The value for “ClinicalDocument / code” SHALL be “34133-9” “Summarization of episode note” 2.16.840.1.113883.6.1 LOINC STATIC 2.1 13 A CCD SHALL contain exactly one ClinicalDocument / documentationOf / serviceEvent 2.1 14 The value for “ClinicalDocument / documentationOf / serviceEvent / @classCode” SHALL be “PCPR” “Care provision” 2.16.840.1.113883.5.6 ActClass STATIC 2.1 14 ClinicalDocument / documentationOf / serviceEvent SHALL contain exactly one serviceEvent / effectiveTime / low and exactly one serviveEvent / effectiveTime / high 2.1 14 CCD SHALL contain exactly one ClinicalDocument / languageCode 2.2 14 ClinicalDocument / languageCode SHALL be in the form nn, or nn-CC. The nn portion SHALL be an ISO-639-1 language code in lower case. The CC portion, if present, SHALL be an ISO-3166 country code in upper case 2.2 14 CCD SHALL contain one or more ClinicalDocument / templateId 2.3 14 At least one ClinicalDocument / templateId SHALL value ClinicalDocument / templateId / @root with “2.16.840.1.113883.10.20.1”, and SHALL NOT contain ClinicalDocument / templateId / @extension 2.3 14 ClinicalDocument / effectiveTime SHALL be expressed with precision to include seconds 2.4 14 ClinicalDocument / effectiveTime SHALL include an explicit time zone offset 2.4 14 CCD shall contain one to two ClinicalDocument / recordTarget 2.5 15 CCD SHALL contain one or more ClinicalDocument / author / assignedAuthor / assignedPerson and/or ClinicalDocument / author / assignedAuthor / representedOrganization 2.6 15 If author has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument / author / assignedAuthor / id / @NullFlavor” SHALL be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC 2.6 15 CCD MAY contain one or more ClinicalDocument / informationRecipient 2.7 15 CCD MAY contain exactly one and SHALL NOT contain more than one Purpose section (templateId 2.16.840.1.113883.10.20.1.13). The Purpose section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more purpose activities (templateId 2.16.840.1.113883.10.20.1.30) 2.8 15 The purpose section SHALL contain Section / code 2.8.1 15 The value for “Section / code” SHALL be “48764-5” “Summary purpose” 2.16.840.1.113883.6.1 LOINC STATIC 2.8.1 16 The purpose section SHALL contain Section / title 2.8.1 16 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “purpose” 2.8.1 16 A purpose activity (templateId 2.16.840.1.113883.10.20.1.30) SHALL be represented with Act 2.8.2.1 16 The value for “Act / @classCode” in a purpose activity SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC 2.8.2.1 17 The value for “Act / @moodCode” in a purpose activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 2.8.2.1 17 A purpose activity SHALL contain exactly one Act / statusCode 2.8.2.1 17 The value for “Act / statusCode” in a purpose activity SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 2.8.2.1 17 A purpose activity SHALL contain exactly one Act / code, with a value of “23745001” “Documentation procedure” 2.16.840.1.113883.6.96 SNOMED CT STATIC 2.8.2.1 17 A purpose activity SHALL contain exactly one Act / entryRelationship / @typeCode, with a value of “RSON” “Has reason” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC, to indicate the reason or purpose for creating the CCD 2.8.2.1 17 The target of Act / entryRelationship / @typeCode in a purpose activity SHALL be an Act, Encounter, Observation, Procedure, SubstanceAdministration, or Supply 2.8.2.1 17 The value for “ClinicalDocument / component / structuredBody / component / section / entry / @typeCode” MAY be “DRIV” “is derived from” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC, to indicate that the CDA Narrative Block is fully derived from the structured entries 3 19 A CCD entry SHOULD explicitly reference its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1 <content>) 3 19 CCD SHOULD contain exactly one and SHALL NOT contain more than one Payers section (templateId 2.16.840.1.113883.10.20.1.9). The Payers section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more coverage activities (templateId 2.16.840.1.113883.10.20.1.20) 3.1 20 The payer section SHALL contain Section / code 3.1.1 20 The value for “Section / code” SHALL be “48768-6” “Payment sources” 2.16.840.1.113883.6.1 LOINC STATIC 3.1.1 20 The payer section SHALL contain Section / title 3.1.1 20 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “insurance” or “payers” 3.1.1 20 A coverage activity (templateId 2.16.840.1.113883.10.20.1.20) SHALL be represented with Act 3.1.2.1.1 21 The value for “Act / @classCode” in a coverage activity SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC 3.1.2.1.1 21 The value for “Act / @moodCode” in a coverage activity SHALL be “DEF” 2.16.840.1.113883.5.1001 ActMood STATIC 3.1.2.1.1 21 A coverage activity SHALL contain at least one Act / id 3.1.2.1.1 21 A coverage activity SHALL contain exactly one Act / statusCode 3.1.2.1.1 21 The value for “Act / statusCode” in a coverage activity SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.1.2.1.1 21 A coverage activity SHALL contain exactly one Act / code 3.1.2.1.1 21 The value for “Act / code” in a coverage activity SHALL be “48768-6” “Payment sources” 2.16.840.1.113883.6.1 LOINC STATIC 3.1.2.1.1 21 A coverage activity SHALL contain one or more Act / entryRelationship 3.1.2.1.1 21 An entryRelationship in a coverage activity MAY contain exactly one entryRelationship / sequenceNumber, which serves to prioritize the payment sources 3.1.2.1.1 22 The value for “Act / entryRelationship / @typeCode” in a coverage activity SHALL be “COMP” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.1.2.1.1 22 The target of a coverage activity SHALL be a policy activity (templateId 2.16.840.1.113883.10.20.1.26) 3.1.2.1.1 22 A coverage activity SHALL contain one or more sources of information, as defined in section 5.2 Source 3.1.2.1.1 22 A policy activity (templateId 2.16.840.1.113883.10.20.1.26) SHALL be represented with Act 3.1.2.1.2 22 The value for “Act / @classCode” in a policy activity SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC 3.1.2.1.2 22 The value for “Act / @moodCode” in a policy activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.1.2.1.2 22 A policy activity SHALL contain at least one Act / id, which represents the group or contract number related to the insurance policy or program 3.1.2.1.2 22 A policy activity SHALL contain exactly one Act / statusCode 3.1.2.1.2 22 The value for “Act / statusCode” in a policy activity SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.1.2.1.2 22 A policy activity SHOULD contain zero to one Act / code., which represents the type of coverage 3.1.2.1.2 22 The value for “Act / code” in a policy activity SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.19832 ActCoverageType DYNAMIC 3.1.2.1.2 22 A policy activity SHALL contain exactly one Act / performer [@typeCode=”PRF”], representing the payer 3.1.2.1.2 22 A payer in a policy activity SHALL contain one or more performer / assignedEntity / id, to represent the payer identification number. For pharamacy benefit programs this can be valued using the RxBIN and RxPCN numbers assigned by ANSI and NCPDP respectively. When a nationally recognized payer identification number is available, it would be placed here 3.1.2.1.2 22 A policy activity SHALL contain exactly one Act / participant [@typeCode=”COV”], representing the covered party 3.1.2.1.2 22 A covered party in a policy activity SHOULD contain one or more participant / participantRole / id, to represent the patient’s member or subscriber identifier with respect to the payer 3.1.2.1.2 22 A covered party in a policy activity SHOULD contain exactly one participant / participantRole / code, to represent the reason for coverage (e.g. Self, Family dependent, student) 3.1.2.1.2 22 The value for “participant / participantRole / code” in a policy activity’s covered party MAY be selected from ValueSet 2.16.840.1.113883.1.11.19809 PolicyOrProgramCoverageRoleType DYNAMIC 3.1.2.1.2 23 A covered party in a policy activity MAY contain exactly one participant / time, to represent the time period over which the patient is covered 3.1.2.1.2 23 A policy activity MAY contain exactly one Act / participant [@typeCode=”HLD”], representing the subscriber 3.1.2.1.2 23 A subscriber in a policy activity SHOULD contain one or more participant / participantRole / id, to represent the subscriber’s identifier with respect to the payer 3.1.2.1.2 23 A subscriber in a policy activity MAY contain exactly one participant / time, to represent the time period for which the subscriber is enrolled 3.1.2.1.2 23 The value for “Act / entryRelationship / @typeCode” in a policy activity SHALL be “REFR” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.1.2.1.2 23 The target of a policy activity with Act / entryRelationship / @typeCode=”REFR” SHALL be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) or an Act, with Act [@classCode = “ACT”] and Act [@moodCode = “DEF”], representing a description of the coverage plan 3.1.2.1.2 23 A description of the coverage plan SHALL contain one or more Act / Id, to represent the plan identifier 3.1.2.1.2 23 An authorization activity (templateId 2.16.840.1.113883.10.20.1.19) SHALL be represented with Act 3.1.2.1.3 23 The value for “Act / @classCode” in an authorization activity SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC 3.1.2.1.3 23 An authorization activity SHALL contain at least one Act / id 3.1.2.1.3 23 The value for “Act / @moodCode” in an authorization activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.1.2.1.3 23 An authorization activity SHALL contain one or more Act / entryRelationship 3.1.2.1.3 23 The value for “Act / entryRelationship / @typeCode” in an authorization activity SHALL be “SUBJ” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.1.2.1.3 23 The target of an authorization activity with Act / entryRelationship / @typeCode=”SUBJ” SHALL be a clinical statement with moodCode = “PRMS” (Promise) 3.1.2.1.3 23 The target of an authorization activity MAY contain one or more performer, to indicate the providers that have been authorized to provide treatment 3.1.2.1.3 23 CCD SHOULD contain exactly one and SHALL NOT contain more than one Advance directives section (templateId 2.16.840.1.113883.10.20.1.1). The Advance directives section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more advance directive observations (templateId 2.16.840.1.113883.10.20.1.17). An advance directive observation MAY contain exactly one advance directive reference (templateId 2.16.840.1.113883.10.20.1.36) to an external advance directive document 3.2 24 The advance directive section SHALL contain Section / code 3.2.1 24 The value for “Section / code” SHALL be “42348-3” “Advance directives” 2.16.840.1.113883.6.1 LOINC STATIC 3.2.1 24 The advance directive section SHALL contain Section / title 3.2.1 24 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “advance directives” 3.2.1 24 An advance directive observation (templateId 2.16.840.1.113883.10.20.1.17) SHALL be represented with Observation 3.2.2.1 25 The value for “Observation / @classCode” in an advance directive observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 3.2.2.1 25 The value for “Observation / @moodCode” in an advance directive observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.2.2.1 25 An advance directive observation SHALL contain at least one Observation / id 3.2.2.1 25 An advance directive observation SHALL contain exactly one Observation / statusCode 3.2.2.1 25 The value for “Observation / statusCode” in an advance directive observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.2.2.1 25 An advance directive observation SHOULD contain exactly one Observation / effectiveTime, to indicate the effective time of the directive 3.2.2.1 25 An advance directive observation SHALL contain exactly one Observation / code 3.2.2.1 25 The value for “Observation / code” in an advance directive observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.2 AdvanceDirectiveTypeCode STATIC 20061017 3.2.2.1 25 There SHOULD be an advance directive observation whose value for “Observation / code” is “304251008” “Resuscitation status” 2.16.840.1.113883.6.96 SNOMED CT STATIC 3.2.2.1 25 A verification of an advance directive observation (templateId 2.16.840.1.113883.10.20.1.58) SHALL be represented with Observation / participant 3.2.2.1 25 An advance directive observation MAY include one or more verifications 3.2.2.1 25 The value for “Observation / participant / @typeCode” in a verification SHALL be “VRF” “Verifier” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.2.2.1 25 A verification of an advance directive observation SHOULD contain Observation / participant / time 3.2.2.1 25 The data type of Observation / participant / time in a verification SHALL be TS (time stamp) 3.2.2.1 25 An advance directive observation SHALL contain one or more sources of information, as defined in section 5.2 Source 3.2.2.1 25 An advance directive observation SHALL contain exactly one advance directive status observation 3.2.2.2 26 An advance directive status observation (templateId 2.16.840.1.113883.10.20.1.37) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values) 3.2.2.2 26 The value for “Observation / value” in an advance directive status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.1 AdvanceDirectiveStatusCode STATIC 20061017 3.2.2.2 26 An advance directive reference (templateId 2.16.840.1.113883.10.20.1.36) SHALL be represented with Observation / reference / ExternalDocument 3.2.2.3 26 An advance directive observation MAY contain exactly one advance directive reference 3.2.2.3 26 The value for “Observation / reference / @typeCode” in an advance directive reference SHALL be “REFR” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.2.2.3 26 ExternalDocument SHALL contain at least one ExternalDocument / id 3.2.2.3 26 The URL of a referenced advance directive document MAY be present, and SHALL be represented in Observation / reference / ExternalDocument / text / reference. A <linkHTML> element containing the same URL SHOULD be present in the associated CDA Narrative Block 3.2.2.3 26 The MIME type of a referenced advance directive document MAY be present, and SHALL be represented in Observation / reference / ExternalDocument / text / @mediaType 3.2.2.3 26 Where the value of Observation / reference / seperatableInd is “false”, the referenced advance directive document SHOULD be included in the CCD exchange package. The exchange mechanism SHOULD be based on Internet standard RFC 2557 “MIME Encapsulation of Aggregate Documents, such as HTML (MHTML)” (http://www.ietf.org/rfc/rfc2557.txt). (See CDA Release 2, section 3 “CDA Document Exchange in HL7 Messages” for examples and additional details) 3.2.2.3 26 CCD MAY contain one or more patient guardians 3.3 26 A patient guardian SHALL be represented with ClinicalDocument / recordTarget / patientRole / patient / guardian 3.3 27 CCD MAY contain one or more next of kin 3.3 27 A next of kin SHALL be represented with ClinicalDocument / participant / associatedEntity 3.3 27 The value for “ClinicalDocument / participant / @typeCode” in a next of kin participant SHALL be “IND” “Indirect participant” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.3 27 The value for “ClinicalDocument / participant / associatedEntity / @classCode” in a next of kin participant SHALL be “NOK” “Next of kin” 2.16.840.1.113883.5.41 EntityClass STATIC 3.3 27 The value for “ClinicalDocument / participant / associatedEntity / code” in a next of kin participant SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.19579 FamilyHistoryRelatedSubjectCode DYNAMIC or 2.16.840.1.113883.1.11.20.21 FamilyHistoryPersonCode DYNAMIC 3.3 27 CCD MAY contain one or more emergency contact 3.3 27 An emergency contact SHALL be represented with ClinicalDocument / participant / associatedEntity 3.3 27 The value for “ClinicalDocument / participant / @typeCode” in an emergency contact participant SHALL be “IND” “Indirect participant” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.3 27 The value for “ClinicalDocument / participant / associatedEntity / @classCode” in an emergency contact participant SHALL be “ECON” “Emergency contact” 2.16.840.1.113883.5.41 EntityClass STATIC 3.3 27 CCD MAY contain one or more patient caregivers 3.3 27 A patient caregiver SHALL be represented with ClinicalDocument / participant / associatedEntity 3.3 27 The value for “ClinicalDocument / participant / @typeCode” in a patient caregiver participant SHALL be “IND” “Indirect participant” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.3 27 The value for “ClinicalDocument / participant / associatedEntity / @classCode” in a patient caregiver participant SHALL be “CAREGIVER” “Caregiver” 2.16.840.1.113883.5.41 EntityClass STATIC 3.3 27 CCD SHOULD contain exactly one and SHALL NOT contain more than one Functional status section (templateId 2.16.840.1.113883.10.20.1.5). The Functional status section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more problem acts (templateId 2.16.840.1.113883.10.20.1.27) and/or result organizers (templateId 2.16.840.1.113883.10.20.1.32) 3.4 28 The functional status section SHALL contain Section / code 3.4.1 28 The value for “Section / code” SHALL be “47420-5” “Functional status assessment” 2.16.840.1.113883.6.1 LOINC STATIC 3.4.1 28 The functional status section SHALL contain Section / title 3.4.1 28 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “functional status” 3.4.1 28 A problem observation or result observation in the functional status section SHALL contain exactly one observation / code 3.4.2 28 The value for “Observation / code” in a problem observation or result observation in the functional status section MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.6 FunctionalStatusTypeCode STATIC 20061017 3.4.2 28 If the functional status was collected using a standardized assessment instrument, then the instrument itself SHOULD be represented in the “Organizer / code” of a result organizer, with a value selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96) 3.4.2 29 If the functional status was collected using a standardized assessment instrument, then the question within that instrument SHOULD be represented in the “Observation / code” of a result observation, with a value selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96) 3.4.2 29 If the functional status was collected using a standardized assessment instrument containing questions with enumerated values as answers, then the answer SHOULD be represented in the “Observation / value” of a result observation 3.4.2 29 If Observation / value in a result observation in the functional status section is of data type CE or CD, then it SHOULD use the same code system used to code the question in Observation / code 3.4.2 29 Observation / value in a result observation in the functional status section MAY be of datatype CE or CD and MAY contain one or more Observation / value / translation, to represent equivalent values from other code systems 3.4.2 29 A problem observation or result observation in the functional status section MAY use codes from the International Classification of Functioning, Disability, and Health (ICF, http://www.who.int/classifications/icf/en/) (codeSystem 2.16.840.1.113883.6.254) 3.4.2 29 A problem observation in the functional status section SHALL contain exactly one status of functional status observation 3.4.2.1 29 A result observation in the functional status section SHALL contain exactly one status of functional status observation 3.4.2.1 29 A status of functional status observation (templateId 2.16.840.1.113883.10.20.1.44) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values) 3.4.2.1 29 The value for “Observation / value” in a status of functional status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.5 StatusOfFunctionalStatusCode STATIC 20061017 3.4.2.1 29 CCD SHOULD contain exactly one and SHALL NOT contain more than one Problem section (templateId 2.16.840.1.113883.10.20.1.11). The Problem section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more problem acts (templateId 2.16.840.1.113883.10.20.1.27). A problem act SHOULD include one or more problem observations (templateId 2.16.840.1.113883.10.20.1.28) 3.5 29 The problem section SHALL contain Section / code 3.5.1 30 The value for “Section / code” SHALL be “11450-4” “Problem list” 2.16.840.1.113883.6.1 LOINC STATIC 3.5.1 30 The problem section SHALL contain Section / title 3.5.1 30 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “problems” 3.5.1 30 A problem act (templateId 2.16.840.1.113883.10.20.1.27) SHALL be represented with Act 3.5.2.1.1 31 The value for “Act / @classCode” in a problem act SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC 3.5.2.1.1 31 The value for “Act / @moodCode” in a problem act SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.5.2.1.1 31 A problem act SHALL contain at least one Act / id 3.5.2.1.1 31 The value for “Act / code / @NullFlavor” in a problem act SHALL be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC 3.5.2.1.1 31 A problem act MAY contain exactly one Act / effectiveTime, to indicate the timing of the concern (e.g. the interval of time for which the problem is a concern) 3.5.2.1.1 31 A problem act SHALL contain one or more Act / entryRelationship 3.5.2.1.1 31 A problem act MAY reference a problem observation, alert observation (see section 3.8 Alerts) or other clinical statement that is the subject of concern, by setting the value for “Act / entryRelationship / @typeCode” to be “SUBJ” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.5.2.1.1 31 The target of a problem act with Act / entryRelationship / @typeCode=”SUBJ” SHOULD be a problem observation (in the Problem section) or alert observation (in the Alert section, see section 3.8 Alerts), but MAY be some other clinical statement 3.5.2.1.1 31 A problem observation (templateId 2.16.840.1.113883.10.20.1.28) SHALL be represented with Observation 3.5.2.1.2 31 The value for “Observation / @moodCode” in a problem observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.5.2.1.2 31 A problem observation SHALL include exactly one Observation / statusCode 3.5.2.1.2 31 The value for “Observation / statusCode” in a problem observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.5.2.1.2 32 A problem observation SHOULD contain exactly one Observation / effectiveTime, to indicate the biological timing of condition (e.g. the time the condition started, the onset of the illness or symptom, the duration of a condition) 3.5.2.1.2 32 The value for “Observation / code” in a problem observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.14 ProblemTypeCode STATIC 20061017 3.5.2.1.2 32 The value for “Observation / entryRelationship / @typeCode” in a problem observation MAY be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC to reference an age observation (templateId 2.16.840.1.113883.10.20.1.38) 3.5.2.1.2 32 A problem observation SHALL contain one or more sources of information, as defined in section 5.2 Source 3.5.2.1.2 32 A problem observation MAY contain exactly one problem status observation 3.5.2.2 32 A problem status observation (templateId 2.16.840.1.113883.10.20.1.50) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values) 3.5.2.2 32 The value for “Observation / value” in a problem status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.13 ProblemStatusCode STATIC 20061017 3.5.2.2 32 A problem observation MAY contain exactly one problem healthstatus observation 3.5.2.2 32 A problem healthstatus observation (templateId 2.16.840.1.113883.10.20.1.51) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values), except that the value for “Observation / code” in a problem healthstatus observation SHALL be “11323-3” “Health status” 2.16.840.1.113883.6.1 LOINC STATIC 3.5.2.2 32 The value for “Observation / value” in a problem healthstatus observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.12 ProblemHealthStatusCode STATIC 20061017 3.5.2.2 32 A problem act MAY contain exactly one episode observation 3.5.2.3 33 An episode observation (templateId 2.16.840.1.113883.10.20.1.41) SHALL be represented with Observation 3.5.2.3 33 The value for “Observation / @classCode” in an episode observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 3.5.2.3 33 The value for “Observation / @moodCode” in an episode observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.5.2.3 33 An episode observation SHALL include exactly one Observation / statusCode 3.5.2.3 33 The value for “Observation / statusCode” in an episode observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.5.2.3 33 The value for “Observation / Code” in an episode observation SHOULD be “ASSERTION” 2.16.840.1.113883.5.4 ActCode STATIC 3.5.2.3 33 “Observation / value” in an episode observation SHOULD be the following SNOMED CT expression 3.5.2.3 33 An episode observation SHALL be the source of exactly one entryRelationship whose value for “entryRelationship / @typeCode” is “SUBJ” “Has subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC. This is used to link the episode observation to the target problem act or social history observation 3.5.2.3 33 An episode observation MAY be the source of one or more entryRelationship whose value for “entryRelationship / @typeCode” is “SAS” “Starts after start” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC. The target of the entryRelationship SHALL be a problem act or social history observation. This is used to represent the temporal sequence of episodes 3.5.2.3 33 Patient awareness (templateId 2.16.840.1.113883.10.20.1.48) of a problem, observation, or other clinical statement SHALL be represented with participant 3.5.2.4 33 A problem act MAY contain exactly one patient awareness 3.5.2.4 33 A problem observation MAY contain exactly one patient awareness 3.5.2.4 33 The value for “participant / @typeCode” in a patient awareness SHALL be “SBJ” “Subject” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.5.2.4 33 Patient awareness SHALL contain exactly one participant / awarenessCode 3.5.2.4 33 Patient awareness SHALL contain exactly one participant / participantRole / id 3.5.2.4 34 which SHALL have exactly one value, which SHALL also be present in ClinicalDocument / recordTarget / patientRole / id 3.5.2.4 34 CCD SHOULD contain exactly one and SHALL NOT contain more than one Family history section (templateId 2.16.840.1.113883.10.20.1.4). The Family history section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more family history observations (templateId 2.16.840.1.113883.10.20.1.22), which MAY be contained within family history organizers (templateId 2.16.840.1.113883.10.20.1.23) 3.6 34 The family history section SHALL contain Section / code 3.6.1 34 The value for “Section / code” SHALL be “10157-6” “History of family member diseases” 2.16.840.1.113883.6.1 LOINC STATIC 3.6.1 34 The family history section SHALL contain Section / title 3.6.1 34 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “family history” 3.6.1 34 The family history section SHALL NOT contain Section / subject 3.6.1 34 A family history observation (templateId 2.16.840.1.113883.10.20.1.22) SHALL be represented with Observation 3.6.2.1.1 35 The value for “Observation / @moodCode” in a family history observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.6.2.1.1 35 A family history observation SHALL contain at least one Observation / id 3.6.2.1.1 35 A family history observation SHALL include exactly one Observation / statusCode 3.6.2.1.1 35 The value for “Observation / statusCode” in a family history observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.6.2.1.1 35 A family history observation SHOULD include Observation / effectiveTime. (See also section 3.6.2.4 Representation of age) 3.6.2.1.1 35 A family history cause of death observation (templateId 2.16.840.1.113883.10.20.1.42) SHALL conform to the constraints and is a kind of family history observation (templateId 2.16.840.1.113883.10.20.1.22) 3.6.2.1.1 35 A family history cause of death observation SHALL contain one or more entryRelationship / @typeCode 3.6.2.1.1 35 The value for at least one “entryRelationship / @typeCode” in a family history cause of death observation SHALL be “CAUS” “is etiology for” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC, with a target family history observation of death 3.6.2.1.1 35 A family history observation SHALL contain one or more sources of information, as defined in section 5.2 Source 3.6.2.1.1 36 A family history organizer (templateId 2.16.840.1.113883.10.20.1.23) SHALL be represented with Organizer 3.6.2.1.2 36 The value for “Organizer / @classCode” in a family history organizer SHALL be “CLUSTER” 2.16.840.1.113883.5.6 ActClass STATIC 3.6.2.1.2 36 The value for “Organizer / @moodCode” in a family history organizer SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.6.2.1.2 36 A family history organizer SHALL contain exactly one Organizer / statusCode 3.6.2.1.2 36 The value for “Organizer / statusCode” in a family history organizer SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.6.2.1.2 36 A family history organizer SHALL contain one or more Organizer / component 3.6.2.1.2 36 The target of a family history organizer Organizer / component relationship SHOULD be a family history observation, but MAY be some other clinical statement 3.6.2.1.2 36 The representation of “status” values in the family history section is the same as the representation in the problems section 3.6.2.2 36 A family history observation act MAY contain exactly one problem status observation (templateId 2.16.840.1.113883.10.20.1.50) (see section 3.5.2.2 Representation of “status” values) 3.6.2.2 36 A family history organizer SHALL contain exactly one subject participant, representing the family member who is the subject of the family history observations 3.6.2.3 36 A family history observation not contained within a family history organizer SHALL contain exactly one subject participant, representing the family member who is the subject of the observation 3.6.2.3 36 Where the subject of an observation is explicit in a family history observation code (e.g. SNOMED CT concept 417001009 “Family history of tuberous sclerosis”), the subject participant SHALL be equivalent to or further specialize the code 3.6.2.3 36 Where the subject of an observation is not explicit in a family history observation code (e.g. SNOMED CT concept 44054006 “Diabetes Mellitus type 2”), the subject participant SHALL be used to assert the affected relative 3.6.2.3 37 A subject participant SHALL contain exactly one RelatedSubject, representing the relationship of the subject to the patient 3.6.2.3 37 The value for “RelatedSubject / @classCode” SHALL be “PRS” “Personal relationship” 2.16.840.1.113883.5.110 RoleClass STATIC 3.6.2.3 37 RelatedSubject SHALL contain exactly one RelatedSubject / code 3.6.2.3 37 The value for “RelatedSubject / code” SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.19579 FamilyHistoryRelatedSubjectCode DYNAMIC or 2.16.840.1.113883.1.11.20.21 FamilyHistoryPersonCode DYNAMIC 3.6.2.3 37 Representation of a pedigree graph SHALL be done using RelatedSubject / code values (e.g. “great grandfather”) to designate a hierarchical family tree 3.6.2.3 37 RelatedSubject SHOULD contain exactly one RelatedSubject / subject 3.6.2.3 37 RelatedSubject / subject SHOULD contain exactly one RelatedSubject / subject / administrativeGenderCode 3.6.2.3 37 RelatedSubject / subject SHOULD contain exactly one RelatedSubject / subject / birthTime 3.6.2.4 37 RelatedSubject / subject MAY contain exactly one RelatedSubject / subject / sdtc:deceasedInd. (See section 7.4 Extensions to CDA R2 for details on representation of CDA extensions) 3.6.2.4 37 RelatedSubject / subject MAY contain exactly one RelatedSubject / subject / sdtc:deceasedTime. (See section 7.4 Extensions to CDA R2 for details on representation of CDA extensions) 3.6.2.4 37 The age of a relative at the time of a family history observation SHOULD be inferred by comparing RelatedSubject / subject / birthTime with Observation / effectiveTime 3.6.2.4 37 The age of a relative at the time of death MAY be inferred by comparing RelatedSubject / subject / birthTime with RelatedSubject / subject / sdtc:deceasedTime 3.6.2.4 37 The value for “Observation / entryRelationship / @typeCode” in a family history observation MAY be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC to reference an age observation 3.6.2.4 37 An age observation (templateId 2.16.840.1.113883.10.20.1.38) SHALL be represented with Observation 3.6.2.4 37 The value for “Observation / @classCode” in an age observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 3.6.2.4 38 The value for “Observation / @moodCode” in an age observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.6.2.4 38 The value for “Observation / code” in an age observation SHALL be “397659008” “Age” 2.16.840.1.113883.6.96 SNOMED CT STATIC 3.6.2.4 38 An age observation SHALL include exactly one Observation / statusCode 3.6.2.4 38 The value for “Observation / statusCode” in an age observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.6.2.4 38 An age observation SHALL include exactly one Observation / value, valued using appropriate datatype 3.6.2.4 38 CCD SHOULD contain exactly one and SHALL NOT contain more than one Social history section (templateId 2.16.840.1.113883.10.20.1.15). The Social history section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more social history observations (templateId 2.16.840.1.113883.10.20.1.33) 3.7 38 The social history section SHALL contain Section / code 3.7.1 38 The value for “Section / code” SHALL be “29762-2” “Social history” 2.16.840.1.113883.6.1 LOINC STATIC 3.7.1 38 The social history section SHALL contain Section / title 3.7.1 38 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “social history” 3.7.1 38 A social history observation (templateId 2.16.840.1.113883.10.20.1.33) SHALL be represented with Observation 3.7.2.1 39 The value for “Observation / @classCode” in a social history observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 3.7.2.1 39 The value for “Observation / @moodCode” in a social history observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.7.2.1 39 A social history observation SHALL contain at least one Observation / id 3.7.2.1 39 A social history observation SHALL include exactly one Observation / statusCode 3.7.2.1 39 The value for “Observation / statusCode” in a social history observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.7.2.1 39 The value for “Observation / code” in a social history observation SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), or MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.18 SocialHistoryTypeCode STATIC 20061017 3.7.2.1 39 Observation / value can be any datatype. Where Observation / value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression 3.7.2.1 39 A social history observation SHALL contain one or more sources of information, as defined in section 5.2 Source 3.7.2.1 39 A social history observation MAY contain exactly one social history status observation 3.7.2.2 40 A social history status observation (templateId 2.16.840.1.113883.10.20.1.56) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values) 3.7.2.2 40 The value for “Observation / value” in a social history status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.17 SocialHistoryStatusCode STATIC 20061017 3.7.2.2 40 The representation of episode in the social history section is the same as the representation in the problems section. See section 3.5.2.3 Episode observations for details 3.7.2.3 40 A social history observation MAY contain exactly one episode observation (templateId 2.16.840.1.113883.10.20.1.41) (see section 3.5.2.3 Episode observations) 3.7.2.3 40 Marital status SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / maritalStatusCode. Additional information MAY be represented as social history observations 3.7.2.4 40 Religious affiliation SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / religiousAffiliationCode. Additional information MAY be represented as social history observations 3.7.2.4 40 A patient’s race SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / raceCode. Additional information MAY be represented as social history observations 3.7.2.4 40 The value for “ClinicalDocument / recordTarget / patientRole / patient / raceCode” MAY be selected from codeSystem 2.16.840.1.113883.5.104 (Race) 3.7.2.4 40 A patient’s ethnicity SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / ethnicGroupCode. Additional information MAY be represented as social history observations 3.7.2.4 40 The value for “ClinicalDocument / recordTarget / patientRole / patient / ethnicGroupCode” MAY be selected from codeSystem 2.16.840.1.113883.5.50 (Ethnicity) 3.7.2.4 40 CCD SHOULD contain exactly one and SHALL NOT contain more than one Alerts section (templateId 2.16.840.1.113883.10.20.1.2). The Alerts section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more problem acts (templateId 2.16.840.1.113883.10.20.1.27). A problem act SHOULD include one or more alert observations (templateId 2.16.840.1.113883.10.20.1.18) 3.8 41 The absence of known allergies, adverse reactions, or alerts SHALL be explicitly asserted 3.8 41 The alert section SHALL contain Section / code 3.8.1 41 The value for “Section / code” SHALL be “48765-2” “Allergies, adverse reactions, alerts” 2.16.840.1.113883.6.1 LOINC STATIC 3.8.1 41 The alert section SHALL contain Section / title 3.8.1 41 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “alert” and/or “allergies and adverse reactions” 3.8.1 41 An alert observation (templateId 2.16.840.1.113883.10.20.1.18) SHALL be represented with Observation 3.8.2.1.2 42 The value for “Observation / @moodCode” in an alert observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.8.2.1.2 43 An alert observation SHALL include exactly one Observation / statusCode 3.8.2.1.2 43 The value for “Observation / statusCode” in an alert observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.8.2.1.2 43 An alert observation MAY contain exactly one Observation / effectiveTime, to indicate the biological timing of condition (e.g. the time the condition started, the onset of the illness or symptom, the duration of a condition) 3.8.2.1.2 43 The value for “Observation / value” in an alert observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.4 AlertTypeCode STATIC 20061017 3.8.2.1.2 43 The absence of known allergies SHOULD be represented in an alert observation by valuing Observation / value with 160244002 “No known allergies” 2.16.840.1.113883.6.96 SNOMED CT STATIC 3.8.2.1.2 43 An alert observation SHALL contain one or more sources of information, as defined in section 5.2 Source 3.8.2.1.2 43 An alert observation MAY contain exactly one alert status observation 3.8.2.2 43 An alert status observation (templateId 2.16.840.1.113883.10.20.1.39) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values) 3.8.2.2 43 The value for “Observation / value” in an alert status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.3 AlertStatusCode STATIC 20061017 3.8.2.2 43 An alert observation SHOULD contain at least one Observation / participant, representing the agent that is the cause of the allergy or adverse reaction 3.8.2.3 43 An agent participation in an alert observation SHALL contain exactly one participant / participantRole / playingEntity 3.8.2.3 43 The value for Observation / participant / @typeCode in an agent participation SHALL be “CSM” “Consumable” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.8.2.3 43 The value for Observation / participant / participantRole / @classCode in an agent participation SHALL be “MANU” “Manufactured” 2.16.840.1.113883.5.110 RoleClass STATIC 3.8.2.3 43 The value for Observation / participant / participantRole / playingEntity / @classCode in an agent participation SHALL be “MMAT” “Manufactured material” 2.16.840.1.113883.5.41 EntityClass STATIC 3.8.2.3 44 An agent participation in an alert observation SHALL contain exactly one participant / participantRole / playingEntity / code 3.8.2.3 44 The value for “participant / participantRole / playingEntity / code” in an agent participation SHOULD be selected from the RxNorm (2.16.840.1.113883.6.88) code system for medications, and from the CDC Vaccine Code (2.16.840.1.113883.6.59) code system for immunizations 3.8.2.3 44 An alert observation MAY contain one or more reaction observations (templateId 2.16.840.1.113883.10.20.1.54), each of which MAY contain exactly one severity observation (templateId 2.16.840.1.113883.10.20.1.55) AND/OR one or more reaction interventions 3.8.2.4 44 The value for “entryRelationship / @typeCode” in a relationship between an alert observation and reaction observation SHALL be “MFST” “Is manifestation of” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.8.2.4 44 A reaction observation (templateId 2.16.840.1.113883.10.20.1.54) SHALL be represented with Observation 3.8.2.4.1.1 44 The value for “Observation / @classCode” in a reaction observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 3.8.2.4.1.1 44 The value for “Observation / @moodCode” in a reaction observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.8.2.4.1.1 44 A reaction observation SHALL include exactly one Observation / statusCode 3.8.2.4.1.1 44 The value for “Observation / statusCode” in a reaction observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.8.2.4.1.1 44 A severity observation (templateId 2.16.840.1.113883.10.20.1.55) SHALL be represented with Observation 3.8.2.4.1.2 44 The value for “entryRelationship / @typeCode” in a relationship between a reaction observation and severity observation SHALL be “SUBJ” “Has subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.8.2.4.1.2 45 The value for “Observation / @classCode” in a severity observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 3.8.2.4.1.2 45 The value for “Observation / @moodCode” in a severity observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.8.2.4.1.2 45 A severity observation SHALL include exactly one Observation / statusCode 3.8.2.4.1.2 45 The value for “Observation / statusCode” in a severity observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 3.8.2.4.1.2 45 A severity observation SHALL contain exactly one Observation / code 3.8.2.4.1.2 45 The value for “Observation / code” in a severity observation SHALL be “SEV” “Severity observation” 2.16.840.1.113883.5.4 ActCode STATIC 3.8.2.4.1.2 45 A severity observation SHALL contain exactly one Observation / value 3.8.2.4.1.2 45 The value for “entryRelationship / @typeCode” in a relationship between a reaction observation and reaction intervention SHALL be “RSON” “Has reason” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.8.2.4.1.3 45 A reaction intervention SHALL be represented as a procedure activity (templateId 2.16.840.1.113883.10.20.1.29), a medication activity (templateId 2.16.840.1.113883.10.20.1.24), or some other clinical statement 3.8.2.4.1.3 45 CCD SHOULD contain exactly one and SHALL NOT contain more than one Medications section (templateId 2.16.840.1.113883.10.20.1.8). The Medications section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more medication activities (templateId 2.16.840.1.113883.10.20.1.24) and/or supply activities (templateId 2.16.840.1.113883.10.20.1.34) 3.9 45 The absence of known medications SHALL be explicitly asserted 3.9 45 The medications section SHALL contain Section / code 3.9.1 45 The value for “Section / code” SHALL be “10160-0” “History of medication use” 2.16.840.1.113883.6.1 LOINC STATIC 3.9.1 46 The medications section SHALL contain Section / title 3.9.1 46 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “medication” 3.9.1 46 A medication activity (templateId 2.16.840.1.113883.10.20.1.24) SHALL be represented with SubstanceAdministration 3.9.2.1.1 47 The value for “SubstanceAdministration / @moodCode” in a medication activity SHALL be “EVN” or “INT” 2.16.840.1.113883.5.1001 ActMood STATIC 3.9.2.1.1 47 A medication activity SHALL contain at least one SubstanceAdministration / id 3.9.2.1.1 47 A medication activity SHOULD contain exactly one SubstanceAdministration / statusCode 3.9.2.1.1 47 A medication activity SHOULD contain one or more SubstanceAdministration / effectiveTime elements, used to indicate the actual or intended start and stop date of a medication, and the frequency of administration. (See section 5.4.1 Dates and Times for additional details about time representation) 3.9.2.1.1 47 A medication activity SHOULD contain exactly one SubstanceAdministration / routeCode 3.9.2.1.1 47 The value for “SubstanceAdministration / routeCode” in a medication activity SHOULD be selected from the HL7 RouteOfAdministration (2.16.840.1.113883.5.112) code system 3.9.2.1.1 47 A medication activity SHOULD contain exactly one SubstanceAdministration / doseQuantity or SubstanceAdministration / rateQuantity 3.9.2.1.1 47 A medication activity MAY contain exactly one SubstanceAdministration / maxDoseQuantity, which represents a maximum dose limit 3.9.2.1.1 47 A medication activity MAY contain one or more SubstanceAdministration / performer, to indicate the person administering a substance 3.9.2.1.1 47 A medication activity MAY have one or more associated consents, represented in the CCD Header as ClinicalDocument / authorization / consent 3.9.2.1.1 47 A medication activity SHALL contain one or more sources of information, as defined in section 5.2 Source 3.9.2.1.1 47 A supply activity (templateId 2.16.840.1.113883.10.20.1.34) SHALL be represented with Supply 3.9.2.1.2 48 The value for “Supply / @moodCode” in a supply activity SHALL be “EVN” or “INT” 2.16.840.1.113883.5.1001 ActMood STATIC 3.9.2.1.2 48 A supply activity SHALL contain at least one Supply / id 3.9.2.1.2 48 A supply activity SHOULD contain exactly one Supply / statusCode 3.9.2.1.2 48 A supply activity SHOULD contain exactly one Supply / effectiveTime, to indicate the actual or intended time of dispensing 3.9.2.1.2 48 A supply activity MAY contain exactly one Supply / repeatNumber, to indicate the number of fills. (Note that Supply / repeatNumber corresponds to the number of “fills”, as opposed to the number of “refills”) 3.9.2.1.2 48 A supply activity MAY contain exactly one Supply / quantity, to indicate the actual or intended supply quantity 3.9.2.1.2 48 A supply activity MAY contain one or more Supply / author, to indicate the prescriber 3.9.2.1.2 48 A supply activity MAY contain one or more Supply / performer, to indicate the person dispensing the product 3.9.2.1.2 48 A supply activity MAY contain exactly one Supply / participant / @typeCode = “LOC”, to indicate the supply location 3.9.2.1.2 48 A supply activity SHALL contain one or more sources of information, as defined in section 5.2 Source 3.9.2.1.2 48 A medication activity MAY contain one or more SubstanceAdministration / precondition / Criterion, to indicate that the medication is administered only when the associated (coded or free text) criteria are met 3.9.2.2.1 48 A medication activity MAY contain one or more SubstanceAdministration / entryRelationship, whose value for “entryRelationship / @typeCode” SHALL be “RSON” “Has reason” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC, where the target of the relationship represents the indication for the activity 3.9.2.2.1 48 SubstanceAdministration / entryRelationship / @typeCode=”RSON” in a medication activity SHALL have a target of problem act (templateId 2.16.840.1.113883.10.20.1.27), problem observation (templateId 2.16.840.1.113883.10.20.1.28), or some other clinical statement 3.9.2.2.1 49 A medication activity MAY contain one or more patient instructions 3.9.2.2.2 49 A patient instruction (templateId 2.16.840.1.113883.10.20.1.49) SHALL be represented with Act 3.9.2.2.2 49 The value for “Act / @moodCode” in a patient instruction SHALL be “INT” “Intent” 2.16.840.1.113883.5.1001 ActMood STATIC 3.9.2.2.2 49 The value for “entryRelationship / @typeCode” in a relationship to a patient instruction SHALL be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.9.2.2.2 49 A supply activity MAY contain one or more fulfillment instructions 3.9.2.2.3 49 A fulfillment instruction (templateId 2.16.840.1.113883.10.20.1.43) SHALL be represented with Act 3.9.2.2.3 49 The value for “Act / @moodCode” in a fulfillment instruction SHALL be “INT” “Intent” 2.16.840.1.113883.5.1001 ActMood STATIC 3.9.2.2.3 49 The value for “entryRelationship / @typeCode” in a relationship between a supply activity and fulfillment instruction SHALL be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.9.2.2.3 49 A medication activity MAY contain exactly one medication series number observations 3.9.2.2.4 49 The value for “entryRelationship / @typeCode” in a relationship between a medication activity and medication series number observation SHALL be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.9.2.2.4 49 A medication series number observation (templateId 2.16.840.1.113883.10.20.1.46) SHALL be represented with Observation 3.9.2.2.4 49 The value for “Observation / @classCode” in a medication series number observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 3.9.2.2.4 49 The value for “Observation / @moodCode” in a medication series number observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.9.2.2.4 50 A medication series number observation SHALL include exactly one Observation / statusCode 3.9.2.2.4 50 A medication series number observation SHALL contain exactly one Observation / code 3.9.2.2.4 50 The value for “Observation / code” in a medication series number observation SHALL be “30973-2” “Dose number” 2.16.840.1.113883.6.1 LOINC STATIC 3.9.2.2.4 50 A medication series number observation SHALL contain exactly one Observation / value 3.9.2.2.4 50 The data type for “Observation / value” in a medication series number observation SHALL be INT (integer) 3.9.2.2.4 50 A medication activity MAY contain one or more reaction observations (templateId 2.16.840.1.113883.10.20.1.54), each of which MAY contain exactly one severity observation (templateId 2.16.840.1.113883.10.20.1.55) AND/OR one or more reaction interventions 3.9.2.2.5 50 The value for “entryRelationship / @typeCode” in a relationship between a medication activity and reaction observation SHALL be “CAUS” “Is etiology for” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 3.9.2.2.5 50 A medication activity MAY contain exactly one medication status observation 3.9.2.3 50 A supply activity MAY contain exactly one medication status observation 3.9.2.3 50 A medication status observation (templateId 2.16.840.1.113883.10.20.1.47) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values) 3.9.2.3 50 The value for “Observation / value” in a medication status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.7 MedicationStatusCode STATIC 20061017 3.9.2.3 50 A medication activity SHALL contain exactly one SubstanceAdministration / consumable, the target of which is a product template 3.9.2.4 51 A supply activity MAY contain exactly one Supply / product, the target of which is a product template 3.9.2.4 51 A product (templateId 2.16.840.1.113883.10.20.1.53) SHALL be represented with the ManufacturedProduct class 3.9.2.4 51 A ManufacturedProduct in a product template SHALL contain exactly one manufacturedProduct / manufacturedMaterial 3.9.2.4 51 A manufacturedMaterial in a product template SHALL contain exactly one manufacturedMaterial / code 3.9.2.4 51 The value for “manufacturedMaterial / code” in a product template SHOULD be selected from the RxNorm (2.16.840.1.113883.6.88) code system for medications, and from the CDC Vaccine Code (2.16.840.1.113883.6.59) code system for immunizations, or MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.8 MedicationTypeCode STATIC 20061017 3.9.2.4 51 The value for “manufacturedMaterial / code” in a product template MAY contain a precoordinated product strength, product form, or product concentration (e.g. “metoprolol 25mg tablet”, “amoxicillin 400mg/5mL suspension”) 3.9.2.4 51 If manufacturedMaterial / code contains a precoordinated unit dose (e.g. “metoprolol 25mg tablet”), then SubstanceAdministration / doseQuantity SHALL be a unitless number that indicates the number of products given per administration 3.9.2.4 51 If manufacturedMaterial / code does not contain a precoordinated unit dose (e.g. “metoprolol product”), then SubstanceAdministration / doseQuantity SHALL be a physical quantity that indicates the amount of product given per administration 3.9.2.4 51 A manufacturedMaterial in a product template SHALL contain exactly one Material / code / originalText, which represents the generic name of the product 3.9.2.4 51 A manufacturedMaterial in a product template MAY contain exactly one Material / name, which represents the brand name of the product 3.9.2.4 51 A ManufacturedProduct in a product template MAY contain exactly one manufacturedProduct / manufacturerOrganization, which represents the manufacturer of the Material 3.9.2.4 51 A ManufacturedProduct in a product template MAY contain one or more manufacturedProduct / id, which uniquely represent a particular kind of product 3.9.2.4 51 If ManufacturedProduct in a product template contains manufacturedProduct / id, then ManufacturedProduct SHOULD also contain manufacturedProduct / manufacturerOrganization 3.9.2.4 51 A medication activity MAY contain one or more product instance templates (templateId 2.16.840.1.113883.10.20.1.52) (see section 3.14.2.2 Procedure related products), to identify a particular product instance 3.9.2.4 52 A supply activity MAY contain one or more product instance templates (templateId 2.16.840.1.113883.10.20.1.52) (see section 3.14.2.2 Procedure related products), to identify a particular product instance 3.9.2.4 52 Supply / participant / participantRole / id SHOULD be set to equal a [Act | Observation | Procedure] / participant / participantRole / id (see section 3.14.2.2 Procedure related products) to indicate that the Supply and the Procedure are referring to the same product instance 3.9.2.4 52 CCD SHOULD contain exactly one and SHALL NOT contain more than one Medical Equipment section (templateId 2.16.840.1.113883.10.20.1.7). The Medical Equipment section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more supply activities (templateId 2.16.840.1.113883.10.20.1.34) and MAY include one or more medication activities (templateId 2.16.840.1.113883.10.20.1.24) 3.1 52 The medical equipment section SHALL contain Section / code 3.1 52 The value for “Section / code” SHALL be “46264-8” “History of medical device use” 2.16.840.1.113883.6.1 LOINC STATIC 3.1 52 The medical equipment section SHALL contain Section / title 3.1 52 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “equipment” 3.1 52 CCD SHOULD contain exactly one and SHALL NOT contain more than one Immunizations section (templateId 2.16.840.1.113883.10.20.1.6). The Immunizations section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more medication activities (templateId 2.16.840.1.113883.10.20.1.24) and/or supply activities (templateId 2.16.840.1.113883.10.20.1.34) 3.11 53 The immunizations section SHALL contain Section / code 3.1 53 The value for “Section / code” SHALL be “11369-6” “History of immunizations” 2.16.840.1.113883.6.1 LOINC STATIC 3.1 53 The immunizations section SHALL contain Section / title 3.1 53 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “immunization” 3.1 53 CCD SHOULD contain exactly one and SHALL NOT contain more than one Vital signs section (templateId 2.16.840.1.113883.10.20.1.16). The Vital signs section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more vital signs organizers (templateId 2.16.840.1.113883.10.20.1.35), each of which SHALL contain one or more result observations (templateId 2.16.840.1.113883.10.20.1.31) 3.1 53 The vital signs section SHALL contain Section / code 3.12.1 54 The value for “Section / code” SHALL be “8716-3” “Vital signs” 2.16.840.1.113883.6.1 LOINC STATIC 3.12.1 54 The vital signs section SHALL contain Section / title 3.12.1 54 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “vital signs” 3.12.1 54 A vital signs organizer (templateId 2.16.840.1.113883.10.20.1.35) SHALL be a conformant results organizer (templateId 2.16.840.1.113883.10.20.1.32) 3.12.2 54 A vital signs organizer SHALL contain one or more sources of information, as defined in section 5.2 Source 3.12.2 54 CCD SHOULD contain exactly one and SHALL NOT contain more than one Results section (templateId 2.16.840.1.113883.10.20.1.14). The Results section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more result organizers (templateId 2.16.840.1.113883.10.20.1.32), each of which SHALL contain one or more result observations (templateId 2.16.840.1.113883.10.20.1.31) 3.13 54 The result section SHALL contain Section / code 3.13.1 55 The value for “Section / code” SHALL be “30954-2” “Relevant diagnostic tests and/or laboratory data” 2.16.840.1.113883.6.1 LOINC STATIC 3.13.1 55 The results section SHALL contain Section / title 3.13.1 55 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “results” 3.13.1 55 A result organizer (templateId 2.16.840.1.113883.10.20.1.32) SHALL be represented with Organizer 3.13.2.1.1 56 The value for “Organizer / @moodCode” in a result organizer SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.13.2.1.1 56 A result organizer SHALL contain at least one Organizer / id 3.13.2.1.1 56 A result organizer SHALL contain exactly one Organizer / statusCode 3.13.2.1.1 56 A result organizer SHALL contain exactly one Organizer / code 3.13.2.1.1 56 The value for “Organizer / code” in a result organizer SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12) or ValueSet 2.16.840.1.113883.1.11.20.16 ResultTypeCode STATIC 3.13.2.1.1 56 A result organizer SHOULD include one or more Organizer / specimen if the specimen isn't inherent in Organizer / code 3.13.2.1.1 56 Organizer / specimen SHALL NOT conflict with the specimen inherent in Organizer / code 3.13.2.1.1 56 Organizer / specimen / specimenRole / id SHOULD be set to equal a Procedure / specimen / specimenRole / id (see section 3.14 Procedures) to indicate that the Results and the Procedure are referring to the same specimen 3.13.2.1.1 56 A result organizer SHALL contain one or more Organizer / component 3.13.2.1.1 56 The target of one or more result organizer Organizer / component relationships MAY be a procedure, to indicate the means or technique by which a result is obtained, particularly if the means or technique isn’t inherent in Organizer / code or if there is a need to further specialize the Organizer / code value 3.13.2.1.1 56 A result organizer Organizer / component / procedure MAY be a reference to a procedure described in the Procedure section. (See section 5.3 InternalCCRLink for more on referencing within CCD) 3.13.2.1.1 56 The target of one or more result organizer Organizer / component relationships SHALL be a result observation 3.13.2.1.1 56 A result organizer SHALL contain one or more sources of information, as defined in section 5.2 Source 3.13.2.1.1 56 A result observation (templateId 2.16.840.1.113883.10.20.1.31) SHALL be represented with Observation 3.13.2.1.2 57 The value for “Observation / @moodCode” in a result observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.13.2.1.2 57 A result observation SHALL contain at least one Observation / id 3.13.2.1.2 57 A result observation SHALL contain exactly one Observation / statusCode 3.13.2.1.2 57 A result observation SHOULD contain exactly one Observation / effectiveTime, which represents the biologically relevant time (e.g. time the specimen was obtained from the patient) 3.13.2.1.2 57 A result observation SHALL contain exactly one Observation / code 3.13.2.1.2 57 The value for “Observation / code” in a result observation SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12) 3.13.2.1.2 57 A result observation MAY contain exactly one Observation / methodCode if the method isn't inherent in Observation / code or if there is a need to further specialize the method in Observation / code 3.13.2.1.2 57 Observation / methodCode SHALL NOT conflict with the method inherent in Observation / code 3.13.2.1.2 57 A result observation SHALL contain exactly one Observation / value 3.13.2.1.2 57 Where Observation / value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression 3.13.2.1.2 57 A result observation SHOULD contain exactly one Observation / interpretationCode, which can be used to provide a rough qualitative interpretation of the observation, such as “N” (normal), “L” (low), “S” (susceptible), etc. Interpretation is generally provided for numeric results where an interpretation range has been defined, or for antimicrobial susceptibility test interpretation 3.13.2.1.2 57 A result observation SHOULD contain one or more Observation / referenceRange to show the normal range of values for the observation result 3.13.2.1.2 57 A result observation SHALL NOT contain Observation / referenceRange / observationRange / code, as this attribute is not used by the HL7 Clinical Statement or Lab Committee models 3.13.2.1.2 57 A result observation SHALL contain one or more sources of information, as defined in section 5.2 Source 3.13.2.1.2 57 CCD SHOULD contain exactly one and SHALL NOT contain more than one Procedures section (templateId 2.16.840.1.113883.10.20.1.12). The Procedures section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more procedure activities (templateId 2.16.840.1.113883.10.20.1.29) 3.14 58 The procedure section SHALL contain Section / code 3.14.1 58 The value for “Section / code” SHALL be “47519-4” “History of procedures” 2.16.840.1.113883.6.1 LOINC STATIC 3.14.1 58 The procedure section SHALL contain Section / title 3.14.1 58 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “procedures” 3.14.1 58 A procedure activity (templateId 2.16.840.1.113883.10.20.1.29) SHALL be represented with Act, Observation, or Procedure 3.14.2.1 59 The value for “[Act | Observation | Procedure] / @moodCode” in a procedure activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.14.2.1 59 A procedure activity SHALL contain at least one [Act | Observation | Procedure] / id 3.14.2.1 59 A procedure activity SHALL contain exactly one [Act | Observation | Procedure] / statusCode 3.14.2.1 59 The value for “[Act | Observation | Procedure] / statusCode” in a procedure activity SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.15 ProcedureStatusCode STATIC 20061017 3.14.2.1 59 A procedure activity SHOULD contain exactly one [Act | Observation | Procedure] / effectiveTime 3.14.2.1 59 A procedure activity SHALL contain exactly one [Act | Observation | Procedure] / code 3.14.2.1 59 The value for “[Act | Observation | Procedure] / code” in a procedure activity SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12), ICD9 Procedures (codeSystem 2.16.840.1.113883.6.104), ICD10 Procedure Coding System (codeSystem 2.16.840.1.113883.6.4) 3.14.2.1 59 A procedure activity MAY contain one or more [Observation | Procedure] / methodCode if the method isn't inherent in [Observation | Procedure] / code or if there is a need to further specialize the method in [Observation | Procedure] / code. [Observation | Procedure] / methodCode SHALL NOT conflict with the method inherent in [Observation | Procedure] / code 3.14.2.1 60 A procedure activity MAY contain one or more [Observation | Procedure] / targetSiteCode to indicate the anatomical site or system that is the focus of the procedure, if the site isn't inherent in [Observation | Procedure] / code or if there is a need to further specialize the site in [Observation | Procedure] / code. [Observation | Procedure] / targetSiteCode SHALL NOT conflict with the site inherent in [Observation | Procedure] / code 3.14.2.1 60 A procedure activity MAY contain one or more location participations (templateId 2.16.840.1.113883.10.20.1.45) (see section 3.15.2.2 Encounter location), to represent where the procedure was performed 3.14.2.1 60 A procedure activity MAY contain one or more [Act | Observation | Procedure] / performer, to represent those practioners who performed the procedure 3.14.2.1 60 A procedure activity MAY contain one or more entryRelationship / @typeCode=”RSON”, the target of which represents the indication or reason for the procedure 3.14.2.1 60 [Act | Observation | Procedure] / entryRelationship / @typeCode=”RSON” in a procedure activity SHALL have a target of problem act (templateId 2.16.840.1.113883.10.20.1.27), problem observation (templateId 2.16.840.1.113883.10.20.1.28), or some other clinical statement 3.14.2.1 60 A procedure activity MAY contain one or more patient instructions (templateId 2.16.840.1.113883.10.20.1.49) (see section 3.9.2.2.2 Patient instructions), to represent any additional information provided to a patient related to the procedure 3.14.2.1 60 A procedure activity MAY have one or more associated consents, represented in the CCD Header as ClinicalDocument / authorization / consent 3.14.2.1 60 A Procedure in a procedure activity MAY have one or more Procedure / specimen, reflecting specimens that were obtained as part of the procedure 3.14.2.1 60 Procedure / specimen / specimenRole / id SHOULD be set to equal an Organizer / specimen / specimenRole / id (see section 3.13 Results) to indicate that the Procedure and the Results are referring to the same specimen 3.14.2.1 60 The value for “[Act | Observation | Procedure] / entryRelationship / @typeCode” in a procedure activity MAY be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC to reference an age observation (templateId 2.16.840.1.113883.10.20.1.38) 3.14.2.1 60 A procedure activity MAY have one or more [Act | Observation | Procedure] / entryRelationship [@typeCode=”COMP”], the target of which is a medication activity (templateId 2.16.840.1.113883.10.20.1.24) (see section 3.9.2.1.1 Medication activity), to describe substances administered during the procedure 3.14.2.1 60 A procedure activity SHALL contain one or more sources of information, as defined in section 5.2 Source 3.14.2.1 60 A procedure activity MAY have one or more [Act | Observation | Procedure] / participant [@typeCode=”DEV”], the target of which is a product instance template 3.14.2.2 61 A product instance (templateId 2.16.840.1.113883.10.20.1.52) SHALL be represented with the ParticipantRole class 3.14.2.2 61 The value for “participantRole / @classCode” in a product instance SHALL be “MANU” “Manufactured product” 2.16.840.1.113883.5.110 RoleClass STATIC 3.14.2.2 61 If participantRole in a product instance contains participantRole / id, then participantRole SHOULD also contain participantRole / scopingEntity 3.14.2.2 61 [Act | Observation | Procedure] / participant / participantRole / id SHOULD be set to equal a Supply / participant / participantRole / id (see section 3.9.2.4 Representation of a product) to indicate that the Procedure and the Supply are referring to the same product instance 3.14.2.2 61 CCD SHOULD contain exactly one and SHALL NOT contain more than one Encounters section (templateId 2.16.840.1.113883.10.20.1.3). The Encounters section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more encounter activities (templateId 2.16.840.1.113883.10.20.1.21) 3.15 61 The encounters section SHALL contain Section / code 3.15.1 61 The value for “Section / code” SHALL be “46240-8” “History of encounters” 2.16.840.1.113883.6.1 LOINC STATIC 3.15.1 61 The encounters section SHALL contain Section / title 3.15.1 61 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “encounters” 3.15.1 61 An encounter activity (templateId 2.16.840.1.113883.10.20.1.21) SHALL be represented with Encounter 3.15.2.1 62 The value for “Encounter / @classCode” in an encounter activity SHALL be “ENC” 2.16.840.1.113883.5.6 ActClass STATIC 3.15.2.1 62 The value for “Encounter / @moodCode” in an encounter activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 3.15.2.1 62 An encounter activity SHALL contain at least one Encounter / id 3.15.2.1 62 An encounter activity SHOULD contain exactly one Encounter / code 3.15.2.1 62 The value for “Encounter / code” in an encounter activity SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.13955 EncounterCode 2.16.840.1.113883.5.4 ActCode DYNAMIC 3.15.2.1 63 An encounter activity MAY contain exactly one Encounter / effectiveTime, to indicate date, time, and/or duration of an encounter 3.15.2.1 63 An encounter activity MAY contain one or more Encounter / entryRelationship, whose value for “entryRelationship / @typeCode” SHALL be “RSON” “Has reason” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC, where the target of the relationship represents the indication for the activity 3.15.2.1 63 An encounter activity MAY contain one or more Encounter / performer, used to define the practioners involved in an encounter 3.15.2.1 63 Encounter / performer MAY contain exactly one Encounter / performer / assignedEntity / code, to define the role of the practioner 3.15.2.1 63 An encounter activity MAY contain one or more patient instructions (templateId 2.16.840.1.113883.10.20.1.49) 3.15.2.1 63 The value for “Encounter / entryRelationship / @typeCode” in an encounter activity MAY be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC to reference an age observation (templateId 2.16.840.1.113883.10.20.1.38) 3.15.2.1 63 An encounter activity SHALL contain one or more sources of information, as defined in section 5.2 Source 3.15.2.1 63 An encounter activity MAY contain one or more location participations 3.15.2.2 63 A location participation (templateId 2.16.840.1.113883.10.20.1.45) SHALL be represented with the participant participation 3.15.2.2 63 The value for “participant / @typeCode” in a location participation SHALL be “LOC” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.15.2.2 63 A location participation SHALL contain exactly one participant / participantRole 3.15.2.2 63 The value for “participant / participantRole / @classCode” in a location participation SHALL be “SDLOC” “Service delivery location” 2.16.840.1.113883.5.110 RoleClass STATIC 3.15.2.2 63 Participant / participantRole in a location participation MAY contain exactly one participant / participantRole / code 3.15.2.2 63 The value for “participant / participantRole / code” in a location participation SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType 2.16.840.1.113883.5.111 RoleCode DYNAMIC 3.15.2.2 63 Participant / participantRole in a location participation MAY contain exactly one participant / participantRole / playingEntity 3.15.2.2 63 The value for “participant / participantRole / playingEntity / @classCode” in a location participation SHALL be “PLC” “Place” 2.16.840.1.113883.5.41 EntityClass STATIC 3.15.2.2 63 CCD SHOULD contain exactly one and SHALL NOT contain more than one Plan of Care section (templateId 2.16.840.1.113883.10.20.1.10). The Plan of Care section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHALL include one or more plan of care activities (templateId 2.16.840.1.113883.10.20.1.25) 3.16 64 The plan of care section SHALL contain Section / code 3.16.1 64 The value for “Section / code” SHALL be “18776-5” “Treatment plan” 2.16.840.1.113883.6.1 LOINC STATIC 3.16.1 64 The plan of care section SHALL contain Section / title 3.16.1 64 Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “plan” 3.16.1 64 A plan of care activity (templateId 2.16.840.1.113883.10.20.1.25) SHALL be represented with Act, Encounter, Observation, Procedure, SubstanceAdministration, or Supply 3.16.2.1 64 A plan of care activity SHALL contain at least one [Act | Encounter | Observation | Procedure | SubstanceAdministration | Supply] / id 3.16.2.1 64 A plan of care activity SHALL contain exactly one [Act | Encounter | Observation | Procedure | SubstanceAdministration | Supply] / @moodCode 3.16.2.1 64 The value for “[Act | Encounter | Procedure] / @moodCode” in a plan of care activity SHALL be [“INT” (intent) | “ARQ” (appointment request) | “PRMS” (promise) | “PRP” (proposal) | “RQO” (request)] 2.16.840.1.113883.5.1001 ActMood STATIC 3.16.2.1 64 The value for “[SubstanceAdministration | Supply] / @moodCode” in a plan of care activity SHALL be [“INT” (intent) | “PRMS” (promise) | “PRP” (proposal) | “RQO” (request)] 2.16.840.1.113883.5.1001 ActMood STATIC 3.16.2.1 65 The value for “Observation / @moodCode” in a plan of care activity SHALL be [“INT” (intent) | “PRMS” (promise) | “PRP” (proposal) | “RQO” (request) | “GOL” (goal)] 2.16.840.1.113883.5.1001 ActMood STATIC 3.16.2.1 65 A plan of care activity SHALL contain one or more sources of information, as defined in section 5.2 Source 3.16.2.1 65 The value for “ClinicalDocument / documentationOf / serviceEvent / performer / @typeCode SHALL be “PRF” “Participation physical performer” 2.16.840.1.113883.5.90 ParticipationType STATIC 3.17 65 A value for “ClinicalDocument / documentationOf / serviceEvent / performer / assignedEntity / id” MAY be the HIPAA National Provider Identifier 3.17 65 A value for “ClinicalDocument / documentationOf / serviceEvent / performer / assignedEntity / code” MAY be the National Uniform Claims Committee Provider Taxonomy Code 3.17 66 Each actor shall appear in the appropriate section of the CDA at least once with all information fully specified, and should include an entity identifier 4.1 80 Other references to the same entity (a person or organization) in the same or different role need not fully specify the actor information, provided they include the same entity identifier 4.1 80 There shall be a one-to-one relationship between entity identifiers in a CDA and ActorID as represented in the CCR data set 4.1 80 A clinical statement in a CCD section MAY contain one or more Observation / reference / externalDocument, to represent externally an externally referenced document 4.2 81 An externally referenced document MAY contain exactly one Observation / reference / ExternalDocument / text / reference, to indicate the URL of the referenced document. A <linkHTML> element containing the same URL SHOULD be present in the associated CDA Narrative Block 4.2 81 An externally referenced document MAY contain exactly one Observation / reference / ExternalDocument / text / @mediaType, to indicate the MIME type of the referenced document 4.2 81 Where the value of Observation / reference / seperatableInd is “false”, the referenced document SHOULD be included in the CCD exchange package. The exchange mechanism SHOULD be based on Internet standard RFC 2557 “MIME Encapsulation of Aggregate Documents, such as HTML (MHTML)” (http://www.ietf.org/rfc/rfc2557.txt). (See CDA Release 2, section 3 “CDA Document Exchange in HL7 Messages” for examples and additional details) 4.2 81 A CCD section MAY contain one or more comments, either as a clinical statement or nested under another clinical statement 4.3 81 A comment (templateId 2.16.840.1.113883.10.20.1.40) SHALL be represented with Act 4.3 81 The value for “Act / @classCode” in a comment SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC 4.3 81 The value for “Act / @moodCode” in a comment SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 4.3 81 A comment SHALL contain exactly one Act / code 4.3 81 The value for “Act / code” in a comment SHALL be 48767-8 “Annotation comment” 2.16.840.1.113883.6.1 LOINC STATIC 4.3 81 A status observation (templateId 2.16.840.1.113883.10.20.1.57) SHALL be represented with Observation 5.1 86 A status observation SHALL be the target of an entryRelationship whose value for “entryRelationship / @typeCode” SHALL be “REFR” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 5.1 86 The value for “Observation / @classCode” in a status observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 5.1 86 The value for “Observation / @moodCode” in a status observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 5.1 86 A status observation SHALL contain exactly one Observation / code 5.1 86 The value for “Observation / code” in a status observation SHALL be “33999-4” “Status” 2.16.840.1.113883.6.1 LOINC STATIC 5.1 86 A status observation SHALL contain exactly one Observation / statusCode 5.1 86 The value for “Observation / statusCode” in a status observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 5.1 86 A status observation SHALL contain exactly one Observation / value, which SHALL be of datatype “CE” 5.1 86 A status observation SHALL NOT contain any additional Observation attributes 5.1 86 A status observation SHALL NOT contain any Observation participants 5.1 86 A status observation SHALL NOT be the source of any Observation relationships 5.1 86 A person source of information SHALL be represented with informant 5.2 87 An organization source of information SHALL be represented with informant 5.2 87 A reference source of information SHALL be represented with reference [@typeCode = “XCRPT”] 5.2 87 Any other source of information SHALL be represented with a source of information observation 5.2 87 A source of information observation SHALL be the target of an entryRelationship whose value for “entryRelationship / @typeCode” SHALL be “REFR” “Refers to” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC 5.2 87 A source of information observation SHALL be represented with Observation 5.2 87 The value for “Observation / @classCode” in a source of information observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC 5.2 87 The value for “Observation / @moodCode” in a source of information observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC 5.2 87 A source of information observation SHALL contain exactly one Observation / statusCode 5.2 87 The value for “Observation / statusCode” in a source of information observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC 5.2 87 A source of information observation SHALL contain exactly one Observation / code 5.2 87 The value for “Observation / code” in a source of information observation SHALL be “48766-0” “Information source” 2.16.840.1.113883.6.1 LOINC STATIC 5.2 87 A source of information observation SHALL contain exactly one Observation / value 5.2 87 The absence of a known source of information SHALL be explicity asserted by valuing Observation / value in a source of information observation with the text string “Unknown” 5.2 87 When representing the any of the coding systems listed above, the codeSystem attribute shall be present using the values listed in that table 5.5.2 98 When the codeSystemName attribute is present, it shall be valued with the appropriate values from Table 18 above 5.5.2 98 Where SNOMED CT is used, it shall be used per the “Using SNOMED CT in HL7 Version 3” Implementation Guide 5.5.2 98 An assignedPerson, informationRecipient, maintainingPerson, guardianPerson, relatedPerson, associatedPerson or subject MAY include an id element from the urn:hl7-org:sdtc namespace to uniquely identify the person 7.4.1 110 The id element SHALL use the instance identifier (II) data type 7.4.1 110 The id element SHALL appear just before the name element of the entity 7.4.1 110 A subject MAY include a deceasedInd element from the urn:hl7-org:sdtc namespace to indicate whether the person is deceased 7.4.2 110 The deceasedInd element SHALL be of the Boolean (BL) data type 7.4.2 110 The deceasedInd element SHALL appear immediately following the birthTime element 7.4.2 110 A subject MAY include a deceasedTime element from the urn:hl7-org:sdtc namespace to indicate when the person died 7.4.2 110 The deceasedTime element SHALL be of the Time Stamp (TS) data type 7.4.2 110 The deceasedTime element SHALL appear immediately following the deceasedInd element 7.4.2 110 sdtc:asPatientRelationship SHALL contain exactly one sdtc:asPatientRelationship / @classCode, valued with “PRS” 7.4.3 111 sdtc:asPatientRelationship SHALL contain exactly one sdtc:asPatientRelationship / code, of datatype CE 7.4.3 111 The value for “sdtc:asPatientRelationship / code” SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.19579 FamilyHistoryRelatedSubjectCode DYNAMIC or 2.16.840.1.113883.1.11.20.21 FamilyHistoryPersonCode DYNAMIC 7.4.3 111 An informant SHALL NOT contain any relatedPerson / sdtc:asPatientRelationship elements 7.4.3 111