>'''
 +
 
 +
<span class="change-highlight">An indication that the Procedure 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 Procedure and its dependent Acts is questioned. The Procedure.uncertaintyCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActUncertainty ActUncertainty] concept domain.</span>
 +
 
 +
'''Procedure.languageCode'''
 +
 
 +
The primary language in which this Procedure statement is specified, particularly the language of the Procedure.text.  The Procedure.languageCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage HumanLanguage] concept domain.
 +
 
 +
'''<span class="change-highlight">Procedure.isCriterionInd</span>'''
 +
 
 +
<span class="change-highlight">Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.</span>
 +
 
 +
'''<span class="change-highlight">Procedure.methodCode</span>'''
 +
 
 +
<span class="change-highlight">The means or technique used to ascertain the observation. In some procedures the method is already partially specified by the Procedure.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 Procedure.code. However, an information consumer system or process SHOULD NOT depend on this methodCode information for method detail that is implied by the Procedure.code.</span>
 +
 
 +
'''<span class="change-highlight">Procedure.approachSiteCode</span>'''
 +
 
 +
<span class="change-highlight">The anatomical site or system through which the procedure reaches its target.</span>
 +
 
 +
'''<span class="change-highlight">Procedure.targetSiteCode</span>'''
 +
 
 +
<span class="change-highlight">The anatomical site or system that is the focus of the procedure.  Most procedure target sites are implied by the procedure definition and Procedure.code, or Procedure.value. If the subject of the procedure is something other than a human patient or animal, the attribute is used analogously to specify a structural landmark of the thing where the Procedure occurred.</span>
 +
 
 +
====<big><big>RegionOfInterest</big></big>====
 +
 
 +
[[Image:RegionOfInterest.png|800px|border|center|Region of Interest]]
 +
 
 +
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 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 &lt;renderMultimedia> reference, then it shall only reference an ObservationMedia and not an ExternalObservation.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: RegionOfInterest Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#ActClassOverlayRoi ROIOVL]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ROIOverlayShape V:ROIOverlayShape]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-value-att value]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-LIST LIST]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-INT 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 &lt;renderMultiMedia> reference (see [[#.3CrenderMultiMedia.3E|&lt;renderMultiMedia>]] (&sect; 5.3.5.6)). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).
 +
 
 +
'''RegionOfInterest.classCode'''
 +
 
 +
The RegionOfInterest.classCode is fixed to "ROIOVL" which is a Region of Interest (ROI) specified for an image using an overlay shape. Typically used to make reference to specific regions in images, e.g., to specify the location of a radiologic finding in an image or 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 are in pixels. 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 ROI and its referenced Act is specified through an ActRelationship of type "subject" (SUBJ), which must always be present.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed RegionOfInterest.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ActClassOverlayRoi ROIOVL]||overlay ROI
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''RegionOfInterest.moodCode'''
 +
 
 +
The RegionOfInterest.moodCode is fixed to "EVN" or event mood to indicate that this is region of interest, was created.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed RegionOfInterest.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN] ('''Fixed''')||event (occurrence)
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''RegionOfInterest.id'''
 +
 
 +
The optional RegionOfInterest.id allows for the unique identification of the region of interest.
 +
 
 +
'''RegionOfInterest.code'''
 +
 
 +
There are 4 types of regions that can be created, they are determined by the RegionOfInterest.code which can take on 1 of the following codes: circle, ellipse, point and polyline.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for RegionOfInterest.code
 +
! style="text-align:left;"  colspan="5" |  V:ROIOverlayShape <small>[2.16.840.1.113883.1.11.16117] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActCode.htm#CIRCLE CIRCLE]||circle|| ||[http://cda/infrastructure/vocabulary/ActCode.htm#ELLIPSE ELLIPSE]||ellipse
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActCode.htm#POINT POINT]||point|| ||[http://cda/infrastructure/vocabulary/ActCode.htm#POLY POLY]||polyline
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActCode (HL7) Code System OID: 2.16.840.1.113883.5.4</small>
 +
|}
 +
 
 +
'''RegionOfInterest.value'''
 +
 
 +
The RegionOfInterest.value units are 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.
 +
 
 +
 
 +
'''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 &lt;renderMultiMedia> tag, and the referenced RegionOfInterest references the hand image.
 +
 
 +
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
 +
<nowiki>
 +
<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>
 +
</nowiki>
 +
 
 +
====<big><big>SubstanceAdministration</big></big>====
 +
 
 +
[[Image:SubstanceAdministration.png|800px|border|center|Substance Administration]]
 +
 
 +
A derivative of the RIM SubstanceAdministration class, used for representing medication-related events such as medication history or planned medication administration orders.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: SubstanceAdministration Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#SBADM SBADM]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActMood.htm#x_DocumentSubstanceMood V:x_DocumentSubstanceMood]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ActSubstanceAdministrationCode D:ActSubstanceAdministrationCode]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-actionNegationInd-att  actonNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-negationInd-att negationInd] ('''Deprecated''')||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-statusCode-att statusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActStatus.htm#ActStatus V:ActStatus]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-effectiveTime-att effectiveTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-activityTime-att activityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-availabilityTime-att availabilityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-priorityCode-att priorityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority D:ActPriority]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality D:Confidentiality]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-repeatNumber-att repeatNumber]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-INT INT]>||[0..1]||  ||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-isCriterionInd-att isCriterionInd]</span> ||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#SubstanceAdministration-routeCode-att routeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#RouteOfAdministration D:RouteOfAdministration]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Procedure-approachSiteCode-att approachSiteCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActSite D:ActSite]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#SubstanceAdministration-doseQuantity-att doseQuantity]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ]>||<span class="change-highlight">[0..*]</span>||  ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#SubstanceAdministration-rateQuantity-att rateQuantity]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ]>||<span class="change-highlight">[0..*]</span>||  ||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#SubstanceAdministration-doseCheckQuantity-att doseCheckQuantity]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-RTO RTO]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ],[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ].TIME>>||[0..*]||  ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#SubstanceAdministration-maxDoseQuantity-att maxDoseQuantity]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-RTO RTO]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ],[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ].TIME>>||<span class="change-highlight">[0..*]</span>||  ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#SubstanceAdministration-administrationUnitCode-att administrationUnitCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#AdministrableDrugForm D:AdministrableDrugForm ]||Open
 +
|}
 +
 
 +
'''SubstanceAdministration.classCode'''
 +
 
 +
The SubstanceAdministration.classCode is fixed to "SBADM" which indicates an act of introducing or otherwise applying a substance to the subject.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed SubstanceAdministration.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SBADM SBADM]||substance administration
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''SubstanceAdministration.moodCode'''
 +
 
 +
SubstanceAdministration.moodCode has been bound to the x_DocumentSubstanceMood value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed SubstanceAdministration.moodCode
 +
! style="text-align:left;"  colspan="5" | V:x_DocumentSubstanceMood  <small>[2.16.840.1.113883.1.11.19461] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!! !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActMood.htm#DEF DEF]</span>||definition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#RQO RQO]||request||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#INT INT]||intent
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#PRMS PRMS]||promise||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#PRP PRP]||proposal
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''SubstanceAdministration.id'''
 +
 
 +
The optional SubstanceAdministration.id can be used to uniquely identify the substance administration.
 +
 
 +
'''SubstanceAdministration.code'''
 +
 
 +
The SubstanceAdministration.code has been bound to the ActSubstanceAdministrationCode concept domain.
 +
 
 +
'''<span class="change-highlight">SubstanceAdministration.actionNegationInd</span>'''
 +
 
 +
<span class="change-highlight">The SubstanceAdministration.actionNegationInd works as a negative existence quantifier on the actual, intended or described substance administration event. In Event mood, it indicates the defined substance administration did not occur. In Intent mood, it indicates the defined substance administration is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.
 +
 
 +
The actionNegationInd negates the SubstanceAdministration as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, repeatNumber, isCriterionInd, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode and any of their components.
 +
 
 +
The remaining properties represent the document characteristics, E.g. SubstanceAdministration.id, SubstanceAdministration.moodCode, SubstanceAdministration.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.</span>
 +
 
 +
'''SubstanceAdministration.negationInd'''
 +
 
 +
SubstanceAdministration.negationInd, <b><i>is deprecated in RIM 2.35</i></b>, and CDA R2.1 retains it for backwards compatibility.  CDA R2.1 compliant implementation guides should use actionNegationInd moving forward.
 +
 
 +
 
 +
 
 +
'''SubstanceAdministration.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 SubstanceAdministration. The SubstanceAdministration.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.
 +
 
 +
'''SubstanceAdministration.statusCode'''
 +
 
 +
The status reflects the state of the activity.  The RIM based [http://cda/infrastructure/rim/rim.htm#ActStatus  state machine diagram] depicts the allowable state transitions that an SubstanceAdministration.StatusCode can take on. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for SubstanceAdministration.statusCode
 +
! style="text-align:left;"  colspan="5" | V:ActStatus <small>[2.16.840.1.113883.1.11.15933] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#normal normal]||normal|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#aborted aborted]||aborted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#active active]||active|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#cancelled cancelled]||cancelled
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#completed completed]||completed|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#held held]||held
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#new new]||new|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#suspended suspended]||suspended
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#nullified nullified]||nullified|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#obsolete obsolete]||obsolete
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14</small>
 +
|}
 +
 
 +
'''SubstanceAdministration.effectiveTime'''
 +
 
 +
<span class="change-highlight">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). </span>  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.
 +
 
 +
'''<span class="change-highlight">SubstanceAdministration.activityTime</span>'''
 +
 
 +
<span class="change-highlight">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. </span>
 +
 
 +
'''<span class="change-highlight">SubstanceAdministration.availabilityTime</span>'''
 +
 
 +
<span class="change-highlight">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. </span>
 +
 
 +
'''SubstanceAdministration.priorityCode'''
 +
 
 +
The urgency under which the SubstanceAdministration happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. The SubstanceAdministration.priorityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority ActPriority] concept domain.
 +
 
 +
'''<span class="change-highlight">SubstanceAdministration.confidentialityCode</span>'''
 +
 
 +
<span class="change-highlight">Constraints around appropriate disclosure of information about this SubstanceAdministration, regardless of mood. The SubstanceAdministration.confidentialityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality Confidentiality] concept domain.</span>
 +
 
 +
 
 +
'''SubstanceAdministration.repeatNumber'''
 +
 
 +
An interval of integer numbers stating the minimal and maximal number of repetitions of the SubstanceAdministration.
 +
 
 +
'''<span class="change-highlight">SubstanceAdministration.languageCode</span>'''
 +
 
 +
<span class="change-highlight">The primary language in which this SubstanceAdministrationstatement is specified, particularly the language of the SubstanceAdministration.text.  The SubstanceAdministration.languageCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage HumanLanguage] concept domain.</span>
 +
 
 +
'''<span class="change-highlight">SubstanceAdministration.isCriterionInd</span>'''
 +
 
 +
<span class="change-highlight">Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.</span>
 +
 
 +
'''SubstanceAdministration.routeCode'''
 +
 
 +
The physiological path or route for introducing the therapeutic material into or onto the subject. Route, site of administration (administrationSiteCode), method of administration (methodCode) and the device used in administration are closely related. All four (if present) must be closely coordinated and in agreement. In some cases, the coding system used to specify one may pre-coordinate one or more of the others.
 +
 
 +
'''SubstanceAdministration.approachSiteCode'''
 +
 
 +
The anatomical site or system through which the procedure reaches its target.
 +
 
 +
'''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).
 +
 
 +
'''<span class="change-highlight">SubstanceAdministration.doseCheckQuantity</span>'''
 +
 
 +
<span class="change-highlight">The ratio of a quantity to be consumed over the period of time during which it expected to be consumed.</span>
 +
 
 +
'''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'''
 +
 
 +
A unit for the administered substance.
 +
# This attribute SHOULD be used if and only if the material specified as the player of the Role attaching to the consumable participation is not in itself the finished dose form to be administered but a larger whole, pack, etc.
 +
# If the material so specified is the proper administered dose form, such as a tablet, capsule, etc. then this attribute SHOULD be valued NULL (not applicable).
 +
# If the material so specified is an amorphous substance (liquid, gas, powder, etc.) to be measured as a volume, mass, etc., then this attribute SHOULD remain NULL (not applicable).
 +
# If the material so specified is a container, and the content is to be measured as a volume, mass, etc., then this attribute SHOULD be specified as "measured portion".
 +
 
 +
 
 +
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
 +
<nowiki>
 +
<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>
 +
</nowiki>
 +
 
 +
=====consumable=====
 +
The capture of medication-related information also involves the interrelationship of SubstanceAdministration with several other classes.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: consumable
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-typeCode-att  typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ParticipationType.htm#CSM CSM]||consumable
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-contextControlCode-att contextControlCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ContextControl.htm#OP OP]||Fixed
 +
|}
 +
 
 +
'''consumable.typeCode'''
 +
 
 +
The consumable.typeCode is fixed to "CSM" to represent a consumable participation.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed consumable.typeCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#CSM CSM]||consumable
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90</small>
 +
|}
 +
 
 +
'''consumable.contextControlCode'''
 +
 
 +
The consumable.contextControlCode is fixed to "OP". It means that the consumable identified will replace the set of consumables that have propagated from ancestor Acts, and will itself be the only consumable to propagate to any child Acts that allow context to be propagated.
 +
 
 +
=====ManufacturedProduct=====
 +
 
 +
The consumable participation is used to bring in the LabeledDrug or Material entity that describes the administered substance via the ManufacturedProduct role class.
 +
 
 +
'''ManufacturedProduct.classCode'''
 +
 
 +
The ManufacturedProduct.typeCode is fixed to "MANU" to represent the role of manufactured. The playing role is what was manufactured and the scoping role identifies the manufacturer.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed ManufacturedProduct.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#MANU MANU]||manufactured
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110</small>
 +
|}
 +
 
 +
'''ManufacturedProduct.id'''
 +
 
 +
An optional unique identifier assigned by the manufacturer.
 +
 
 +
=====LabeledDrug=====
 +
 
 +
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.
 +
 
 +
'''LabeledDrug.classCode'''
 +
 
 +
The LabeledDrug.classCode is fixed to "MMAT" which indicates the substance administered was manufactured. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed LabeledDrug.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#MMAT MMAT] ||A manufactured material.
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41</small>
 +
|}
 +
 
 +
'''LabeledDrug.determinerCode'''
 +
 
 +
The determinerCode is fixed to "KIND", which indicates that the LabeledDrug referenced, represents a kind or class of Labeled drug. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed LabeledDrug.determinerCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#KIND KIND]||described
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30</small>
 +
|}
 +
 
 +
'''LabeledDrug.code'''
 +
 
 +
The LabeledDrug.code is bound to the DrugEntity concept domain, which identifies a substance whose therapeutic effect is produced by chemical action within the body.
 +
 
 +
'''LabeledDrug.name''''
 +
 
 +
An optional non-unique textual identifier or moniker for the LabeledDrug.
 +
 
 +
=====Material=====
 +
 
 +
The Material entity can be used to identify non-drug administered substances such as vaccines and blood products and drugs.
 +
 
 +
'''Material.classCode'''
 +
 
 +
The Material.classCode is fixed to "MMAT" which indicates the material administered was manufactured.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed Material.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#MMAT MMAT]||A manufactured material.
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41</small>
 +
|}
 +
 
 +
'''Material.determinerCode'''
 +
 
 +
The determinerCode is fixed to "KIND", which indicates that the Material referenced, represents a kind or class of Material.
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed Material.determinerCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#KIND KIND]||described
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30</small>
 +
|}
 +
 
 +
'''Material.code'''
 +
 
 +
The Material.code is bound to the MaterialEntityClassType concept domain, which identifies types of materials.
 +
 
 +
'''Material.name'''
 +
 
 +
An optional non-unique textual identifier or moniker for the Material.
 +
 
 +
'''Material.desc'''
 +
 
 +
A textual or multimedia depiction of the Material.
 +
 
 +
'''Material.formCode'''
 +
 
 +
The physical state and nature of the material.
 +
 
 +
'''Material.lotNumberText'''
 +
 
 +
An identifier for a particular batch of manufactured material.
 +
 
 +
====<big><big>Supply</big></big>====
 +
 
 +
[[Image:Supply.png|800px|border|center|Supply]]
 +
 
 +
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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Supply Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#SPLY SPLY]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_ActMood.htm#x_DocumentSubstanceMood V:x_DocumentSubstanceMood]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET] <[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActSupplyType D:ActSupplyType]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-actionNegationInd-att  actionNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-statusCode-att statusCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActStatus.htm#ActStatus V:ActStatus]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-effectiveTime-att effectiveTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-activityTime-att activityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpltiming GTS]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-availabilityTime-att availabilityTime]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-priorityCode-att priorityCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority D:ActPriority]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-confidentialityCode-att confidentialityCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality D:Confidentiality]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-repeatNumber-att repeatNumber]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-INT INT]>||[0..1]||  ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-independentInd-att independentInd] ||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-languageCode-att languageCode]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage D:HumanLanguage]||Closed
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-isCriterionInd-att isCriterionInd]</span> ||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Supply-quantity-att quantity]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ]||[0..1]||  ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Supply-expectedUseTime-att expectedUseTime]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]||  ||
 +
|}
 +
 
 +
'''Supply.classCode'''
 +
 
 +
The Supply.classCode is fixed to "SPLY" which is used to represent a Supply. Supply orders and deliveries are simple Acts that focus on the delivered product. The product is associated with the Supply Act via Participation.typeCode="product". With general Supply Acts, the precise identification of the Material (manufacturer, serial numbers, etc.) is important. Most of the detailed information about the Supply should be represented using the Material class.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed Supply.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SPLY SPLY]||supply||
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''Supply.moodCode'''
 +
 
 +
The Supply.moodCode is bound to the x_ClinicalStatementSubstanceMood value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Supply.moodCode
 +
! style="text-align:left;"  colspan="5" |  V:x_ClinicalStatementSubstanceMood <small>[2.16.840.1.113883.1.11.19645] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event|| ||[http://cda/infrastructure/vocabulary/ActMood.htm#DEF DEF]||definition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#RQO RQO]||request||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#INT INT]||intent
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#PRMS PRMS]||promise||  ||[http://cda/infrastructure/vocabulary/ActMood.htm#PRP PRP]||proposal
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''Supply.id'''
 +
 
 +
The optional Supply.id is used to uniquely identify the supply activity.
 +
 
 +
'''Supply.code'''
 +
 
 +
The optional Supply.code is bound to the ActSupplyType concept domain, which is used to further define the type of supply for order or distribution.  Examples:
 +
* central supply
 +
* materials management
 +
* nurse station supply
 +
 
 +
'''<span class="change-highlight">Supply.actionNegationInd</span>'''
 +
 
 +
<span class="change-highlight">The Supply.actionNegationInd works as a negative existence quantifier on the actual, intended or described Supply event. In Event mood, it indicates the defined supply act did not occur. In Intent mood, it indicates the defined supply act is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.
 +
 
 +
The actionNegationInd negates the Supply act as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, repeatNumber, independentInd, isCriterionInd, quantity, expectedUseTime and any of their components.
 +
 
 +
The remaining properties represent the document characteristics, E.g. Supply.id, Supply.moodCode, Supply.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance. </span>
 +
 
 +
'''Supply.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 Supply activity.
 +
 
 +
'''Supply.statusCode'''
 +
 
 +
The status reflects the state of the activity.  The RIM based [http://cda/infrastructure/rim/rim.htm#ActStatus  state machine diagram] depicts the allowable state transitions that an Supply.StatusCodes can take on. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Supply.statusCode
 +
! style="text-align:left;"  colspan="5" | V:ActStatus <small>[2.16.840.1.113883.1.11.15933] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#normal normal]||normal|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#aborted aborted]||aborted
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#active active]||active|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#cancelled cancelled]||cancelled
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#completed completed]||completed|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#held held]||held
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#new new]||new|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#suspended suspended]||suspended
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActStatus.htm#nullified nullified]||nullified|| ||[http://cda/infrastructure/vocabulary/ActStatus.htm#obsolete obsolete]||obsolete
 +
|-
 +
!style="text-align:left;"  colspan="5" |<small> Code System: ActStatus (HL7) Code System OID: 2.16.840.1.113883.5.14</small>
 +
|}
 +
 
 +
'''Supply.effectiveTime'''
 +
 
 +
<span class="change-highlight">Supply.effectiveTime is used to indicate the clinically or operationally relevant time of a supply, exclusive of administrative activity. </span>
 +
 
 +
'''<span class="change-highlight">Supply.activityTime</span>'''
 +
 
 +
<span class="change-highlight">Supply.activityTime is a time expression specifying when a supply 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 Supply activity occurred, is supposed to occur, is scheduled to occur, etc. </span>
 +
 
 +
'''<span class="change-highlight">Supply.availabilityTime</span>'''
 +
 
 +
<span class="change-highlight">Supply.availabilityTime is the point in time at which information about an Supply instance (regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the Supply itself.</span>
 +
 
 +
'''Supply.priorityCode'''
 +
 
 +
The urgency under which the Supply activity happened, can happen, is happening, is intended to happen, or is requested/demanded to happen. The Supply.priorityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActPriority ActPriority] concept domain.
 +
 
 +
'''<span class="change-highlight">Supply.confidentialityCode</span>'''
 +
 
 +
<span class="change-highlight">Constraints around appropriate disclosure of information about this Supply activity, regardless of mood. The Supply.confidentialityCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#Confidentiality Confidentiality] concept domain.</span>
 +
 
 +
'''Supply.repeatNumber'''
 +
 
 +
An interval of integer numbers stating the minimal and maximal number of repetitions of the Supply activity.
 +
 
 +
'''Supply.independentInd'''
 +
 
 +
An indicator specifying whether the Act can be manipulated independently of other Acts or only through a super-ordinate composite Act that has this Act as a component. By default the independentInd should be true. An Act definition is sometimes marked with independentInd=false if the business rules would not allow this act to be ordered without ordering the containing act group.
 +
 
 +
'''<span class="change-highlight">Supply.languageCode</span>'''
 +
 
 +
<span class="change-highlight">The primary language in which this Supply statement is specified, particularly the language of the Supply.text.  The Supply.languageCode is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#HumanLanguage HumanLanguage] concept domain.</span>
 +
 
 +
 
 +
'''<span class="change-highlight">Supply.isCriterionInd</span>'''
 +
 
 +
<span class="change-highlight">Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.</span>
 +
 
 +
'''Supply.quantity'''
 +
 
 +
The optional Supply.quantity is used to represent the amount of material that was or is to be supplied.
 +
 
 +
'''Supply.expectedUseTime'''
 +
 
 +
Th optional Supply.expectedUseTime is used to identify the period time over which the supplied product is expected to be used.
 +
 
 +
=====Product=====
 +
 
 +
The dispensed product is associated with the Supply act via a product participant, which connects to the same ManufacturedProduct role used for SubstanceAdministration.
 +
 
 +
'''Product.typeCode'''
 +
 
 +
The Product.typeCode is fixed to "PRD" which represents a product participation.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed product.typeCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#PRD PRD]||product
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90</small>
 +
|}
 +
 
 +
=====ManufacturedProduct @a@=====
 +
 
 +
See [[#ManufacturedProduct|ManufacturedProduct]] (&sect; 5.3.6.8.2) above.
 +
 
 +
 
 +
<div align="center">Example {{AUTOEXAMPLENUM}}</div>
 +
<nowiki>
 +
<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>
 +
</nowiki>
 +
 
 +
===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|CDA Context]] (&sect; 5.4)), participants propagated from the header can be overridden within the body.
 +
 
 +
[[Image:Performer.png|800px|border|center|Entry Participants]]
 +
 
 +
====<big>author @b@</big>====
 +
 
 +
The author participant (described above, see [[#author|author]] (&sect; 5.2.2.2)), 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.
 +
 
 +
====<big>consumable</big>====
 +
 
 +
The consumable participant is described above (see [[#consumable|Consumable]] (&sect; 5.3.6.8.1)).
 +
 
 +
====<big>informant @a@</big>====
 +
 
 +
The informant participant is described above (see [[#informant|informant]] (&sect; 5.2.2.6)). The 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.
 +
 
 +
====<big>participant @a@</big>====
 +
 
 +
[[Image:Specimen.png|800px|border|center|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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: informant
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-typeCode-att  typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ParticipationType.htm#INF INF]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-functionCode-att  functionCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ParticipationFunction D:ParticipationFunction]|| Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-contextControlCode-att contextControlCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ContextControl.htm#_ContextControlPropagating OP]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-time-att time]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-awarenessCode-att awarenessCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#TargetAwareness D:TargetAwareness]||Open
 +
|}
 +
 
 +
'''participant.typeCode'''
 +
 
 +
The participant.typeCode is bound to the v:ParticipationType value set.  This enables a wide range of participation types to be selected.  '''Note''': Where an existing participation exists, it should be used in preference to the generic participation, failure to do so, will result in needlessly additional complexity for implementations. 
 +
 
 +
{| class='wikitable'   
 +
|+Table {{AUTOTABLENUM}}: Value set for participant.typeCode
 +
! style="text-align:left;"  colspan="5" | v:ParticipationType <small>[2.16.840.1.113883.1.11.10901] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!! !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#PART PART]||Participation||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#ADM ADM]||admitter
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#ATND ATND]||attender||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#AUTHEN AUTHEN]||authenticator
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#CALLBCK CALLBCK]|| callback contact ||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#CON CON]||consultant
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#DIS DIS]||discharger||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#ESC ESC]||escort
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#REF REF]||referrer||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#TRANS TRANS]||Transcriber
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#ENT ENT]||data entry person||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#WIT WIT]||witness
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#CST CST]||custodian||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#DIR DIR]||direct target
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#BBY BBY]||baby||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#DEV DEV]||device
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#NRD NRD]||non-reuseable device||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#RDV RDV]||reusable device
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#EXPAGNT EXPAGNT]||ExposureAgent||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#EXPART EXPART]||ExposureParticipation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#EXPTRGT EXPTRGT]||ExposureTarget||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#EXSRC EXSRC]||ExposureSource
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#IND IND]||indirect target||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#BEN BEN]||beneficiary
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#CAGNT CAGNT]||causative agent||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#COV COV]||coverage target
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#GUAR GUAR]||guarantor party||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#HLD HLD]||holder
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#DON DON]||donor||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#RCV RCV]||receiver
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#IRCP IRCP]||information recipient||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#NOT NOT]||ugent notification contact
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#PRCP PRCP]||primary information recipient||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#REFB REFB]||Referred By
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#REFT REFT]||Referred to||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#TRC TRC]||tracker
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#LOC LOC]||location||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#DST DST]||destination
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#ELOC ELOC]||entry location||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#ORG ORG]||origin
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#RML RML]||remote||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#VIA VIA]||via
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#RESP RESP]||responsible party||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#VRF VRF]||verifier
 +
|-
 +
!colspan="5" |Use the following participations, only if the other participations provided in CDA will not work
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#RCT RCT]||record target||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#AUT AUT]||author (originator)
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#INF INF]||informant||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#CSM CSM]||consumable
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#PRD PRD]||product||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#SBJ SBJ]||subject
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#SPC SPC]||specimen||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#PRF PRF]||performer
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#DIST DIST]||distributor||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#PPRF PPRF]||primary performer
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#SPRF SPRF]||secondary performer||
 +
||[http://cda/infrastructure/vocabulary/ParticipationType.htm#LA LA]||legal authenticator
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90</small>
 +
|}
 +
 
 +
'''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". Any participant(s) defined in a clinical entry, will override the participants with the same typeCode propagating from ancestor elements, in the header, body or sections.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed participant.contextControlCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ContextControl.htm#_ContextControlPropagating OP]||overriding, propagating
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System:  ContextControl (HL7) Code System OID: 2.16.840.1.113883.5.1057</small>
 +
|}
 +
 
 +
'''participant.time'''
 +
 
 +
The time during which the participant is involved in the act through this Participation.
 +
 
 +
'''participant.awarenessCode'''
 +
 
 +
The extent to which the Entity playing the participating Role is aware of the associated Act. For diagnostic observations, the patient, family member or other participant may not be aware of the patient's terminal illness. Because this attribute typically indicates that awareness is in question, it normally describes a target Participation (e.g., that of a patient). If the awareness, denial, unconsciousness, etc. is the subject of medical considerations (e.g., part of the problem list), explicit observations should be employed: this simple attribute in the Participation cannot represent information sufficient to support medical decision-making.
 +
 
 +
=====ParticipantRole=====
 +
 
 +
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).
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: ParticipantRole
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Role-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[1..1]||[http://cda/infrastructure/vocabulary/vs_RoleClass.htm#RoleClassRoot V:RoleClassRoot]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Role-id-att  id ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Role-code-att  code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#RoleCode D:RoleCode]|| Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Role-addr-att  addr ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-AD AD]>||[0..*]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Role-telecom-att  telecom ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TEL TEL]>||[0..*]|| ||
 +
|}
 +
 
 +
'''ParticipantRole.classCode'''
 +
 
 +
The ParticipantRole.classCode can be any role defined in the V:RoleClassRoot value set, not already provided for the Clinical Statement choice pattern.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for ParticipantRole.classCode 
 +
! style="text-align:left;"  colspan="5" |  V:RoleClassRoot <small>[2.16.840.1.113883.1.11.13940] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!! !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#ROL ROL] ('''Default''')||role||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#AFFL AFFL]||affiliate
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#AGNT AGNT]||agent||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#ASSIGNED ASSIGNED]||assigned entity
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#COMPAR COMPAR]||commissioning party||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#SGNOFF SGNOFF]||signing authority or officer
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#CON CON]||contact||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#ECON ECON]||emergency contact
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#NOK NOK]||next of kin||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#GUARD GUARD]||guardian
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#CIT CIT]||citizen||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#COVPTY COVPTY]||covered party
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#CLAIM CLAIM]||claimant||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#NAMED NAMED]||named insured
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#DEPEN DEPEN]||dependent||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#INDIV INDIV]||individual
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#SUBSCR SUBSCR]||subscriber||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#PROG PROG]||program eligible
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#CRINV CRINV]||clinical research investigator||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#CRSPNSR CRSPNSR]||clinical research sponsor
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#EMP EMP]||employee||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#MIL MIL]||military person
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#GUAR GUAR]||guarantor||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#INVSBJ INVSBJ]||Investigation Subject
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#CASEBJ CASEBJ]||Case Subject||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#RESBJ RESBJ]||research subject
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#LIC LIC]||licensed entity||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#NOT NOT]||notary public
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#PROV PROV]||healthcare provider||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#PAT PAT]||patient
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#PAYEE PAYEE]||payee||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#PAYOR PAYOR]||invoice payor
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#POLHOLD POLHOLD]||policy holder||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#QUAL QUAL]||qualified entity
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#SPNSR SPNSR]||underwriter||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#STD STD]||student
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#UNDWRT UNDWRT]||coverage sponsor||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#CAREGIVER CAREGIVER]||caregiver
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#PRS PRS]||personal relationship||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#ACCESS ACCESS]||access
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#ADMM ADMM]||Administerable Material||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#BIRTHPL BIRTHPL]||birthplace
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#DEATHPLC DEATHPLC]||place of death||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#DST DST]||distributed material
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#RET RET]||retailed material||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#EXPR EXPR]||exposed entity
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#HLD HLD]||held entity||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#HLTHCHRT HLTHCHRT]||health chart
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#IDENT IDENT]||identified entity||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#MANU MANU]||manufactured product
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#THER THER]||therapeutic agent||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#MNT MNT]||maintained entity
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#OWN OWN]||owned entity||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#RGPR RGPR]||regulated product
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#SDLOC SDLOC]||service delivery location||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#DSDLOC DSDLOC]||dedicated service delivery location, health care facility
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#ISDLOC ISDLOC]||incidental service delivery location||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#TERR TERR]||territory of authority
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#USED USED]||used entity||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#WRTE WRTE]||warranted product
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#EQUIV EQUIV]||equivalent entity||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#SAME SAME]||same
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#SUBY SUBY]||subsumed by||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#GEN GEN]||has generalization
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#GRIC GRIC]||has generic||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#INST INST]||instance
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#SUBS SUBS]||subsumer||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#CONT CONT]||content
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#EXPAGTCAR EXPAGTCAR]||exposure agent carrier||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#EXPVECTOR EXPVECTOR]||exposure vector
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#FOMITE FOMITE]||fomite||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#INGR INGR]||ingredient
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#ACTI ACTI]||active ingredient||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#ACTIB ACTIB]||active ingredient - basis of strength
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#ACTIM ACTIM]||active ingredient - moiety is basis of strength||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#ACTIR ACTIR]||active ingredient - reference substance is basis of strength
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#ADTV ADTV]||additive||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#BASE BASE]||base
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#IACT IACT]||inactive ingredient||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#COLR COLR]||color additive, color
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#FLVR FLVR]||flavor additive, flavor ||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#PRSV PRSV]||preservative
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#STBL STBL]||stabilizer||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#LOCE LOCE]||located entity
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#STOR STOR]||stored entity||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#MBR MBR]||member
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#PART PART]||part||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#ACTM ACTM]||active moiety
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#SPEC SPEC]||specimen||
 +
||[http://cda/infrastructure/vocabulary/RoleClass.htm#ALQT ALQT]||aliquot
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#ISLT ISLT]||isolate||
 +
|| ||
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110</small>
 +
|}
 +
 
 +
'''ParticipantRole.id'''
 +
 
 +
The optional participantRole.id is a unique identifier for the player Entity in this Role.
 +
 
 +
'''ParticipantRole.code'''
 +
 
 +
The optional ParticipantRole.code is bound the the EntityCode concept domain.
 +
 
 +
'''ParticipantRole.addr'''
 +
 
 +
The optional ParticipantRole.addr is the postal address for the Entity while in the Role.
 +
 
 +
'''ParticipantRole.telecom'''
 +
 
 +
The optional ParticipantRole.telecom is the telecommunication address (phone number) for the Entity while in the Role.
 +
 
 +
=====Device=====
 +
 
 +
Scoping the ParticipantRole is an entity (Entity class).
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Device
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityClass.htm#DEV DEV]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-determinerCode-att determinerCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE  INSTANCE]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-code-att  code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#EntityCode D:EntityCode] ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Device-manufacturerModelName-att  manufacturerModelName ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SC SC]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ManufacturerModelName  D:ManufacturerModelName ] ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Device-softwareName-att  softwareName ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SC SC]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#SoftwareName  D:SoftwareName ] ||
 +
|}
 +
 
 +
'''Device.classCode'''
 +
 
 +
The Device.classCode is defaulted to "DEV", but can take on any value defined in the EntityClassDevice value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Device.classCode 
 +
! style="text-align:left;"  colspan="5" |  V:EntityClassDevice <small>[2.16.840.1.113883.1.11.11623] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!! !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#DEV DEV] ('''Default''')||role||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#CER CER]||certificate representation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#MODDV MODDV]||imaging modality, ImagingModalityEntity||
 +
|| ||
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41</small>
 +
|}
 +
 
 +
'''Device.determinerCode'''
 +
 
 +
The determinerCode is fixed to "INSTANCE", which indicates we are referencing a specific device.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed Device.determinerCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE INSTANCE]||specific
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System:  EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30</small>
 +
|}
 +
 
 +
'''Device.code'''
 +
 
 +
The optional Device.code is bound to the EntityCode domain.
 +
 
 +
'''Device.manufacturerModelName'''
 +
 
 +
The optional Device.manufacturerModelName is used to convey a coded name for the device.
 +
 
 +
'''Device.softwareName'''
 +
 
 +
The optional Device.softwareName is used to convey a coded name for the software used to author content.
 +
 
 +
<div id="div-PlayingEntity"></div>
 +
 
 +
=====PlayingEntity=====
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: PlayingEntity
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityClass.htm#DEV DEV]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-determinerCode-att determinerCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE  INSTANCE]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-code-att  code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#EntityCode D:EntityCode] ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-quantity-att  quantity]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PQ PQ]>||[0..*]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-name-att  name]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-PN PN]>||[0..*]||  ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-desc-att  desc]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||  ||
 +
|}
 +
Note: Support for more than one quantity element in PlayingEntity has been deprecated in CDA R2.1. The CDA R2.1 schema will continue to support multiple quantities for backwards compatibility with CDA R2, but implementers of new templates and document instances are encouraged to support only [0..1] instances.
 +
 
 +
 
 +
'''PlayingEntity.classCode'''
 +
 
 +
The PlayingEntity.classCode is bound to the V:EntityClassRoot value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for PlayingEntity.classCode 
 +
! style="text-align:left;"  colspan="5" |  V:EntityClassRoot <small>[2.16.840.1.113883.1.11.13922] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!! !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#ENT ENT] ('''Default''')||entity||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#HCE HCE]||health chart entity
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#LIV LIV]||living subject||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#NLIV NLIV]||non-person living subject
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#ANM ANM]||animal||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#MIC MIC]||microorganism
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#PLNT PLNT]||plant||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#PSN PSN]||person
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#MAT MAT]||material||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#CHEM CHEM]||chemical substance
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#FOOD FOOD]||food||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#MMAT MMAT]||manufactured material
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#CONT CONT]||container||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#HOLD HOLD]||holder
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#DEV DEV]||device||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#CER CER]||certificate representation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#MODDV MODDV]||imaging modality, ImagingModalityEntity||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#ORG ORG]||organization
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#PUB PUB]||public institution||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#STATE STATE]||state
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#NAT NAT]||Nation||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#PLC PLC]||place
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#CITY CITY]||city or town||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#COUNTRY COUNTRY]||country
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#COUNTY COUNTY]||county or parish||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#PROVINCE PROVINCE]||state or province
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#RGRP RGRP]||group||
 +
|| ||
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41</small>
 +
|}
 +
 
 +
'''PlayingEntity.determinerCode'''
 +
 
 +
The determinerCode is fixed to "INSTANCE", which indicates we are referencing a specific entity.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed PlayingEntity.determinerCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE INSTANCE]||specific
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System:  EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30</small>
 +
|}
 +
 
 +
'''PlayingEntity.code'''
 +
 
 +
The optional PlayingEntity.code is bound to the EntityCode domain. For each Entity, the value for this attribute is drawn from one of several coding systems as suggested by the Entity.classCode, such as living subject (animal and plant taxonomies), chemical substance (e.g., IUPAC code), organization (e.g., CMS provider number), etc. It is possible that Entity.code may be so fine grained that it represents a single instance. An example is the CDC vaccine manufacturer code, modeled as a concept vocabulary, when in fact each concept refers to a single instance. The boundary cases distinguishing codes and identifiers are controversial: this specification allows a certain amount of flexibility.
 +
 
 +
'''PlayingEntity.quantity'''
 +
 
 +
The optional PlayingEntity.quantity defines the a physical quantity specifying the amount of the physical thing represented by the Entity object, either as a count of the members of a group, or as some other physical quantity. In order to explicitly identify a group of like entities, a static model design should constrain the PQ data type of this attribute to INT, thus providing a count of the entities in the group.
 +
 
 +
Note: Support for more than one quantity element in PlayingEntity has been deprecated in CDA R2.1. The CDA R2.1 schema will continue to support multiple quantities for backwards compatibility with CDA R2, but implementers of new templates and document instances are encouraged to support only [0..1] instances.
 +
 
 +
'''PlayingEntity.name'''
 +
 
 +
Most entities have a commonly used name that can be used to differentiate them from other Entities, but that does not provide a necessarily unique identifier.
 +
 
 +
'''PlayingEntity.desc'''
 +
 
 +
A textual or multimedia depiction of the Entity.
 +
 
 +
=====Entity=====
 +
 
 +
A physical thing, group of physical things or an organization capable of participating in Acts while in a role.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Entity
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityClass.htm#ENT ENT]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-determinerCode-att determinerCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE  INSTANCE]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-id-att  id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-code-att  code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#EntityCode D:EntityCode] ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Entity-desc-att  desc]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||  ||
 +
|}
 +
 
 +
'''Entity.classCode'''
 +
 
 +
The Entity.classCode is bound to the V:EntityClassRoot value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Entity.classCode 
 +
! style="text-align:left;"  colspan="5" |  V:EntityClassRoot <small>[2.16.840.1.113883.1.11.13922] (CLOSED) </small>
 +
|-
 +
!Code!!Display Name!! !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#ENT ENT] ('''Default''')||entity||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#HCE HCE]||health chart entity
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#LIV LIV]||living subject||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#NLIV NLIV]||non-person living subject
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#ANM ANM]||animal||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#MIC MIC]||microorganism
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#PLNT PLNT]||plant||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#PSN PSN]||person
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#MAT MAT]||material||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#CHEM CHEM]||chemical substance
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#FOOD FOOD]||food||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#MMAT MMAT]||manufactured material
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#CONT CONT]||container||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#HOLD HOLD]||holder
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#DEV DEV]||device||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#CER CER]||certificate representation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#MODDV MODDV]||imaging modality, ImagingModalityEntity||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#ORG ORG]||organization
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#PUB PUB]||public institution||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#STATE STATE]||state
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#NAT NAT]||Nation||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#PLC PLC]||place
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#CITY CITY]||city or town||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#COUNTRY COUNTRY]||country
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#COUNTY COUNTY]||county or parish||
 +
||[http://cda/infrastructure/vocabulary/EntityClass.htm#PROVINCE PROVINCE]||state or province
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityClass.htm#RGRP RGRP]||group||
 +
|| ||
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: EntityClass (HL7) Code System OID: 2.16.840.1.113883.5.41</small>
 +
|}
 +
 
 +
'''Entity.determinerCode'''
 +
 
 +
The determinerCode is fixed to "INSTANCE", which indicates we are referencing a specific entity.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed Entity.determinerCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/EntityDeterminer.htm#INSTANCE INSTANCE]||specific
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System:  EntityDeterminer (HL7) Code System OID: 2.16.840.1.113883.5.30</small>
 +
|}
 +
 
 +
'''Entity.id'''
 +
 
 +
The optional Entity.id is used to uniquely identify the Entity.
 +
 
 +
'''Entity.code'''
 +
 
 +
The optional Entity.code is bound to the EntityCode domain.
 +
 
 +
'''Entity.desc'''
 +
 
 +
The optional Entity.desc is a textual or multimedia depiction of the Entity.
 +
 
 +
====<big>performer @a@</big>====
 +
 
 +
[[Image:Performer.png|800px|border|center|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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: performer
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-typeCode-att  typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ParticipationType.htm#PRF PRF]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-functionCode-att  functionCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ParticipationFunction D:ParticipationFunction]|| Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-time-att  time]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-IVL IVL]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-TS TS]>||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-modeCode-att  modeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ParticipationMode.htm#ParticipationMode D:ParticipationMode ]||Fixed
 +
|}
 +
 
 +
'''performer.typeCode'''
 +
 
 +
The performer.typeCode is fixed to "PRF" which indicates a person, or organization that actually and principally carries out the action. Need not be the principal responsible actor.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed performer.typeCode
 +
|-
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#PRF PRF]||performer
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90</small>
 +
|}
 +
 
 +
'''performer.functionCode'''
 +
 
 +
The performer.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).
 +
 
 +
 
 +
'''performer.time'''
 +
 
 +
An optional interval of time which indicating the performer's participation in the associated Act.
 +
 
 +
'''performer.modeCode'''
 +
 
 +
The modality by which the Entity playing the Role is participating in the Act.
 +
 
 +
=====AssignedEntity @g@=====
 +
 
 +
A performer is an entity in the role of assigned entity (see [[#div-AssignedEntity|AssignedEntity]] (&sect; 5.2.2.1.1)).
 +
 
 +
=====Person @i@=====
 +
 
 +
An assigned entity is a person assigned to the role by the scoping organization.
 +
The entity playing the role is a person (see [[#div-person|Person]] (&sect; 5.2.2.2.2)).
 +
 
 +
=====Organization @j@=====
 +
 
 +
The entity scoping the role is an organization (see [[#div-Organization|Organization]] (&sect; 5.2.2.1.3)).
 +
 
 +
====<big>product @a@</big>====
 +
 
 +
The product participant is described above (see [[#product|product]] (&sect; 5.3.6.9.1)).
 +
 
 +
====<big>specimen</big>====
 +
 
 +
[[Image:Specimen.png|800px|border|center|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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: informant
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Participation-typeCode-att  typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ParticipationType.htm#SPC SPC]||Fixed
 +
|}
 +
 
 +
'''specimen.typeCode'''
 +
 
 +
The specimen.typeCode is fixed to "SPC" to indicate the subject of non-clinical (e.g. laboratory) observation services is a specimen.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed specimen.typeCode
 +
!Code!!Display Name!!
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ParticipationType.htm#SPC SPC]||specimen
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ParticipationType (HL7) Code System OID: 2.16.840.1.113883.5.90</small>
 +
|}
 +
 
 +
=====SpecimenRole=====
 +
 
 +
A role played by a material entity that is a specimen for an act.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: AssignedAuthor
 +
!style="text-align:left;"|Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Role-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/RoleClass.htm#SPEC SPEC]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Role-id-att  id ]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]>||[0..*]|| ||
 +
|}
 +
 
 +
'''SpecimenRole.classCode'''
 +
 
 +
The SpecimenRole.classCode is fixed to "SPEC". 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed SpecimenRole.classCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/RoleClass.htm#SPEC SPEC]||specimen
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: RoleClass (HL7) Code System OID: 2.16.840.1.113883.5.110</small>
 +
|}
 +
 
 +
'''SpecimenRole.id'''
 +
 
 +
An optional SpecimenRole.id can be used to uniquely identify the specimen.
 +
 
 +
=====PlayingEntity @a@=====
 +
 
 +
A specimen is an PlayingEntity in the role of SpecimenRole ([[#div-PlayingEntity|PlayingEntity]] (&sect; 5.3.7.4.3)).
 +
 
 +
====<big>subject @a@</big>====
 +
 
 +
The subject participant (described above, see [[#subject|subject]] (&sect; 5.3.3.3)), 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.
 +
 
 +
===Entry Relationships===
 +
 
 +
====<big>component @c@</big>====
 +
 
 +
The component relationship has a source of Organizer (see [[#Organizer|Organizer]] (&sect; 5.3.6.5)), and a target that is another CDA entry, and is used to create groupings of CDA entries within an Organizer.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: documentationOf Attributes
 +
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-typeCode-att typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COMP COMP]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-contextConductionInd-att contextConductionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-sequenceNumber-att sequenceNumber]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-INT INT]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-seperatableInd-att seperatableInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|}
 +
 
 +
'''component.typeCode'''
 +
 
 +
The component.typeCode is fixed to "COMP", which indicates that the associated Clinical Statement choice is a component part of the Organizer.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed component.typeCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COMP COMP] ('''FIXED''')||has component
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002</small>
 +
|}
 +
 
 +
'''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.
 +
 
 +
'''component.sequenceNumber'''
 +
 
 +
The optional component.sequenceNumber is an integer specifying the relative sequential ordering of this relationship among other like-types relationships having the same source Act.
 +
 
 +
'''component.seperatableInd'''
 +
 
 +
The optional component.seperatableInd is an indication that the source Act is intended to be interpreted independently of the target Act.  The default value is true.
 +
 
 +
====<big>precondition</big>====
 +
 
 +
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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: precondition Attributes
 +
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-typeCode-att typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#PRCN PRCN]||Fixed
 +
|}
 +
 
 +
'''precondition.typeCode'''
 +
 
 +
The precondition.typeCode is fixed to PRCN which indicates a requirement to be true before a service is performed. The target can be any service in criterion mood. For multiple pre-conditions a conjunction attribute (AND, OR, XOR) is applicable.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed precondition.typeCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#PRCN PRCN]||has pre-condition
 +
|-
 +
!style="text-align:left;"  colspan="2" | <small> Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002</small>
 +
|}
 +
 
 +
=====Criterion=====
 +
 
 +
Criterion class is used to express a condition that must hold true before some over activity occurs.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Criterion Attributes
 +
!RIM Attribute(s)!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||  <= OBS  is [http://cda/infrastructure/vocabulary/vs_ActClass.htm#ActClassObservation V:ActClassObservation]||Closed w/ Default
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS] ||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN.CRT ENV.CRT] ||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[1..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActCode D:ActCode]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Act-actionNegationInd-att  actonNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-isCriterionInd-att isCriterionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-value-att value]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ANY ANY]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ObservationValue D:ObservationValue]||Open
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/rim/rim.htm#Observation-valueNegationInd-att valueNegationInd]</span>||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Observation-interpretationCode-att interpretationCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-SET SET]<[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]>||[0..*]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ObservationInterpretation D:ObservationInterpretation]||Open
 +
|}
 +
 
 +
'''Criterion.classCode'''
 +
 
 +
The Criterion.classCode is defaulted to "OBS" which represents an observation, but can take only any value defined in the ActClassObservation value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for Criterion.classCode
 +
! style="text-align:left;"  colspan="5" | V:ActClassObservation <small> [2.16.840.1.113883.1.11.11529] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBS OBS] ('''Default''')||Observation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ALRT ALRT]||detected issue
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#BATTERY BATTERY]||battery||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CLNTRL CLNTRL]||clinical trial
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONC CONC]||concern||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#COND COND]||Condition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CASE CASE]||public health case||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OUTB OUTB]||outbreak
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DGIMG DGIMG]||diagnostic image||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#GEN GEN]||genomic observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DETPOL DETPOL]||determinant peptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#EXP EXP]||expression level
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#LOC LOC]||locus||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#PHN PHN]||phenotype
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POL POL]||polypeptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SEQ SEQ]||bio sequence
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SEQVAR SEQVAR]||bio sequence variation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#INVSTG INVSTG]||investigation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBSSER OBSSER]||observation series||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OBSCOR OBSCOR]||correlated observation sequences
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POS POS]||position||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#POSACC POSACC]||position accuracy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POSCOORD POSCOORD]||position coordinate||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SPCOBS SPCOBS]||specimen observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#VERIF VERIF]||Verification||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ROIBND ROIBND]||bounded ROI
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ROIOVL ROIOVL]||overlay ROI||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#LLD LLD] ('''Deprecated''')||left lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#PRN PRN] ('''Deprecated''')||prone ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#RLD RLD] ('''Deprecated''')||right lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SFWL SFWL] ('''Deprecated''')||Semi-Fowler's ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SIT SIT] ('''Deprecated''')||sitting
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#STN STN] ('''Deprecated''')||standing ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SUP SUP] ('''Deprecated''')||supine
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#RTRD RTRD] ('''Deprecated''')|| reverse trendelenburg ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#TRD TRD] ('''Deprecated''')||trendelenburg
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CNOD CNOD] ('''Deprecated''')||Condition Node ||  ||  || 
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''Criterion.moodCode'''
 +
 
 +
The Criterion.moodCode is fixed to "EVN.CRT" which indicates a criterion or condition over service events that must apply for an associated service to be considered.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed Criterion.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN.CRT EVN.CRT]||event criterion
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''Criterion.code'''
 +
 
 +
The particular kind of Criterion that the Criterion-instance represents. Criterion.code, if used, SHALL be a specialization of the Criterion.classCode. This attribute defines a specific sub-type of a given Criterion type. It allows the use of rich terminologies such as LOINC and SNOMED to represent sub-types of the Criterion.  The Criterion.code is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActCode ActCode] concept domain.
 +
 
 +
'''<span class="change-highlight">Criterion.actionNegationInd</span>'''
 +
 
 +
<span class="change-highlight">The Criterion.actionNegationInd indicates that the condition is based on the non-occurrence of the event. 
 +
 
 +
The actionNegationInd negates the Criterion as described by the descriptive properties which are:  classCode, code, isCriterionInd, value, valueNegationInd, interpretationCode and any of their components.
 +
 
 +
The remaining properties represent the document characteristics, E.g. Criterion.moodCode, Criterion.text are not negated.  Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.</span>
 +
 
 +
'''Criterion.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 Criterion.  The Criterion.text attribute can reference  the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.
 +
 
 +
'''Criterion.isCriterionInd'''
 +
 
 +
Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.
 +
 
 +
 
 +
'''Criterion.value'''
 +
 
 +
The result of the observation action. Extensive usage notes are available in the RIM, reference [http://cda/infrastructure/rim/rim.htm#Observation-value-att Value UsageNotes]
 +
 
 +
'''<span class="change-highlight">Criterion.valueNegationInd</span>'''
 +
 
 +
<span class="change-highlight">Criterion.valueNegationInd, indicates that the Criterion, as defined in in this Criterion class is NOT true. Note: This attribute should only be used when the terminology used for Criterion.value is not itself capable of expressing negated findings. (E.g. ICD9).</span>
 +
 
 +
'''Criterion.interpretationCode'''
 +
 
 +
A qualitative interpretation of the Criterion. 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."
 +
 
 +
====<big>referenceRange</big>====
 +
 
 +
The referenceRange relationship (see [[#Observation|Observation]] (&sect; 5.3.6.3)), has a source of Observation, and a target of ObservationRange.
 +
 
 +
====<big>entryRelationship</big>====
 +
 
 +
[[Image:EntryRelationship.png|800px|border|center|Entry Relationship]]
 +
 
 +
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).
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: entryRelationship Attributes
 +
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-typeCode-att typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm V:ActRelationshipType]||Closed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-inversionInd-att inversionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-contextConductionInd-att contextConductionInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-sequenceNumber-att sequenceNumber]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-INT INT]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-negationInd-att negationInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-seperatableInd-att seperatableInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|}
 +
 
 +
In CDA R2.0, the following entryRelationships scenarios were provided as informative content: 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Examples of typical entryRelationships
 +
!ActRelationship Type!!Reasonable Source and Target entries!!Comments
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#CAUS CAUS] <br/>(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").
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COMP COMP] <br/>(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").
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#GEVL GEVL] <br/>(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").
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#MFST MFST] <br/>(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").
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#REFR REFR] <br/>(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.
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RSON RSON] <br/>(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").
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#_ActClassTemporallyPertains SAS] <br/>(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").
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SPRT SPRT] <br/>(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").
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SUBJ SUBJ] <br/>(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.
 +
 
 +
'''entryRelationship.typeCode'''
 +
 
 +
<span class="change-highlight">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 value set 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.
 +
</span>
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for entryRelationship.typeCode
 +
! style="text-align:left;"  colspan="5" | V:ActRelationshipType <small> [2.16.840.1.113883.1.11.10317] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#CIND CIND]</span>||has contra-indication|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#PRCN PRCN]</span>||has pre-condition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RSON RSON]||has reason|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#BLOCK BLOCK]</span>||Blocks
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#CURE CURE]</span>||curative indication|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#CURE.ADJ CURE.ADJ]</span>||adjunct curative indication
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#DIAG DIAG]</span>||diagnosis|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#MITGT MITGT]</span>||mitigates
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RCVY RCVY]</span>||Recovery|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#MTGT.ADJ MTGT.ADJ]</span>||adjunct mitigation
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SYMP SYMP]</span>||symptomatic relief|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#TRIG TRIG]</span>||has trigger
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COMP COMP]||has component|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#ARR ARR]</span>||arrival
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#CTRLV CTRLV]</span>||has control variable|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#DEP DEP]</span>||departure
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#OUTC OUTC]</span>||has outcome|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#OBJC OBJC]</span>||has continuing objective
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#OBJF OBJF]</span>||has final objective|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#GOAL GOAL]</span>||has goal
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RISK RISK]</span>||has risk|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#PERT PERT]</span>||has pertinent information
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#_ActClassTemporallyPertains SAE]</span>||starts after end of|| ||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#_ActClassTemporallyPertains SAS]||starts after start of
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#CHRG CHRG]</span>||has charge|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#_ActRelationshipAccounting COST]</span>||has cost
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#_ActRelationshipAccounting CREDIT]</span>||has credit|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#_ActRelationshipAccounting DEBIT]</span>||has debit
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#AUTH AUTH]</span>||authorized by|| ||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#CAUS CAUS]||is etiology for
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COVBY COVBY]</span>||covered by|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#DRIV DRIV]</span>||is derived from
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#ELNK ELNK]</span>||episodeLink|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#EVID EVID]</span>||provides evidence for
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#EXACBY EXACBY]</span>||exacerbated by|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#EXPL EXPL]</span>||has explanation
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#ITEMSLOC ITEMSLOC]</span>||items located|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#LIMIT LIMIT]</span>||limited by
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#MFST MFST]||is manifestation of|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#NAME NAME]</span>||assigns name
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#PREV PREV]</span>||has previous instance|| ||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#REFR REFR]||refers to
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#REFV REFV]</span>||has reference values|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RELVBY RELVBY]</span>||relieved by
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SPRT SPRT]||has support|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SPRTBND SPRTBND]</span>||has bounded support
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SUBJ SUBJ]||has subject|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SUMM SUMM]</span>||summarized by
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SEQL SEQL]</span>||is sequel|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#APND APND]</span>||is appendage
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#COMPLY COMPLY]</span>||Update|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#DOC DOC]</span>||documents
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#FLFS FLFS]</span>||fulfills|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#OCCR OCCR]</span>||occurrence
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#OREF OREF]</span>||references order|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SCH SCH]</span>||schedules request
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#GEN GEN]</span>||has generalization|| ||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#GEVL GEVL]||evaluates (goal)
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#INST INST]</span>||instantiates (master)|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#MOD MOD]</span>||modifies
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#MTCH MTCH]</span>||matches (trigger)|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#OPTN OPTN]</span>||has option
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RCHAL RCHAL]</span>||re-challenge|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#REV REV]</span>||reverses
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RPLC RPLC]</span>||replaces|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SUCC SUCC]</span>||succeeds
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#UPDT UPDT]</span>||updates (condition)|| ||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#XCRPT XCRPT]||Excerpts
 +
|-
 +
|<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#VRXCRPT VRXCRPT]</span>||Excerpt verbatim|| ||<span class="change-highlight">[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#XFRM XFRM]</span>||transformation
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002</small>
 +
|}
 +
:'''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. </span>
 +
 
 +
'''entryRelationship.inversionInd'''
 +
 
 +
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.
 +
 
 +
'''entryRelationship.contextConductionInd'''
 +
 
 +
The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute (see [[#CDA_Context|CDA Context]] (&sect; 5.4)) 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.
 +
 
 +
'''entryRelationship.sequenceNumber'''
 +
 
 +
An integer specifying the relative sequential ordering of this relationship among other like-types relationships having the same source Act.
 +
 
 +
'''entryRelationship.negationInd'''
 +
 
 +
An indicator that asserts that the meaning of the link is negated.
 +
 
 +
'''entryRelationship.seperatableInd'''
 +
 
 +
An indication that the source Act is intended to be interpreted independently of the target Act. The value is defaulted to true.
 +
 
 +
====<big>reference</big>====
 +
 
 +
[[Image:External.png|800px|border|center|External]]
 +
 
 +
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".
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: reference Attributes
 +
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-typeCode-att typeCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActRelationshipType.htm#x_ActRelationshipExternalReference V:ActRelationshipExternalReference]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ActRelationship-seperatableInd-att seperatableInd]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-BL BL]||[0..1]|| ||
 +
|}
 +
 
 +
 
 +
'''reference.typeCode'''
 +
 
 +
A description of allowable reference.typeCode values are shown in the following table.
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for reference.typeCode
 +
! style="text-align:left;"  colspan="5" | V:ActRelationshipType <small> [2.16.840.1.113883.1.11.10317] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#ELNK ELNK]||episodeLink||
 +
||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#REFR REFR]||refers to
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SPRT SPRT]||has support||
 +
||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RPLC RPLC]||replaces
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#XCRPT XCRPT]||Excerpts||
 +
||[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SUBJ SUBJ]||has subject
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002</small>
 +
|}
 +
 
 +
'''reference.seperatableInd'''
 +
 
 +
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.
 +
 
 +
 
 +
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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: EXAMPLE entryRelationship Types
 +
!ActRelationship Type!!Reasonable Source and Target classes!!Comments
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#ELNK ELNK] <br/>(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).
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#REFR REFR]<br/>(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.
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#RPLC RPLC]<br/>(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.
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SPRT SPRT]<br/>(has support)|||(Observation) '''SPRT''' (ExternalDocument | ExternalObservation)||Used to show that the target provides supporting evidence for the source.
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#SUBJ SUBJ]<br/>(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.
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActRelationshipType.htm#XCRPT XCRPT]<br/>(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=====
 +
 
 +
The ExternalAct is a derivative of the RIM Act class, to be used when the other more specific classes are not appropriate.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: ExternalAct  Attributes
 +
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]|| <= ACT is [http://cda/infrastructure/vocabulary/ActClass.htm V:ActClassRoot]||Closed w/ Default
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]||[1..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ActCode D:ActCode]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]|| ||
 +
|}
 +
 
 +
'''ExternalAct.classCode'''
 +
 
 +
The ExternalAct.classCode is bound to the ActClassRoot value set.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for ExternalAct.classCode
 +
! style="text-align:left;"  colspan="5" | V:ActClassRoot <small> [2.16.840.1.113883.1.11.13856] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ACT ACT] ('''Default''')||act||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#COMPOSITION COMPOSITION]||composition, Attestable unit
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DOC DOC]||document||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#DOCCLIN DOCCLIN]||clinical document
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CDALVLONE CDALVLONE]||CDA Level One clinical document||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#CONTAINER CONTAINER]||record container
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CATEGORY CATEGORY]||category||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#DOCBODY DOCBODY]||document body
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DOCSECT CATEGORY]||document section, Section||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#TOPIC TOPIC]||topic
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#EXTRACT EXTRACT]||extract||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#EHR EHR]||electronic health record
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#FOLDER FOLDER]||folder||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#GROUPER GROUPER]||grouper
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CLUSTER CLUSTER]||Cluster||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#ACCM ACCM]||accommodation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ACCT ACCT]||account||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#ACSN ACSN]||accession
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ADJUD ADJUD]||financial adjudication, financial adjudication results ||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#CACT CACT]||control act
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ACTN ACTN]||action||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#INFO INFO]||information
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#STC STC]||state transition control||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#CNTRCT CNTRCT]||contract
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#FCNTRCT FCNTRCT]||financial contract||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#COV COV]||coverage
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONS CONS]||consent||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#CONTREG CONTREG]||container registration
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CTTEVENT CTTEVENT]||clinical trial timepoint event||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#DISPACT DISPACT]||disciplinary action
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#EXPOS EXPOS]||exposure||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#AEXPOS AEXPOS]||acquisition exposure
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#TEXPOS TEXPOS]||transmission exposure||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#INC INC]||incident
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#INFRM INFRM]||inform||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#INVE INVE]||invoice element
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#LIST LIST]||working list||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#MPROT MPROT]||monitoring program
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBS OBS]||Observation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ALRT ALRT]||detected issue
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#BATTERY BATTERY]||battery||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CLNTRL CLNTRL]||clinical trial
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONC CONC]||concern||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#COND COND]||Condition
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CASE CASE]||public health case||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OUTB OUTB]||outbreak
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DGIMG DGIMG]||diagnostic image||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#GEN GEN]||genomic observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DETPOL DETPOL]||determinant peptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#EXP EXP]||expression level
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#LOC LOC]||locus||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#PHN PHN]||phenotype
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POL POL]||polypeptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SEQ SEQ]||bio sequence
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SEQVAR SEQVAR]||bio sequence variation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#INVSTG INVSTG]||investigation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBSSER OBSSER]||observation series||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OBSCOR OBSCOR]||correlated observation sequences
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POS POS]||position||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#POSACC POSACC]||position accuracy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#POSCOORD POSCOORD]||position coordinate||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SPCOBS SPCOBS]||specimen observation
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#VERIF VERIF]||Verification||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ROIBND ROIBND]||bounded ROI
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ROIOVL ROIOVL]||overlay ROI|| 
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#PCPR PCPR]||care provision
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#ENC ENC]||encounter|| 
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#POLICY POLICY]||policy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#JURISPOL JURISPOL]||jurisdictional policy|| 
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#ORGPOL ORGPOL]||organizational policy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SCOPOL SCOPOL]||scope of practice policy|| 
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#STDPOL STDPOL]||standard of practice policy
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#PROC PROC]||procedure||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#SBEXT SBEXT]||Substance Extraction
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SPECCOLLECT SPECCOLLECT]||Specimen Collection||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#SBADM SBADM]||substance administration
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#REG REG]||registration||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#REV REV]||review
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SPCTRT SPCTRT]||specimen treatment||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#SPLY SPLY]||supply
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DIET DIET]||diet||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#STORE STORE]||storage
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SUBST SUBST]||Substitution||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#TRFR TRFR]||transfer
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#TRNS TRNS]||transportation||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#XACT XACT]|| financial transaction
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CNOD CNOD] ('''Deprecated''')||Condition Node||
 +
||[http://cda/infrastructure/vocabulary/ActClass.htm#LLD LLD] ('''Deprecated''')||left lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#PRN PRN] ('''Deprecated''')||prone ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#RLD RLD] ('''Deprecated''')||right lateral decubitus
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#SFWL SFWL] ('''Deprecated''')||Semi-Fowler's ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SIT SIT] ('''Deprecated''')||sitting
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#STN STN] ('''Deprecated''')||standing ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SUP SUP] ('''Deprecated''')||supine
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#RTRD RTRD] ('''Deprecated''')|| reverse trendelenburg ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#TRD TRD] ('''Deprecated''')||trendelenburg
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''ExternalAct.moodCode'''
 +
 
 +
The ExternalAct.moodCode is fixed to "EVN" which represents the event mood. Indicating that the act has taken place and this is information about that act.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed ExternalAct.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''ExternalAct.id'''
 +
 
 +
The unique instance identifier for the ExternalAct.
 +
 
 +
'''ExternalAct.code'''
 +
 
 +
The particular kind of Act that the Act-instance represents within its class. ExternalAct.code, if used, SHALL be a specialization of the ExternalAct.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 ExternalAct.code is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActCode ActCode] concept domain.
 +
 
 +
'''ExternalAct.text'''
 +
 
 +
A reference to a renderable textual or multimedia description of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the ExternalAct.
 +
 
 +
=====ExternalDocument=====
 +
 
 +
The 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.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: ExternalDocument  Attributes
 +
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att    classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]|| <=DOC is [http://cda/infrastructure/vocabulary/vs_ActClass.htm#ActClassDocument V:ActClassDocument]||Closed w/ Default
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att    moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#InfrastructureRoot-typeId-att  typeId]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]||[1..1]|| ||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]||[1..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CE CE]||[1..1]||[http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#DocumentType D:DocumentType]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ContextStructure-setId-att setId]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]||[0..1]||||
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#ContextStructure-versionNumber-att versionNumber]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ST ST]||[0..1]||||
 +
|}
 +
 
 +
'''ExternalDocument.classCode'''
 +
 
 +
The ExternalDocument.classCode is fixed to "DOCCLIN"
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed ExternalDocument.classCode
 +
! style="text-align:left;"  colspan="5" | V:ActClassDocument <small> [2.16.840.1.113883.1.11.18938] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#DOC DOC]'''(Default)'''||document|| ||
 +
[http://cda/infrastructure/vocabulary/ActClass.htm#DOCCLIN DOCCLIN]||clinical document
 +
|- 
 +
|[http://cda/infrastructure/vocabulary/ActClass.htm#CDALVLONE CDALVLONE]||CDA Level One clinical document|| ||  ||
 +
|-
 +
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 +
|}
 +
 
 +
'''ExternalDocument..moodCode'''
 +
 
 +
The ExternalDocument.moodCode is fixed to "EVN" which represents the event mood. Indicating that the document has been created and is available. 
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Fixed ExternalDocument.moodCode
 +
!Code!!Display Name
 +
|-
 +
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event
 +
|-
 +
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 +
|}
 +
 
 +
'''ExternalDocument.id'''
 +
 
 +
The unique instance identifier for the ExternalDocument.
 +
 
 +
'''ExternalDocument.code'''
 +
 
 +
The ExternalDocument.code is bound to the DocumentType concept domain.
 +
 
 +
'''ExternalDocument.text'''
 +
 
 +
A reference to the external document.
 +
 
 +
'''ExternalDocument.setId'''
 +
 
 +
The ExternalDocument.setId is an optional identifier that does not change with revisions to a document.
 +
 
 +
'''ExternalDocument.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 r2b datatypes. 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.
 +
 
 +
=====ExternalObservation=====
 +
 
 +
The ExternalObservation is a derivative of the RIM Observation class, used for representing external coded and other observations.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: ExternalObservation Attributes
 +
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]|| <= OBS is [http://cda/infrastructure/vocabulary/vs_ActClass.htm#ActClassObservation V:ActClassObservation]||Closed w/ Default
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]||[1..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ActCode D:ActCode]||Open
 +
|-
 +
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]|| ||
 +
|}
 +
 
 +
'''ExternalObservation.classCode'''
 +
 
 +
The ExternalObservation.classCode is defaulted to "OBS" in indicate an observation, but be be set to any code in the ActCode concept domain.
 +
 
 +
{| class='wikitable' 
 +
|+Table {{AUTOTABLENUM}}: Value set for ExternalObservation.classCode
 +
! style="text-align:left;"  colspan="5" | V:ActClassObservation <small> [2.16.840.1.113883.1.11.11529] (CLOSED)</small>
 +
|-
 +
!Code!!Display Name!!  !!Code!!Display Name
 
|-
 
|-
−
|Any ParticipationType subtype||See vocabulary domain "ParticipationType" for allowable values.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBS OBS] ('''Default''')||Observation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ALRT ALRT]||detected issue
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for participant.contextControlCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|OP (overriding propagating) ['''default''']||The participant overrides associations with the same typeCode. This overriding association will propagate to any descendant Acts reached by conducting ActRelationships. (See section "CDA Context" below.)
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#BATTERY BATTERY]||battery||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#CLNTRL CLNTRL]||clinical trial
−
|}
 
−
 
 
−
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).
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for ParticipantRole.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|Any ROL (RoleClassRoot) subtype||See vocabulary domain "RoleClassRoot" for allowable values.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#CONC CONC]||concern||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#COND COND]||Condition
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Device.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|DEV (device) ['''default''']||An entity used in an activity, without being substantially changed through that activity.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#CASE CASE]||public health case||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OUTB OUTB]||outbreak
 
|-
 
|-
−
|Any DEV subtype||See vocabulary domain "EntityClassDevice" for allowable values.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#DGIMG DGIMG]||diagnostic image||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#GEN GEN]||genomic observation
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Device.determinerCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|INSTANCE (instance) ['''default''']||The INSTANCE determiner indicates an actual occurrence of an entity, as opposed to the KIND determiner, which refers to the general description of a kind of entity. For example, one can refer to a specific car (a car instance), or one can refer to cars in general (a car kind).
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#DETPOL DETPOL]||determinant peptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#EXP EXP]||expression level
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for PlayingEntity.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|ENT (entity) ['''default''']||A physical thing, group of physical things or an organization capable of participating in Acts, while in a role.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#LOC LOC]||locus||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#PHN PHN]||phenotype
 
|-
 
|-
−
|Any ENT subtype||See vocabulary domain "EntityClassRoot" for allowable values.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#POL POL]||polypeptide||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SEQ SEQ]||bio sequence
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for PlayingEntity.determinerCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|INSTANCE (instance) ['''default''']||The INSTANCE determiner indicates an actual occurrence of an entity, as opposed to the KIND determiner, which refers to the general description of a kind of entity. For example, one can refer to a specific car (a car instance), or one can refer to cars in general (a car kind).
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#SEQVAR SEQVAR]||bio sequence variation||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#INVSTG INVSTG]||investigation
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Entity.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|ENT (entity) ['''default''']||A physical thing, group of physical things or an organization capable of participating in Acts, while in a role.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#OBSSER OBSSER]||observation series||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#OBSCOR OBSCOR]||correlated observation sequences
 
|-
 
|-
−
|Any ENT subtype||See vocabulary domain "EntityClassRoot" for allowable values.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#POS POS]||position||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#POSACC POSACC]||position accuracy
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Entity.determinerCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|INSTANCE (instance) ['''default''']||The INSTANCE determiner indicates an actual occurrence of an entity, as opposed to the KIND determiner, which refers to the general description of a kind of entity. For example, one can refer to a specific car (a car instance), or one can refer to cars in general (a car kind).
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#POSCOORD POSCOORD]||position coordinate||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SPCOBS SPCOBS]||specimen observation
−
|}
 
−
 
 
−
====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.
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for performer.typeCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|PRF (performer) ['''default''']||A person who actually and principally carries out or will carry out the action. The traditional order filler is a performer.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#VERIF VERIF]||Verification||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#ROIBND ROIBND]||bounded ROI
−
|}
 
−
 
 
−
====product====
 
−
 
 
−
The product participant is described above (see [[#Entry_Acts|Entry Acts]]).
 
−
 
 
−
====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.
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for specimen.typeCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|SPC (specimen) ['''default''']||The subject of non-clinical (e.g. laboratory) observation services.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#ROIOVL ROIOVL]||overlay ROI||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#LLD LLD] ('''Deprecated''')||left lateral decubitus
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for SpecimenRole.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|SPEC (specimen) ['''default''']||A role played by a material entity that is a specimen for an act.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#PRN PRN] ('''Deprecated''')||prone || ||[http://cda/infrastructure/vocabulary/ActClass.htm#RLD RLD] ('''Deprecated''')||right lateral decubitus
−
|}
 
−
 
 
−
====subject====
 
−
 
 
−
The subject participant (described above, see [[#subject|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.
 
−
 
 
−
===Entry Relationships===
 
−
 
 
−
====component====
 
−
 
 
−
The component relationship has a source of Organizer (see [[#Organizer|Organizer]], and a target that is another CDA entry, and is used to create groupings of CDA entries within an Organizer.
 
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for component.typeCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|COMP (component) ['''default''']||The associated CDA entry is a component of the organizer.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#SFWL SFWL] ('''Deprecated''')||Semi-Fowler's ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SIT SIT] ('''Deprecated''')||sitting
−
|}
 
−
 
 
−
====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.
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for precondition.typeCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|PRCN (precondition) ['''default''']||A requirement to be true before a service is performed.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#STN STN] ('''Deprecated''')||standing ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#SUP SUP] ('''Deprecated''')||supine
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Criterion.classCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|OBS (observation) ['''default''']||Observations are actions performed in order to determine an answer or result value.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#RTRD RTRD] ('''Deprecated''')|| reverse trendelenburg ||  ||[http://cda/infrastructure/vocabulary/ActClass.htm#TRD TRD] ('''Deprecated''')||trendelenburg
 
|-
 
|-
−
|Any OBS subtype||See vocabulary domain "ActClassObservation" for allowable values.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#CNOD CNOD] ('''Deprecated''')||Condition Node || ||  || 
−
|}
 
−
 
 
−
{| class='wikitable'  
 
−
|+Table {{AUTOTABLENUM}}: Value set for Criterion.moodCode (CNE)
 
−
!Code!!Definition
 
 
|-
 
|-
−
|EVN.CRT (event criterion) ['''default''']||A criterion or condition that must apply for an associated service to be considered.
+
!style="text-align:left;"  colspan="5" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 
|}
 
|}
  
−
====referenceRange====
+
'''ExternalObservation.moodCode'''
−
 
 
−
The referenceRange relationship (described above, see [[#Observation|Observation]]), has a source of Observation, and a target of ObservationRange.
 
  
−
====entryRelationship====
+
The ExternalObservation.moodCode is fixed to "EVN" which represents the event mood. Indicating that the observation has taken place and this is information about that observation.
−
 
 
−
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).
 
−
 
 
−
:'''NOTE:''' The CDA specification permits any CDA entry to relate to any CDA entry using any of the following relationship types. In many cases, this would result in nonsensical relationships. The following table is a guideline for reasonable relationships between CDA entries, and is not a conformance constraint.
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: CDA entryRelationship Types
+
|+Table {{AUTOTABLENUM}}: Fixed ExternalObservation.moodCode
−
!ActRelationship Type!!Reasonable Source and Target entries!!Comments
+
!Code!!Display Name
−
|-
 
−
|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.
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event
 
|-
 
|-
−
|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").
+
!style="text-align:left;" colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
−
|-
 
−
|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").
 
 
|}
 
|}
  
−
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.
+
'''ExternalObservation.id'''
  
−
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 unique instance identifier for the ExternalObservation.
  
−
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.
+
'''ExternalObservation.code'''
  
−
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. In the example in the table above, "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 particular kind of observation that the observation-instance represents within its class. ExternalObservation.code, if used, SHALL be a specialization of the ExternalObservation.classCode. This attribute defines a specific sub-type of a given Observation 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 observation types defined by "classCode." The ExternalObservation.code is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActCode ActCode] concept domain.
  
−
The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute (see [[#CDA_Context|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.
+
'''ExternalObservation.text'''
  
−
====reference====
+
A reference to a renderable textual or multimedia description of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the ExternalObservation.
  
−
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.
+
=====ExternalProcedure=====
  
−
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 ExternalProcedure is a derivative of the RIM Procedure class, used for representing external procedures.
−
 
 
−
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. 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.
 
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: CDA reference Types
+
|+Table {{AUTOTABLENUM}}: ExternalProcedure Attributes
−
!ActRelationship Type!!Reasonable Source and Target classes!!Comments
+
!Attribute Name!!Data Type!!Cardinality!!Code Binding!!Binding Type
−
|-
 
−
|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.
+
|[http://cda/infrastructure/rim/rim.htm#Act-classCode-att classCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActClass.htm#PROC PROC]||Fixed
 
|-
 
|-
−
|SPRT (has support)|||(Observation) '''SPRT''' (ExternalDocument | ExternalObservation)||Used to show that the target provides supporting evidence for the source.
+
|[http://cda/infrastructure/rim/rim.htm#Act-moodCode-att moodCode]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CS CS]||[0..1]||[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||Fixed
 
|-
 
|-
−
|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.
+
|[http://cda/infrastructure/rim/rim.htm#Act-id-att id]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-II II]||[1..*]||||
 +
|- 
 +
|[http://cda/infrastructure/rim/rim.htm#Act-code-att code]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-CD CD]||[0..1]||[http://cda/infrastructure/vocabulary/vs_ActCode.htm#ActCode D:ActCode]||Open
 
|-
 
|-
−
|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").
+
|[http://cda/infrastructure/rim/rim.htm#Act-text-att text]||[http://cda/infrastructure/itsxml/datatypes-its-xml.htm#dtimpl-ED ED]||[0..1]|| ||
 
|}
 
|}
  
−
Target classes of the reference relationship include ExternalAct, ExternalDocument, ExternalObservation, and External Procedure.
+
'''ExternalProcedure.classCode'''
  
−
ExternalAct is a derivative of the RIM Act class, to be used when the other more specific classes are not appropriate.
+
The ExternalProcedure.classCode is fixed to "PROC".
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalAct.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Fixed ExternalProcedure.classCode  
−
!Code!!Definition
+
!Code!!Display Name
 
|-
 
|-
−
|ACT (act) ['''default''']||A healthcare service.
+
|[http://cda/infrastructure/vocabulary/ActClass.htm#PROC PROC]||procedure
 
|-
 
|-
−
|Any ACT subtype.||See vocabulary domain "ActClassRoot" for allowable values.
+
!style="text-align:left;"  colspan="2" | <small> Code System: ActClass (HL7) Code System OID: 2.16.840.1.113883.5.6</small>
 
|}
 
|}
  
−
{| class='wikitable'
+
'''ExternalProcedure.moodCode'''
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalAct.moodCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|EVN (event) ['''default''']||An actual occurrence of an event.
 
−
|}
 
  
−
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.
+
The ExternalProcedure.moodCode is fixed to "EVN" which represents the event mood. Indicating that the procedure has taken place and this is information about that procedure.
  
 
{| class='wikitable'   
 
{| class='wikitable'   
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalDocument.classCode (CNE)
+
|+Table {{AUTOTABLENUM}}: Fixed ExternalProcedure.moodCode
−
!Code!!Definition
+
!Code!!Display Name
 
|-
 
|-
−
|DOC (document) ['''default''']||The notion of a document comes particularly from the paper world, where it corresponds to the contents recorded on discrete pieces of paper. In the electronic world, a document is a kind of composition that bears resemblance to their paper world counter-parts. Documents typically are meant to be human-readable. HL7's notion of document differs from that described in the W3C XML Recommendation, in which a document refers specifically to the contents that fall between the root element's start-tag and end-tag. Not all XML documents are HL7 documents.
+
|[http://cda/infrastructure/vocabulary/ActMood.htm#EVN EVN]||event
 
|-
 
|-
−
|Any DOC subtype||See vocabulary domain "ActClassDocument" for allowable values.
+
!style="text-align:left;"  colspan="2" |<small> Code System: ActMood (HL7) Code System OID: 2.16.840.1.113883.5.1001</small>
 
|}
 
|}
  
−
{| class='wikitable'
+
'''ExternalProcedure.id'''
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalDocument.moodCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|EVN (event) ['''default''']||An actual occurrence of an event.
 
−
|}
 
  
−
ExternalObservation is a derivative of the RIM Observation class, used for representing external coded and other observations.
+
The unique instance identifier for the ExternalProcedure.
  
−
{| class='wikitable'
+
'''ExternalProcedure.code'''
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalObservation.classCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|OBS (observation) ['''default''']||Observations are actions performed in order to determine an answer or result value.
 
−
|-
 
−
|Any OBS subtype||See vocabulary domain "ActClassObservation" for allowable values.
 
−
|}
 
  
−
{| class='wikitable' 
+
The particular kind of procedure that the procedure-instance represents within its class. ExternalProcedure.code, if used, SHALL be a specialization of the ExternalProcedure.classCode. This attribute defines a specific sub-type of a given Procedure 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 Procedure types defined by "classCode." The ExternalProcedure.code is bound to the [http://cda/infrastructure/vocabulary/voc_ConceptDomains.htm#ActCode ActCode] concept domain.
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalObservation.moodCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|EVN (event) ['''default''']||An actual occurrence of an event.
 
−
|}
 
  
−
ExternalProcedure is a derivative of the RIM Procedure class, used for representing external procedures.
+
'''ExternalProcedure.text'''
−
 
 
−
{| class='wikitable' 
 
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalProcedure.classCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|PROC (procedure) ['''default''']||An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject.
 
−
|}
 
−
 
 
−
{| class='wikitable'
 
−
|+Table {{AUTOTABLENUM}}: Value set for ExternalProcedure.moodCode (CNE)
 
−
!Code!!Definition
 
−
|-
 
−
|EVN (event) ['''default''']||An actual occurrence of an event.
 
−
|}
 
  
 +
A reference to a renderable textual or multimedia description of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the ExternalProcedure.
  
 
=[[CDA Hierarchical Description]]=
 
=[[CDA Hierarchical Description]]=

Latest revision as of 12:44, 23 April 2019

Editing tips and notes

Contents

1 CDA Overview

(content on separate page)

2 Introduction to CDA Technical Artifacts

(content on separate page)

3 CDA Document Exchange in HL7 Messages

(content on separate page)

4 CDA Templating

(content on separate page)

5 CDA Design

5.1 Clinical Document

(remaining content on separate page)

5.2 Header

(content on separate page)

5.3 Body

5.3.1 Body Choice

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.

5.3.1.1 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.

5.3.1.2 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 CS [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 (see CDA Context (§ 5.4)).

5.3.1.3 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 CS [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.

StructuredBody.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 StructuredBody.languageCode overrides the value propagated from the header (see CDA Context (§ 5.4) for more details).

5.3.1.3.1 component @a@

A component class is used to relate the body choice (NonXMLBody, StructuredBody) to it's component Section(s) (see component (§ 5.3.1.1) for modeling).

5.3.2 Section Attributes

Section

Document sections can nest, can override context propagated from the header, and can contain narrative and CDA entries (see CDA Context (§ 5.4)).

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 CS [0..1] D:HumanLanguage Closed

NOTE: XML ID Attribute added. For more information, see ID/IDREF discussion in Section Narrative Block (§ 5.3.5).

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 in the US Realm, but has an OPEN binding to enable other coding systems in other realms.

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 (§ 5.3.5) for details).

Section.confidentialityCode

A value for Section.confidentialityCode overrides the value propagated from StructuredBody (see CDA Context (§ 5.4) 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 (§ 5.4) for more details).

5.3.3 Section Participants

5.3.3.1 author @a@

The author participant (see author (§ 5.2.2.2)), can be ascribed to a CDA section, where it overrides the value(s) propagated from the CDA header.

5.3.3.2 informant @a@

The informant participant (see informant (§ 5.2.2.6)), can be ascribed to a CDA section where it overrides the value(s) propagated from the CDA header.

5.3.3.3 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 (§ 5.2.2.11)), 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
awarenessCode CE [0..1] D:TargetAwareness Open

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
5.3.3.3.1 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.

5.3.3.3.2 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 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.

5.3.4 Section Relationships

5.3.4.1 component @b@

The "component" Act Relationship is used to nest a Section within a Section. Context propagates to nested sections (see CDA Context (§ 5.4)). Refer to component (§ 5.3.1.1) above for more information.

5.3.4.2 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 (§ 5.3.5.12) 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 (§ 5.3.8.4).

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.

5.3.5 Section Narrative Block

The Section.text field is used to store narrative to be rendered, as described above in CDA Conformance (§ 1.3), 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 (§ 1.2.3)). 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.

5.3.5.1 <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.

5.3.5.2 <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> (§ 5.3.5.6)). 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.

5.3.5.3 <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.

5.3.5.4 <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.

5.3.5.5 <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.

5.3.5.6 <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.

5.3.5.7 <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.

5.3.5.8 <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.

5.3.5.9 <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. For definitions of the @align and @valign attributes see the W3C HTML 4.01 Specification section 11.3.2.

The table.border, table.cellspacing, and table.cellpadding attributes are deprecated, because the styleCode attribute (see styleCode attribute (§ 5.3.5.11)) provides a more consistent way for senders to suggest rendering characteristics.

5.3.5.10 <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.

5.3.5.11 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>

5.3.5.12 Referencing in and out of the narrative block

NOTE: See entry (§ 5.3.4.2) 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> (§ 5.3.5.1)).

The <linkHtml> element of the CDA Narrative Block can reference targets that are either internal or external to the document (see <linkHtml> (§ 5.3.5.2)).

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> (§ 5.3.5.5)).

The <renderMultiMedia> element of the CDA Narrative Block can point out to CDA ObservationMedia and RegionOfInterest entries of the same document (see <renderMultiMedia> (§ 5.3.5.6)).

5.3.6 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.

5.3.6.1 Act

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
actionNegationInd 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 CS [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.actionNegationInd

The Act.actionNegationInd works as a negative existence quantifier on the actual, intended or described Act event. In Event mood, it indicates the defined act did not occur. In Intent mood, it indicates the defined act is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.

The actionNegationInd negates the Act as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, reasonCode and any of their components.

The remaining properties represent the document characteristics, E.g. Act.id, Act.moodCode, Act.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.

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 an act, 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.

5.3.6.2 Encounter

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 (§ 5.2.3)) 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 [0..1] D:ActCode Open
actionNegationInd 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 CS [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 Encounter.id can be used to uniquely identify the encounter.

Encounter.code

The optional Encounter.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.actionNegationInd

The Encounter.actionNegationInd works as a negative existence quantifier on the actual, intended or described Encounter event. In Event mood, it indicates the defined encounter did not occur. In Intent mood, it indicates the defined encounter is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.

The actionNegationInd negates the Encounter as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, reasonCode, admissionReferralSourceCode, lengthOfStayQuantity, dischargeDispositionCode, preAdmitTestInd, specialCourtesiesCode, specialArrangementCode and any of their components.

The remaining properties represent the document characteristics, E.g. Encounter.id, Encounter.moodCode, Encounter.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative encounter. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.

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.specialCourtesiesCode

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

Encounter.specialArrangementCode

Extraordinary provisions required in the context of the patient encounter. For encounters in intention moods, this information can be used to identify special arrangements that will need to be made for the incoming patient.

5.3.6.3 Observation

Observation

A derivative of the Observation (§ RIM 2.35) 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] <= OBS is V:ActClassObservation Closed
moodCode CS [1..1] V:x_ActMoodDocumentObservation Closed
id SET <II> [0..*]
code CD [1..1] D:ObservationType Open
actionNegationInd 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 CS [0..1] D:HumanLanguage Closed
isCriterionInd BL [0..1]
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 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

The Observation.actionNegationInd works as a negative existence quantifier on the actual, intended or described observation event. In Event mood, it indicates the defined observation did not occur. In Intent mood, it indicates the defined observation is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.

The actionNegationInd negates the Observation as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, derivationExpr, repeatNumber, isCriterionInd, value, valueNegationInd, interpretationCode, methodCode, targetSiteCode, and any of their components.

The remaining properties represent the document characteristics, E.g. Observatoin.id, Observation.moodCode, Observation.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.

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. In the case of an Observation, this is the status of the activity of observing (e.g., "new," "complete," "cancelled"), not the status of what is being observed (e.g., disease status, "Active" allergy to penicillin). To convey the status of the subject being observed, consider coordinating it into the code or value attribute of the Observation or using a related Observation. 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. Note: Implementation Guides will need to provide explicit guidance on the proper evaluation and interpretation, as well as provide a default value assignment.

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.isCriterionInd

Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.

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: The RIM indicates that this attribute should only be used when the terminology used for Observation.value is not itself capable of expressing negated findings. (E.g. ICD9). Implementation experience may override the RIM definition and it's important to review template definitions and Value Set content and binding for consistent negation implementation. Existing CDA R2.0 implementations use negationInd in many C-CDA templates.

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.

The following is an example of how an author can record a patient that has no known allergies. It uses the new valueNegationInd with an "Allergy to substance" code in the value element.

Example X
<section>
    <templateId .../>
    <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
    <title>ALLERGIES AND ADVERSE REACTIONS</title>
    <text>No Known Allergies</text>
    <entry typeCode="DRIV">
        <!-- Allergy Concern Act -->
        <act classCode="ACT" moodCode="EVN">
            <templateId ... />
            <id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
            <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
            <statusCode code="active"/>
            <effectiveTime>
                <low value="20100103"/>
            </effectiveTime>
            <author> ... </author>
            <entryRelationship typeCode="SUBJ">
                <!-- No Known Allergies -->
                <!-- The <valueNegationInd value="true" /> negates the observation/value -->
                <observation classCode="OBS" moodCode="EVN">
                    <!-- allergy - intolerance observation template -->
                    <templateId ... />
                    <templateId ... />
                    <id ... />
                    <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
                    <statusCode code="completed"/>
                    <effectiveTime>
                        <low nullFlavor="NA"/>
                    </effectiveTime>
                    <value xsi:type="CD" code="419199007"
                        displayName="Allergy to substance (disorder)"
                        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                    <valueNegationInd value="true"/>
                    <author> ... </author>
                    <participant typeCode="CSM">
                        <participantRole classCode="MANU">
                            <playingEntity classCode="MMAT">
                                <code nullFlavor="NA"/>
                            </playingEntity>
                        </participantRole>
                    </participant>
                </observation>
            </entryRelationship>
        </act>
    </entry>
</section>


5.3.6.3.1 Reference Range

An Observation can have zero to many referenceRange relationships, which relate an Observation to the ObservationRange class.

referenceRange.typeCode

The referenceRange.typeCode has been fixed to "REFV", which indicates an association to a reference range.

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
5.3.6.3.2 ObservationRange

ObservationRange or 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.

Table X: ObservationRange Attributes
RIM Attribute(s) Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] <= OBS is V:ActClassObservation Closed w/ Default
moodCode CS [0..1] ENV.CRT Fixed
code CD [1..1] D:ActCode Open
text ED [0..1]
isCriterionInd BL [0..1]
value SET<ANY> [0..*] D:ObservationValue Open
valueNegationInd BL [0..1]
interpretationCode SET<CE> [0..*] D:ObservationInterpretation Open

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

The ObservationRange.moodCode is fixed to the "EVN.CRT" (event criterion). The "EVN.CRT" is a criterion or condition over service events that must apply for an associated service to be considered.

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

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

ObservationRange.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 ObservationRange. The ObservationRange.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

ObservationRange.isCriterionInd

Is set to true to indicate that the data conveyed by the ObservationRange, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.

ObservationRange.value

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

ObservationRange.valueNegationInd

ObservationRange.valueNegationInd, indicates that when the ObservationRange event occurred, the finding communicated by the value attribute was NOT found. Note: This attribute should only be used when the terminology used for ObservationRange.value is not itself capable of expressing negated findings. (E.g. ICD9).

ObservationRange.interprerationCode

A qualitative interpretation of the ObservationRange. 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."

5.3.6.4 ObservationMedia

Observation Media

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] <= OBS is V:ActClassObservation Closed
moodCode CS [1..1] EVN Fixed
id SET <II> [0..*]
languageCode CS [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> (§ 5.3.5.6)). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).

ObservationMedia.classCode

The ObservationMedia.classCode is defaulted to "OBS" for Observation, but can be set to any sub-type of Observation that may more accurately characterize the multi-media referenced via the ObservationMedia class.

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

The ObservationMedia.moodCode is fixed to "EVN" or event mood to indicate that this is ObservationMedia is from a past service.

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

An optional identifier for the ObservationMedia instance.

ObservationMedia.languageCode

Specifies the human language of character data (whether they be in contents or attribute values).

ObservationMedia.value

The ObservationMedia.value is set to the xsi:type="ED" which enables the referencing of the multi-media object. Review the ED data type for more information about linking to files.

5.3.6.5 Organizer

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 [0..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

The Organizer.classCode can take on one of two values, BATTERY or CLUSTER.

  1. CLUSTER is an ACT that organizes a set of component acts into a semantic grouping that have a shared subject. The subject may be either a subject participation (SBJ), subject act relationship (SUBJ), or child participation/act relationship types.
  2. The BATTERY is an observation that is composed of a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are run together because of automation. A battery can define required and optional component observations and, in some cases, will define complex rules that determine whether or not a particular observation is made. BATTERY is a constraint on the Observation class in that it is understood to always be composed of component observations.
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

The Organizer.moodCode is fixed to the "EVN" or event mood to indicate that the Organizer has been created with the contents specified.


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

An optional identifier for the Organizer instance.

Organizer.code

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

Organizer.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 Organizer. The Organizer.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

Organizer.statusCode

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

Table X: Value set for Organizer.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

Organizer.effectiveTime

The optional Organizer.effectiveTime is used to indicate the clinically or operationally relevant time of an Organizer's component items, 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.

Organizer.activityTime

The optional Organizer.activityTime is a time expression specifying when the activityTime of the Organizer's component items occurred, 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 component Acts occurred, is supposed to occur, is scheduled to occur, etc.

Organizer.availabilityTime

The optional Observation.availabilityTime is the point in time at which information about the component Acts regardless of mood) first became available to a system. The availabilityTime is metadata describing the recording of, not the Organizer's component activities themselves.

Organizer.priorityCode

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

Organizer.confidentialityCode

The optional confidentialityCode identifies any constraints around appropriate disclosure of information about this Organizer and it's component Acts, regardless of mood. The Organizer.confidentialityCode is bound to the Confidentiality concept domain.

5.3.6.6 Procedure

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] <= PROC is V:ActClassProcedure Closed
moodCode CS [1..1] V:x_DocumentProcedureMood Closed
id SET <II> [0..*]
code CD [0..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 CS [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

The defines a specific sub-type of a given Procedure type. The Procedure.classCode is bound to the V:ActClassProcedure value set.

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

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

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

A unique identifier for the Procedure.

Procedure.code

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

Procedure.actionNegationInd

The Procedure.actionNegationInd works as a negative existence quantifier on the actual, intended or described Procedure event. In Event mood, it indicates the defined procedure did not occur. In Intent mood, it indicates the defined procedure is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.

The actionNegationInd negates the Act as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, isCriterionInd, methodCode, approachSiteCode, targetSiteCode and any of their components.

The remaining properties represent the document characteristics, E.g. Procedure.id, Procedure.moodCode, Procedure.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.

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

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 Procedure. The Procedure.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

Procedure.statusCode

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

Table X: Value set for Procedure.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


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

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

Procedure.confidentialityCode

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

Procedure.uncertaintyCode

An indication that the Procedure 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 Procedure and its dependent Acts is questioned. The Procedure.uncertaintyCode is bound to the ActUncertainty concept domain.

Procedure.languageCode

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

Procedure.isCriterionInd

Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.

Procedure.methodCode

The means or technique used to ascertain the observation. In some procedures the method is already partially specified by the Procedure.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 Procedure.code. However, an information consumer system or process SHOULD NOT depend on this methodCode information for method detail that is implied by the Procedure.code.

Procedure.approachSiteCode

The anatomical site or system through which the procedure reaches its target.

Procedure.targetSiteCode

The anatomical site or system that is the focus of the procedure. Most procedure target sites are implied by the procedure definition and Procedure.code, or Procedure.value. If the subject of the procedure is something other than a human patient or animal, the attribute is used analogously to specify a structural landmark of the thing where the Procedure occurred.

5.3.6.7 RegionOfInterest

Region of Interest

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 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> (§ 5.3.5.6)). All values of attributes of type XML ID must be unique within the document (per the W3C XML specification).

RegionOfInterest.classCode

The RegionOfInterest.classCode is fixed to "ROIOVL" which is a Region of Interest (ROI) specified for an image using an overlay shape. Typically used to make reference to specific regions in images, e.g., to specify the location of a radiologic finding in an image or 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 are in pixels. 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 ROI and its referenced Act is specified through an ActRelationship of type "subject" (SUBJ), which must always be present.

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

RegionOfInterest.moodCode

The RegionOfInterest.moodCode is fixed to "EVN" or event mood to indicate that this is region of interest, was created.

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.id

The optional RegionOfInterest.id allows for the unique identification of the region of interest.

RegionOfInterest.code

There are 4 types of regions that can be created, they are determined by the RegionOfInterest.code which can take on 1 of the following codes: circle, ellipse, point and polyline.

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

The RegionOfInterest.value units are 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.


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>

5.3.6.8 SubstanceAdministration

Substance Administration

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 [0..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 CS [0..1] D:HumanLanguage Closed
isCriterionInd BL [0..1]
routeCode CE [0..1] D:RouteOfAdministration Open
approachSiteCode 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

The SubstanceAdministration.classCode is fixed to "SBADM" which indicates an act of introducing or otherwise applying a substance to the subject.

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

SubstanceAdministration.moodCode has been bound to the x_DocumentSubstanceMood value set.

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

The optional SubstanceAdministration.id can be used to uniquely identify the substance administration.

SubstanceAdministration.code

The SubstanceAdministration.code has been bound to the ActSubstanceAdministrationCode concept domain.

SubstanceAdministration.actionNegationInd

The SubstanceAdministration.actionNegationInd works as a negative existence quantifier on the actual, intended or described substance administration event. In Event mood, it indicates the defined substance administration did not occur. In Intent mood, it indicates the defined substance administration is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.

The actionNegationInd negates the SubstanceAdministration as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, repeatNumber, isCriterionInd, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode and any of their components.

The remaining properties represent the document characteristics, E.g. SubstanceAdministration.id, SubstanceAdministration.moodCode, SubstanceAdministration.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.

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

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 SubstanceAdministration. The SubstanceAdministration.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

SubstanceAdministration.statusCode

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

Table X: Value set for SubstanceAdministration.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

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

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

SubstanceAdministration.confidentialityCode

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


SubstanceAdministration.repeatNumber

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

SubstanceAdministration.languageCode

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

SubstanceAdministration.isCriterionInd

Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.

SubstanceAdministration.routeCode

The physiological path or route for introducing the therapeutic material into or onto the subject. Route, site of administration (administrationSiteCode), method of administration (methodCode) and the device used in administration are closely related. All four (if present) must be closely coordinated and in agreement. In some cases, the coding system used to specify one may pre-coordinate one or more of the others.

SubstanceAdministration.approachSiteCode

The anatomical site or system through which the procedure reaches its target.

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

The ratio of a quantity to be consumed over the period of time during which it expected to be consumed.

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

A unit for the administered substance.

  1. This attribute SHOULD be used if and only if the material specified as the player of the Role attaching to the consumable participation is not in itself the finished dose form to be administered but a larger whole, pack, etc.
  2. If the material so specified is the proper administered dose form, such as a tablet, capsule, etc. then this attribute SHOULD be valued NULL (not applicable).
  3. If the material so specified is an amorphous substance (liquid, gas, powder, etc.) to be measured as a volume, mass, etc., then this attribute SHOULD remain NULL (not applicable).
  4. If the material so specified is a container, and the content is to be measured as a volume, mass, etc., then this attribute SHOULD be specified as "measured portion".


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>
5.3.6.8.1 consumable

The capture of medication-related information also involves the interrelationship of SubstanceAdministration with several other classes.

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

consumable.typeCode

The consumable.typeCode is fixed to "CSM" to represent a consumable participation.

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

consumable.contextControlCode

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

5.3.6.8.2 ManufacturedProduct

The consumable participation is used to bring in the LabeledDrug or Material entity that describes the administered substance via the ManufacturedProduct role class.

ManufacturedProduct.classCode

The ManufacturedProduct.typeCode is fixed to "MANU" to represent the role of manufactured. The playing role is what was manufactured and the scoping role identifies the manufacturer.

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

An optional unique identifier assigned by the manufacturer.

5.3.6.8.3 LabeledDrug

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.

LabeledDrug.classCode

The LabeledDrug.classCode is fixed to "MMAT" which indicates the substance administered was manufactured.

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

The determinerCode is fixed to "KIND", which indicates that the LabeledDrug referenced, represents a kind or class of Labeled drug.

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

The LabeledDrug.code is bound to the DrugEntity concept domain, which identifies a substance whose therapeutic effect is produced by chemical action within the body.

LabeledDrug.name'

An optional non-unique textual identifier or moniker for the LabeledDrug.

5.3.6.8.4 Material

The Material entity can be used to identify non-drug administered substances such as vaccines and blood products and drugs.

Material.classCode

The Material.classCode is fixed to "MMAT" which indicates the material administered was manufactured.

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

The determinerCode is fixed to "KIND", which indicates that the Material referenced, represents a kind or class of Material.

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

The Material.code is bound to the MaterialEntityClassType concept domain, which identifies types of materials.

Material.name

An optional non-unique textual identifier or moniker for the Material.

Material.desc

A textual or multimedia depiction of the Material.

Material.formCode

The physical state and nature of the material.

Material.lotNumberText

An identifier for a particular batch of manufactured material.

5.3.6.9 Supply

Supply

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.

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 [0..1] D:ActSupplyType Open
actionNegationInd 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..*] D:ActPriority Open
confidentialityCode SET<CE> [0..*] D:Confidentiality Open
repeatNumber IVL<INT> [0..1]
independentInd BL [0..1]
languageCode CS [0..1] D:HumanLanguage Closed
isCriterionInd BL [0..1]
quantity PQ [0..1]
expectedUseTime IVL<TS> [0..1]

Supply.classCode

The Supply.classCode is fixed to "SPLY" which is used to represent a Supply. Supply orders and deliveries are simple Acts that focus on the delivered product. The product is associated with the Supply Act via Participation.typeCode="product". With general Supply Acts, the precise identification of the Material (manufacturer, serial numbers, etc.) is important. Most of the detailed information about the Supply should be represented using the Material class.

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

The Supply.moodCode is bound to the x_ClinicalStatementSubstanceMood value set.

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

The optional Supply.id is used to uniquely identify the supply activity.

Supply.code

The optional Supply.code is bound to the ActSupplyType concept domain, which is used to further define the type of supply for order or distribution. Examples:

  • central supply
  • materials management
  • nurse station supply

Supply.actionNegationInd

The Supply.actionNegationInd works as a negative existence quantifier on the actual, intended or described Supply event. In Event mood, it indicates the defined supply act did not occur. In Intent mood, it indicates the defined supply act is not intended/desired to occur. In Criterion mood, it indicates that the condition is based on the non-occurrence of the event. It is nonsensical to have a negationInd of true for acts with a mood of definition.

The actionNegationInd negates the Supply act as described by the descriptive properties which are: classCode, code, statusCode, effectiveTime, activityTime, priorityCode, repeatNumber, independentInd, isCriterionInd, quantity, expectedUseTime and any of their components.

The remaining properties represent the document characteristics, E.g. Supply.id, Supply.moodCode, Supply.confidentialityCode, and particularly the Author-Participation are not negated. These document characteristic properties always have the same meaning: i.e., the author remains to be the author of the negative observation. Also, most ActRelationships (except for components) are not included in the negation. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.

Supply.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 Supply activity.

Supply.statusCode

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

Table X: Value set for Supply.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

Supply.effectiveTime

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

Supply.activityTime

Supply.activityTime is a time expression specifying when a supply 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 Supply activity occurred, is supposed to occur, is scheduled to occur, etc.

Supply.availabilityTime

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

Supply.priorityCode

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

Supply.confidentialityCode

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

Supply.repeatNumber

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

Supply.independentInd

An indicator specifying whether the Act can be manipulated independently of other Acts or only through a super-ordinate composite Act that has this Act as a component. By default the independentInd should be true. An Act definition is sometimes marked with independentInd=false if the business rules would not allow this act to be ordered without ordering the containing act group.

Supply.languageCode

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


Supply.isCriterionInd

Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.

Supply.quantity

The optional Supply.quantity is used to represent the amount of material that was or is to be supplied.

Supply.expectedUseTime

Th optional Supply.expectedUseTime is used to identify the period time over which the supplied product is expected to be used.

5.3.6.9.1 Product

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

Product.typeCode

The Product.typeCode is fixed to "PRD" which represents a product participation.

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

See ManufacturedProduct (§ 5.3.6.8.2) 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>

5.3.7 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 (§ 5.4)), participants propagated from the header can be overridden within the body.

Entry Participants

5.3.7.1 author @b@

The author participant (described above, see author (§ 5.2.2.2)), 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.

5.3.7.2 consumable

The consumable participant is described above (see Consumable (§ 5.3.6.8.1)).

5.3.7.3 informant @a@

The informant participant is described above (see informant (§ 5.2.2.6)). The 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.

5.3.7.4 participant @a@

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: informant
Attribute Name Data Type Cardinality Code Binding Binding Type
typeCode CS [0..1] INF Fixed
functionCode CE [0..1] D:ParticipationFunction Open
contextControlCode CS [0..1] OP Fixed
time IVL<TS> [0..1]
awarenessCode CE [0..1] D:TargetAwareness Open

participant.typeCode

The participant.typeCode is bound to the v:ParticipationType value set. This enables a wide range of participation types to be selected. Note: Where an existing participation exists, it should be used in preference to the generic participation, failure to do so, will result in needlessly additional complexity for implementations.

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 AUTHEN authenticator
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
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". Any participant(s) defined in a clinical entry, will override the participants with the same typeCode propagating from ancestor elements, in the header, body or sections.

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

participant.time

The time during which the participant is involved in the act through this Participation.

participant.awarenessCode

The extent to which the Entity playing the participating Role is aware of the associated Act. For diagnostic observations, the patient, family member or other participant may not be aware of the patient's terminal illness. Because this attribute typically indicates that awareness is in question, it normally describes a target Participation (e.g., that of a patient). If the awareness, denial, unconsciousness, etc. is the subject of medical considerations (e.g., part of the problem list), explicit observations should be employed: this simple attribute in the Participation cannot represent information sufficient to support medical decision-making.

5.3.7.4.1 ParticipantRole

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).

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

ParticipantRole.classCode

The ParticipantRole.classCode can be any role defined in the V:RoleClassRoot value set, not already provided for the Clinical Statement choice pattern.

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

ParticipantRole.id

The optional participantRole.id is a unique identifier for the player Entity in this Role.

ParticipantRole.code

The optional ParticipantRole.code is bound the the EntityCode concept domain.

ParticipantRole.addr

The optional ParticipantRole.addr is the postal address for the Entity while in the Role.

ParticipantRole.telecom

The optional ParticipantRole.telecom is the telecommunication address (phone number) for the Entity while in the Role.

5.3.7.4.2 Device

Scoping the ParticipantRole is an entity (Entity class).

Table X: Device
Attribute Name Data Type 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

Device.classCode

The Device.classCode is defaulted to "DEV", but can take on any value defined in the EntityClassDevice value set.

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

Device.determinerCode

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

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

Device.code

The optional Device.code is bound to the EntityCode domain.

Device.manufacturerModelName

The optional Device.manufacturerModelName is used to convey a coded name for the device.

Device.softwareName

The optional Device.softwareName is used to convey a coded name for the software used to author content.

5.3.7.4.3 PlayingEntity
Table X: PlayingEntity
Attribute Name Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] DEV Fixed
determinerCode CS [0..1] INSTANCE Fixed
code CE [0..1] D:EntityCode
quantity SET<PQ> [0..*]
name SET<PN> [0..*]
desc ED [0..1]

Note: Support for more than one quantity element in PlayingEntity has been deprecated in CDA R2.1. The CDA R2.1 schema will continue to support multiple quantities for backwards compatibility with CDA R2, but implementers of new templates and document instances are encouraged to support only [0..1] instances.


PlayingEntity.classCode

The PlayingEntity.classCode is bound to the V:EntityClassRoot value set.

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

PlayingEntity.determinerCode

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

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

PlayingEntity.code

The optional PlayingEntity.code is bound to the EntityCode domain. For each Entity, the value for this attribute is drawn from one of several coding systems as suggested by the Entity.classCode, such as living subject (animal and plant taxonomies), chemical substance (e.g., IUPAC code), organization (e.g., CMS provider number), etc. It is possible that Entity.code may be so fine grained that it represents a single instance. An example is the CDC vaccine manufacturer code, modeled as a concept vocabulary, when in fact each concept refers to a single instance. The boundary cases distinguishing codes and identifiers are controversial: this specification allows a certain amount of flexibility.

PlayingEntity.quantity

The optional PlayingEntity.quantity defines the a physical quantity specifying the amount of the physical thing represented by the Entity object, either as a count of the members of a group, or as some other physical quantity. In order to explicitly identify a group of like entities, a static model design should constrain the PQ data type of this attribute to INT, thus providing a count of the entities in the group.

Note: Support for more than one quantity element in PlayingEntity has been deprecated in CDA R2.1. The CDA R2.1 schema will continue to support multiple quantities for backwards compatibility with CDA R2, but implementers of new templates and document instances are encouraged to support only [0..1] instances.

PlayingEntity.name

Most entities have a commonly used name that can be used to differentiate them from other Entities, but that does not provide a necessarily unique identifier.

PlayingEntity.desc

A textual or multimedia depiction of the Entity.

5.3.7.4.4 Entity

A physical thing, group of physical things or an organization capable of participating in Acts while in a role.

Table X: Entity
Attribute Name Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] ENT Fixed
determinerCode CS [0..1] INSTANCE Fixed
id SET<II> [0..*]
code CE [0..1] D:EntityCode
desc ED [0..1]

Entity.classCode

The Entity.classCode is bound to the V:EntityClassRoot value set.

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

Entity.determinerCode

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

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

Entity.id

The optional Entity.id is used to uniquely identify the Entity.

Entity.code

The optional Entity.code is bound to the EntityCode domain.

Entity.desc

The optional Entity.desc is a textual or multimedia depiction of the Entity.

5.3.7.5 performer @a@

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: performer
Attribute Name Data Type Cardinality Code Binding Binding Type
typeCode CS [0..1] PRF Fixed
functionCode CE [0..1] D:ParticipationFunction Open
time IVL<TS> [0..1]
modeCode CE [0..1] D:ParticipationMode Fixed

performer.typeCode

The performer.typeCode is fixed to "PRF" which indicates a person, or organization that actually and principally carries out the action. Need not be the principal responsible actor.

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

performer.functionCode

The performer.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).


performer.time

An optional interval of time which indicating the performer's participation in the associated Act.

performer.modeCode

The modality by which the Entity playing the Role is participating in the Act.

5.3.7.5.1 AssignedEntity @g@

A performer is an entity in the role of assigned entity (see AssignedEntity (§ 5.2.2.1.1)).

5.3.7.5.2 Person @i@

An assigned entity is a person assigned to the role by the scoping organization. The entity playing the role is a person (see Person (§ 5.2.2.2.2)).

5.3.7.5.3 Organization @j@

The entity scoping the role is an organization (see Organization (§ 5.2.2.1.3)).

5.3.7.6 product @a@

The product participant is described above (see product (§ 5.3.6.9.1)).

5.3.7.7 specimen

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: informant
Attribute Name Data Type Cardinality Code Binding Binding Type
typeCode CS [0..1] SPC Fixed

specimen.typeCode

The specimen.typeCode is fixed to "SPC" to indicate the subject of non-clinical (e.g. laboratory) observation services is a specimen.

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

A role played by a material entity that is a specimen for an act.

Table X: AssignedAuthor
Attribute Name Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] SPEC Fixed
id SET<II> [0..*]

SpecimenRole.classCode

The SpecimenRole.classCode is fixed to "SPEC".

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

SpecimenRole.id

An optional SpecimenRole.id can be used to uniquely identify the specimen.

5.3.7.7.2 PlayingEntity @a@

A specimen is an PlayingEntity in the role of SpecimenRole (PlayingEntity (§ 5.3.7.4.3)).

5.3.7.8 subject @a@

The subject participant (described above, see subject (§ 5.3.3.3)), 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.

5.3.8 Entry Relationships

5.3.8.1 component @c@

The component relationship has a source of Organizer (see Organizer (§ 5.3.6.5)), and a target that is another CDA entry, and is used to create groupings of CDA entries within an Organizer.

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

component.typeCode

The component.typeCode is fixed to "COMP", which indicates that the associated Clinical Statement choice is a component part of the 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

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.

component.sequenceNumber

The optional component.sequenceNumber is an integer specifying the relative sequential ordering of this relationship among other like-types relationships having the same source Act.

component.seperatableInd

The optional component.seperatableInd is an indication that the source Act is intended to be interpreted independently of the target Act. The default value is true.

5.3.8.2 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: precondition Attributes
Attribute Name Data Type Cardinality Code Binding Binding Type
typeCode CS [0..1] PRCN Fixed

precondition.typeCode

The precondition.typeCode is fixed to PRCN which indicates a requirement to be true before a service is performed. The target can be any service in criterion mood. For multiple pre-conditions a conjunction attribute (AND, OR, XOR) is applicable.

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
5.3.8.2.1 Criterion

Criterion class is used to express a condition that must hold true before some over activity occurs.

Table X: Criterion Attributes
RIM Attribute(s) Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] <= OBS is V:ActClassObservation Closed w/ Default
moodCode CS [0..1] ENV.CRT Fixed
code CD [1..1] D:ActCode Open
actonNegationInd BL [0..1]
text ED [0..1]
isCriterionInd BL [0..1]
value SET<ANY> [0..*] D:ObservationValue Open
valueNegationInd BL [0..1]
interpretationCode SET<CE> [0..*] D:ObservationInterpretation Open

Criterion.classCode

The Criterion.classCode is defaulted to "OBS" which represents an observation, but can take only any value defined in the ActClassObservation value set.

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

Criterion.moodCode

The Criterion.moodCode is fixed to "EVN.CRT" which indicates a criterion or condition over service events that must apply for an associated service to be considered.

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

Criterion.code

The particular kind of Criterion that the Criterion-instance represents. Criterion.code, if used, SHALL be a specialization of the Criterion.classCode. This attribute defines a specific sub-type of a given Criterion type. It allows the use of rich terminologies such as LOINC and SNOMED to represent sub-types of the Criterion. The Criterion.code is bound to the ActCode concept domain.

Criterion.actionNegationInd

The Criterion.actionNegationInd indicates that the condition is based on the non-occurrence of the event.

The actionNegationInd negates the Criterion as described by the descriptive properties which are: classCode, code, isCriterionInd, value, valueNegationInd, interpretationCode and any of their components.

The remaining properties represent the document characteristics, E.g. Criterion.moodCode, Criterion.text are not negated. Refer to the attribute isDocumentCharacteristic property and the ActRelationshipType and ParticipationType code system isDocumentCharacteristic properties for specific guidance.

Criterion.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 Criterion. The Criterion.text attribute can reference the associated narrative content in the section using the XML ID attribute added to the Narrative Text elements.

Criterion.isCriterionInd

Is defaulted to false, when set to true it indicates that the data conveyed by the act, including outbound associations, represent "criteria" for some other act, not a "real" act. I.e. If an Act exists with a classCode of ACT and a moodCode of RQO and isCriterionInd is true, it does not represent an order for an act. Rather, it represents a criteria that will match on all orders.


Criterion.value

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

Criterion.valueNegationInd

Criterion.valueNegationInd, indicates that the Criterion, as defined in in this Criterion class is NOT true. Note: This attribute should only be used when the terminology used for Criterion.value is not itself capable of expressing negated findings. (E.g. ICD9).

Criterion.interpretationCode

A qualitative interpretation of the Criterion. 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."

5.3.8.3 referenceRange

The referenceRange relationship (see Observation (§ 5.3.6.3)), has a source of Observation, and a target of ObservationRange.

5.3.8.4 entryRelationship

Entry Relationship

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).

Table X: entryRelationship Attributes
Attribute Name Data Type Cardinality Code Binding Binding Type
typeCode CS [0..1] V:ActRelationshipType Closed
inversionInd BL [0..1]
contextConductionInd BL [0..1]
sequenceNumber INT [0..1]
negationInd BL [0..1]
seperatableInd BL [0..1]

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.

entryRelationship.typeCode

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 value set 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.

entryRelationship.inversionInd

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.

entryRelationship.contextConductionInd

The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute (see CDA Context (§ 5.4)) 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.

entryRelationship.sequenceNumber

An integer specifying the relative sequential ordering of this relationship among other like-types relationships having the same source Act.

entryRelationship.negationInd

An indicator that asserts that the meaning of the link is negated.

entryRelationship.seperatableInd

An indication that the source Act is intended to be interpreted independently of the target Act. The value is defaulted to true.

5.3.8.5 reference

External

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".

Table X: reference Attributes
Attribute Name Data Type Cardinality Code Binding Binding Type
typeCode CS [0..1] V:ActRelationshipExternalReference Fixed
seperatableInd BL [0..1]


reference.typeCode

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 SUBJ has subject
Code System: ActRelationshipType (HL7) Code System OID: 2.16.840.1.113883.5.1002

reference.seperatableInd

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.


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: EXAMPLE entryRelationship 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.


5.3.8.5.1 ExternalAct

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

Table X: ExternalAct Attributes
Attribute Name Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] <= ACT is V:ActClassRoot Closed w/ Default
moodCode CS [0..1] EVN Fixed
id II [1..*]
code CD [0..1] D:ActCode Open
text ED [0..1]

ExternalAct.classCode

The ExternalAct.classCode is bound to the ActClassRoot value set.

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

ExternalAct.moodCode

The ExternalAct.moodCode is fixed to "EVN" which represents the event mood. Indicating that the act has taken place and this is information about that act.

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

ExternalAct.id

The unique instance identifier for the ExternalAct.

ExternalAct.code

The particular kind of Act that the Act-instance represents within its class. ExternalAct.code, if used, SHALL be a specialization of the ExternalAct.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 ExternalAct.code is bound to the ActCode concept domain.

ExternalAct.text

A reference to a renderable textual or multimedia description of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the ExternalAct.

5.3.8.5.2 ExternalDocument

The 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: ExternalDocument Attributes
Attribute Name Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] <=DOC is V:ActClassDocument Closed w/ Default
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]

ExternalDocument.classCode

The ExternalDocument.classCode is fixed to "DOCCLIN"

Table X: Fixed 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

ExternalDocument..moodCode

The ExternalDocument.moodCode is fixed to "EVN" which represents the event mood. Indicating that the document has been created and is available.

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

ExternalDocument.id

The unique instance identifier for the ExternalDocument.

ExternalDocument.code

The ExternalDocument.code is bound to the DocumentType concept domain.

ExternalDocument.text

A reference to the external document.

ExternalDocument.setId

The ExternalDocument.setId is an optional identifier that does not change with revisions to a document.

ExternalDocument.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 r2b datatypes. 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.

5.3.8.5.3 ExternalObservation

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

Table X: ExternalObservation Attributes
Attribute Name Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] <= OBS is V:ActClassObservation Closed w/ Default
moodCode CS [0..1] EVN Fixed
id II [1..*]
code CD [0..1] D:ActCode Open
text ED [0..1]

ExternalObservation.classCode

The ExternalObservation.classCode is defaulted to "OBS" in indicate an observation, but be be set to any code in the ActCode concept domain.

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

ExternalObservation.moodCode

The ExternalObservation.moodCode is fixed to "EVN" which represents the event mood. Indicating that the observation has taken place and this is information about that observation.

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

ExternalObservation.id

The unique instance identifier for the ExternalObservation.

ExternalObservation.code

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

ExternalObservation.text

A reference to a renderable textual or multimedia description of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the ExternalObservation.

5.3.8.5.4 ExternalProcedure

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

Table X: ExternalProcedure Attributes
Attribute Name Data Type Cardinality Code Binding Binding Type
classCode CS [0..1] PROC Fixed
moodCode CS [0..1] EVN Fixed
id II [1..*]
code CD [0..1] D:ActCode Open
text ED [0..1]

ExternalProcedure.classCode

The ExternalProcedure.classCode is fixed to "PROC".

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

ExternalProcedure.moodCode

The ExternalProcedure.moodCode is fixed to "EVN" which represents the event mood. Indicating that the procedure has taken place and this is information about that procedure.

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

ExternalProcedure.id

The unique instance identifier for the ExternalProcedure.

ExternalProcedure.code

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

ExternalProcedure.text

A reference to a renderable textual or multimedia description of the complete information which would reasonably be expected to be displayed to a human reader conveyed by the ExternalProcedure.

6 CDA Hierarchical Description

(content on separate page)

7 CDA XML Implementation

(content on separate page)

8 Appendix

(content on separate page)

Retrieved from "https://pubwiki.hl7.org/w/index.php?title=Body&oldid=1975"