#### Non-Coded CDA Document
Domain Message Specification

### Non Coded CDA Document Tabular View

POCD_RM010011GB02 |
ClinicalDocument | This class is a clinical document class. This class and its participations are commonly known as the header of the CDA document.
| Used by:
[1..1] [M] classCode (CS { CNE: ActClass } ) { Fixed="DOCCLIN" } | Model Attribute Description The HL7 attribute classCode uses a code to describe this class as a clinical document. Implementation in XML Instance The XML attribute classCode is fixed to " DOCCLIN".
[1..1] [M] moodCode (CS { CNE: ActMood } ) { Fixed="EVN" } | Model Attribute Description The HL7 attribute moodCode uses a code to describe this class as a clinical document event Implementation in XML Instance The XML attribute moodCode is fixed to " EVN".
[1..1] [M] code (CV { CWE:NonCodedCDADocumentType } ) | Model Attribute Description The HL7 attribute code uses a code from any vocabulary to describe the type of CDA document. There are three possible representations for this attribute: A single code from SNOMED CT A compositional expression consisting of multiple codes from SNOMED CT A single code from a suitable alternative vocabulary Note: the vocabulary contains additional guidance for the use of this attribute with SNOMED CT. Implementation in XML Instance When using a single SNOMED CT code then: The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows: The XML attribute code shall contain a code from the subset stated in NonCodedCDADocumentType vocabulary The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15" The XML attribute displayName may carry a description associated with the code in the subset stated in the NonCodedCDADocumentType vocabulary. It is recommended that the preferred term is used to populate this attribute. When using multiple SNOMED CT codes then: The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows: The XML attribute code shall contain a string composed from codes from the subsets stated in NonCodedCDADocumentType vocabulary as per the guidance in the vocabulary The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15.1" The XML attribute displayName may contain a string composed from the codes and descriptions from the subsets stated in NonCodedCDADocumentType vocabulary as per the guidance in the vocabulary When using an alternative vocabulary code then: The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows: The XML attribute code shall contain a code from the alternative vocabulary The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.337" The XML attribute displayName may carry a description associated with the code in alternative vocabulary
[1..1] [M] confidentialityCode (CE { CWE:x_BasicConfidentialityKind } ) | Model Attribute Description The HL7 attribute confidentiality code uses a code from any vocabulary to describe the confidentiality of the CDA document. This may be implemented using NHS CFH sealing or some form of locally agreed access control. Implementation in XML Instance When implementing NHS CFH Sealing then: A code from the HL7 x_BasicConfidentialityKind vocabulary to denote the level of confidentially applied to the document. The Coded Plain flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element confidentialityCode as follows: The XML attribute code shall contain a fixed value of "V". The XML attribute codeSystem shall contain the OID of "2.16.840.1.113883.1.11.16926". The XML attribute displayName shall carry a value of "very restricted". When this attribute contains a value of "V" ("very restricted") then the relevant centralised ACF service must be consulted prior to rendering to any user. Otherwise it shall be populated with: Either A code from the HL7 x_BasicConfidentialityKind vocabulary to denote the level of confidentially applied to the document. The Coded Plain flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element confidentialityCode as follows: The XML attribute code shall contain a value from the stated HL7 vocabulary. The XML attribute codeSystem shall contain the OID of "2.16.840.1.113883.1.11.16926". The XML attribute displayName shall carry the description associated with the code. These codes should be populated and processed as appropriate for the local requirement for controlling access to the information. Or A code from an alternative locally agreed vocabulary to denote the level of confidentially applied to the document. The Coded Plain flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element confidentialityCode as follows: The XML attribute code shall contain a value from the vocabulary. The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.415" The XML attribute displayName shall carry a value associated with the code. These codes should be populated and processed as appropriate for the local requirement for controlling access to the information.
[1..1] [M] effectiveTime (TS) | Model Attribute Description The HL7 attribute effectiveTime is used to define the creation time of the CDA document. Implementation in XML Instance The XML attribute value of the XML element effectiveTime shall be populated with the time the document was created using a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where: yyyy is the year mm is the month dd is the day hh is the hour mm is the minutes ss is the seconds [+|-ZZzz] is the time zone offset in hours and minutes Sections from the right of this representation may be left off when the sending system does not record to this level of accuracy. When hours are present, the time zone offset must also be present.
[1..1] [M] id (II) | Model Attribute Description The HL7 attribute id uses an identifier to identify each unique instance of a clinical document. Implementation in XML Instance The Identifier Global data type flavour is used to carry the identifier in the XML element id as follows: The XML attribute root shall contain a DCE UUID.
[1..1] [M] messageType (II) { Fixed="POCD_MT010011GB02" } | Model Attribute Description The HL7 (NHS localisation) attribute messageType identifies the CDA document as one that complies with a certain NHS CDA profile. The value of this attribute provides a unique identifier for the profile in question. Implementation in XML Instance The XML element messageType is populated as follows The XML attribute root shall carry the OID "2.16.840.1.113883.2.1.3.2.4.18.17" The XML attribute extension shall carry the value "POCD_MT010011GB02"
[1..1] [M] setId (II) | Model Attribute Description The HL7 attribute setId uses an identifier to identify all documents that are part of a set of documents. Implementation in XML Instance The Identifier Global data type flavour is used to carry the identifier in the XML element setId as follows: The XML attribute root shall contain a DCE UUID
[1..1] [M] title (ST) | Model Attribute Description The HL7 attribute title uses a string which is rendered as a human readable title. Implementation in XML Instance The XML element title is populated as follows: When using a single code in the XML attribute code of the XML element code the XML element title shall contain either: The description associated with the code carried in the XML attribute code of the XML element code or A human readable string deemed to be the title of the document by the sending system. When using multiple SNOMED CT codes in the XML attribute code of the XML element code the XML element title shall contain: A human readable string deemed to be the title of the document by the sending system. This string may be derived from the multiple SNOMED CT code preferred terms. Note: the term sending system is used here as a generic term, how the title is defined is dependant system configuration or design.
[1..1] [M] typeId (II) { Fixed="POCD_HD000040" } | Model Attribute Description The HL7 attribute typeId signals the imposition of constraints defined in an HL7-specified message type. The typeId is used to indicate this is a CDA document that complies with CDA R2. Implementation in XML Instance The XML element typeId is populated as follows: The XML attribute root shall carry the OID "2.16.840.1.113883.1.3" The XML attribute extension shall carry the value "POCD_HD000040"
[1..1] [M] versionNumber (INT) | Model Attribute Description The HL7 attribute versionNumber uses an integer value to allow versioning of the CDA document. The version number here is the version number of this document Implementation in XML Instance The XML element versionNumber is populated as follows: The XML attribute value should contain the version number of the document as an integer value.
[0..1] authenticator | This class is a participation of authentication. It is used for participations where the CDA document needs to be authenticated. This means that the person who authenticated will have overall responsibility for the document not the author. For example a supervisor.
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="AUTHEN" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as an authenticator participation. Implementation in XML Instance The XML attribute classCode is fixed to " AUTHEN".
[1..1] [M] contentId (II) { "NPFIT-000084#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [R] signatureCode (CS { CNE: ParticipationSignature } ) | Model Attribute Description The HL7 attribute signatureCode uses a code to describe signature for the CDA document. This attribute is currently not used for NHS CDA implementations and should be nulled. Implementation in XML Instance The XML attribute nullFlavor of the XML element signatureCode shall contain the value " NA"
[1..1] [R] time (TS) | Model Attribute Description The HL7 attribute authenticator time is used to indicate when the person authenticated the CDA document. Implementation in XML Instance The XML attribute value of the XML element time, shall be populated with a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where: yyyy is the year mm is the month dd is the day hh is the hour mm is the minutes ss is the seconds [+|-ZZzz] is the time zone offset in hours and minutes Sections from the right of this representation may be left off to when the sending system does not record to this accuracy. When hours are present, the time zone offset must also be present. When the time of authentication is not available to the sending system then: The XML attribute nullFlavor of the XML element time shall contain the value "NI"
[1..1] participant (AuthenticatorChoice) | A link to a choice of authenticator templates.
[1..*] [M] author | This class is a participant of authorship. It holds details of how and when the author authored the CDA document.
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="AUT" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as an author participation. Implementation in XML Instance The XML attribute classCode is fixed to " AUT".
[1..1] [M] contextControlCode (CS { CNE: ContextControl } ) { Fixed="OP" } | Model Attribute Description The HL7 attribute contextConductionCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section is conducted across to the child section (also associated with the child section). This set of codes also determine how these participations conduct. The conduction can only take place if the contextConductionInd is set to "true". The value of this attribute is fixed in the HL7 model to "OP": "O" (Overriding)- the author replaces any author that has been conducted from any previous acts. "P" (Propagating)- the author is conducted to all child acts where the contextConductionInd is set to "true". Implementation in XML Instance The XML attribute contextControlCode shall contain the value " OP".
[1..1] [M] contentId (II) { "NPFIT-000081#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] functionCode (CV { CNE:AuthorFunctionType } ) { Fixed="OA" } | Model Attribute Description The HL7 attribute functionCode uses a code from the vocabulary AuthorFunctionType to describe the function of the author. Implementation in XML Instance The Coded Plain flavour of Coded Value (CV) datatype shall be used to carry this information in the XML element functionCode as follows: The XML attribute code shall contain the value "OA" The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.178" The XML attribute displayName will contain the value "Originating Author"
[1..1] [M] time (TS) | Model Attribute Description The HL7 attribute author time is used to indicate when the person authored the CDA document. Implementation in XML Instance The XML attribute value of the XML element time, shall be populated with a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where: yyyy is the year mm is the month dd is the day hh is the hour mm is the minutes ss is the seconds [+|-ZZzz] is the time zone offset in hours and minutes Sections from the right of this representation may be left off to when the sending system does not record to this accuracy. When hours are present, the time zone offset must also be present.
[1..1] [M] participant (AuthorChoice) | A link to the choice of author templates.
[0..*] authorization | Details of the authorisation associated with the CDA document
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } ) { Fixed="AUTH" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as one of authorization. Implementation in XML Instance The XML attribute typeCode is fixed to " AUTH".
[1..1] [M] contentId (II) { "NPFIT-000051#Act" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] authorizingConsent (Consent) | A link to details of the consent associated with the CDA document.
[1..1] [M] component | This class is a component that connects the document header to the structured body.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } ) { Fixed="COMP" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a component. Implementation in XML Instance The XML attribute typeCode is fixed to " COMP".
[1..1] [M] contextConductionInd (BL) { Fixed="true" } | Model Attribute Description The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent section is conducted across to the child section (also associated with the child section). Implementation in XML Instance The XML attribute contextConductionInd is fixed to " true".
[1..1] [M] bodyChoice (BodyChoice) | A link to the choice of document bodies.
[0..1] componentOf | This class is a component of relationship it is used to link the document header to the EncompassingEncounter that the CDA document is documenting.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } ) { Fixed="COMP" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a component. Implementation in XML Instance The XML attribute typeCode is fixed to " COMP".
[1..1] [M] contentId (II) { "NPFIT-000052#Act" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] encompassingEncounter (EncompassingEncounter) | A link to the Encompassing encounter.
[1..1] [M] custodian | A class which is a participation of custodian. The custodian is the legal owner of the CDA document and is the organisation responsible for maintaining the information in the CDA document.
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="CST" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a custodian participation. Implementation in XML Instance The XML attribute classCode is fixed to " CST".
[1..1] [M] contentId (II) { "NPFIT-000014#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] participant (CustodianChoice) | A link to the custodian templates.
[0..1] dataEnterer | This class is a data enterer participation. A data enterer is the person who entered the information contained in the document.
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="ENT" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this participation as a data enterer. Implementation in XML Instance The XML attribute typeCode is fixed to " ENT".
[1..1] [M] contextControlCode (CS { CNE: ContextControl } ) { Fixed="OP" } | Model Attribute Description The HL7 attribute contextConductionCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section is conducted across to the child section (also associated with the child section). This set of codes also determine how these participations conduct. The conduction can only take place if the contextConductionInd is set to "true". The value of this attribute is fixed in the HL7 model to "OP": "O" (Overriding)- the data enterer replaces any data enterer that has been conducted from any previous acts. "P" (Propagating)- the data enterer is conducted to all child acts where the contextConductionInd is set to "true". Implementation in XML Instance The XML attribute contextControlCode shall contain the value " OP".
[1..1] [M] contentId (II) { "NPFIT-000082#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] participant (DataEntererChoice) | A link to the choice of data enterer templates.
[0..*] documentationOf | This class is a documentation of relationship. It is used to link the document header to the Service Event being documented in the CDA document.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } ) { Fixed="DOC" } | Model Attribute Description The HL7 attribute classCode uses a code to describe this class as a document class. Implementation in XML Instance The XML attribute classCode is fixed to " DOC".
[1..1] [M] contentId (II) { "NPFIT-000050#Act" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] serviceEvent (ServiceEvent) | A link to the service event.
[0..*] informant | A class which is a participation of informant. An informant is a person who informed the author about information contained in the CDA document.
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="INF" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as an informant participation. Implementation in XML Instance The XML attribute classCode is fixed to " INF".
[1..1] [M] contextControlCode (CS { CNE: ContextControl } ) { Fixed="OP" } | Model Attribute Description The HL7 attribute contextConductionCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section is conducted across to the child section (also associated with the child section). This set of codes also determine how these participations conduct. The conduction can only take place if the contextConductionInd is set to "true". The value of this attribute is fixed in the HL7 model to "OP": "O" (Overriding)- the custodian replaces any custodian that has been conducted from any previous acts. "P" (Propagating)- the custodian is conducted to all child acts where the contextConductionInd is set to "true". Implementation in XML Instance The XML attribute contextControlCode shall contain the value " OP".
[1..1] [M] contentId (II) { "NPFIT-000085#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] participant (InformantChoice) | A link to the choice of informant templates.
[1..*] [M] informationRecipient | This class is a primary information recipient participation. The primary information recipients of the clinical documents are usually expected to perform some action on receipt of a CDA document. There can be more than one primary recipient.
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="PRCP" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a primary information recipient participation. Implementation in XML Instance The XML attribute classCode is fixed to " PRCP".
[1..1] [M] contentId (II) { "NPFIT-000080#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] participant (InformationRecipientChoice) | A link to the choice of primary information recipient templates.
[0..*] participant | A class which is for all other participants associated with the CDA document not covered by a participation specifically modelled. Participants are people,organisations or devices that are involved in some way with the CDA document.
[1..1] [M] typeCode (CS { CNE:ParticipationType } ) | Model Attribute Description The HL7 attribute typeCode uses a code from the HL7 vocabulary ParticipationType to identify the type of participation. Implementation in XML Instance The XML attribute typeCode shall contain a code from the HL7 vocabulary ParticipationType, The recommended codes to use for NHS use are listed below:
Code | Display name | Definition
--- | --- | ---
BBY | baby | A baby is a type of direct target that represents the participation of a baby (or foetus), this may be used when the mother is the patient and it is required to identify the baby or babies.
CALLBCK | call back contact | A person or organisation who should be specifically contacted for follow-up questions about the document when it is not the author.
CON | consultant | A consultant is a type of ancillary participation that represents an advisor participating by performing evaluations and making recommendations.
DEV | device | A device is a type of direct target that represents something used in delivering the service without being substantially affected by the act. This may be used when it is required to identify a device involved in the creation of the CDA document but when there is a human author.
DIST | distributor | A distributor is a type of performer that distributes material used in or generated during the act. This may be used when the CDA document is distributed by a third party who/ which not involved in it in any other way.
ELOC | entry location | A location when information constrained in the CDA document was entered.
NOT | urgent notification | An information recipient to notify about urgent matter associated with the CDA document
VIA | via | This may be used to indicate that the CDA document came via a third party
REFB | Referred by | A Referred by is a type of information recipient that represents the party that referred the subject of the act (e.g. patient).
REFT | Referred to | A Referred to is a type of information recipient that receives the a referral about a patient.
WIT | witness | This may be used to detail a person who witnessed service events detailed in the document
[1..1] [M] contextControlCode (CS { CNE: ContextControl } ) { Fixed="OP" } | Model Attribute Description The HL7 attribute contextConductionCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section is conducted across to the child section (also associated with the child section). This set of codes also determine how these participations conduct. The conduction can only take place if the contextConductionInd is set to "true". The value of this attribute is fixed in the HL7 model to "OP": "O" (Overriding)- the participation replaces any that has been conducted from any previous acts. "P" (Propagating)- the participation is conducted to all child acts where the contextConductionInd is set to "true". Implementation in XML Instance The XML attribute contextControlCode shall contain the value " OP".
[1..1] [M] contentId (II) { "NPFIT-000086#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[0..1] functionCode (CE { CWE:ParticipationFunction } ) | Model Attribute Description The HL7 attribute functionCode uses a code from the HL7 vocabulary ParticipationFunction or an alternative vocabulary to describe the function of the participant. Implementation in XML Instance The Coded Plain flavour of Coded with Equivalents (CE) data type shall be used to carry this information in the XML element functionCode as follows: The XML attribute code shall contain a code for the HL7 vocabulary ParticipationFunction The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.5.88" The XML attribute displayName shall contain a description associated with the code. The recommended values for functionCode for NHS USE are listed below:
Code | Display name | Definition
--- | --- | ---
ADMPHYS | admitting physician | A physician who admitted a patient to a hospital or other care unit that is the context of this service.
ANEST | anaesthetist | In a typical anaesthesia setting an anaesthesiologist or anaesthesia resident in charge of the anaesthesia and life support, but only a witness to the surgical procedure itself. To clarify responsibilities anaesthesia should always be represented as a separate service related to the surgery.
ANRS | anaesthesia nurse | In a typical anaesthesia setting the nurse principally assisting the anaesthesiologist during the critical periods.
ATTPHYS | attending physician | A physician who is primarily responsible for a patient during the hospitalization, which is the context of the service.
DISPHYS | discharging physician | A physician who discharged a patient from a hospital or other care unit that is the context of this service.
FASST | first assistant surgeon | In a typical surgery setting the assistant facing the primary surgeon. The first assistant performs parts of the operation and assists in others (e.g., incision, approach, electrocoutering, ligatures, sutures).
MDWF | midwife | A person (usually female) helping a woman deliver a baby. Responsibilities vary locally, ranging from a mere optional assistant to a full required participant, responsible for (normal) births and pre- and post-natal care for both mother and baby.
NASST | nurse assistant | In a typical surgery setting the non-sterile nurse handles material supply from the stock, forwards specimen to pathology, and helps with other non-sterile tasks (e.g., phone calls, etc.).
PCP | primary care physician | The healthcare provider that holds primary responsibility for the overall care of a patient.
PRISURG | primary surgeon | In a typical surgery setting the primary performing surgeon.
RNDPHYS | rounding physician | A physician who made rounds on a patient in a hospital or other care center.
SASST | second assistant surgeon | In a typical surgery setting the assistant who primarily holds the hooks.
SNRS | scrub nurse | In a typical surgery setting the nurse in charge of the instrumentation.
TASST | third assistant | In a typical surgery setting there is rarely a third assistant (e.g., in some Hip operations the third assistant postures the affected leg).
AUCG | caregiver information receiver | Caregiver authorized to receive patient health information.
AULR | legitimate relationship information receiver | Provider with legitimate relationship authorized to receive patient health information.
AUTM | care team information receiver | Description: Member of care team authorized to receive patient health information.
AUWA | work area information receiver | Entities within specified work area authorized to receive patient health information.
[1..1] participant (ParticipantChoice) | A link to the choice of participant templates.
[1..1] [M] recordTarget | A class which is a participation of record target (The patient whose record is the target for the information in the Document.)
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="RCT" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a record target participation. Implementation in XML Instance The XML attribute classCode is fixed to " RCT".
[1..1] [M] contextControlCode (CS { CNE: ContextControl } ) { Fixed="OP" } | Model Attribute Description The HL7 attribute contextConductionCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section is conducted across to the child section (also associated with the child section). This set of codes also determine how these participations conduct. The conduction can only take place if the contextConductionInd is set to "true". The value of this attribute is fixed in the HL7 model to "OP": "O" (Overriding)- the record target replaces any record target that has been conducted from any previous acts. "P" (Propagating)- the record target is conducted to all child acts where the contextConductionInd is set to "true". Implementation in XML Instance The XML attribute contextControlCode shall contain the value " OP".
[1..1] [M] contentId (II) { "NPFIT-000083#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] participant (Patient) | A link to the patient role templates.
[0..*] relatedDocument | This class is a related document relationship it links the current document to a related CDA document.
[1..1] [M] typeCode (CS { CNE:x_ActRelationshipDocument } ) | Model Attribute Description The HL7 attribute typeCode uses a code to describe the type of related document relationship. If the typeCode is "APND" then the current document is an addendum to the related document If the typeCode is "RPLC" then the current document is a replacement for the related document If the typeCode is "XFRM" then the current document is a transformation of the related document A conformant CDA document can have a single relatedDocument with typeCode "APND"; a single relatedDocument with typeCode "RPLC"; a single relatedDocument with typeCode "XFRM"; a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; or a combination of two relatedDocuments with typeCodes "XFRM" and "APND". No other combinations are allowed. Implementation in XML Instance The XML attribute typeCode is populated with a value from the HL7 vocabulary x_ActRelationshipDocument to describe the type of related document based on the rules stated above.
[1..1] priorParentDocument (ParentDocument) | A link to the parent document.
[0..*] tracker | This class is a tracker participation. A tracker is a recipient who is sent a copy of the CDA document for information only. They are not normally required to carry out any action on recipient of the CDA document.
[1..1] [M] typeCode (CS { CNE: ParticipationType } ) { Fixed="TRC" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this participation as a tracker. Implementation in XML Instance The XML attribute typeCode is fixed to " TRC".
[1..1] [M] contentId (II) { "NPFIT-000080#Role" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] participant (InformationRecipientChoice) | A link to the choice of tracker templates.
Consent | An abstract placeholder for the templates of consent
| Used by: ClinicalDocument
[1..1] : Template13 | A link to the templates for consent.
ParticipantChoice | An abstract placeholder for the templates of a participant.
| Used by: ClinicalDocument
[1..1] : Template11 | A link to the choice of participant templates.
CustodianChoice | An abstract placeholder for the templates of a custodian.
| Used by: ClinicalDocument
[1..1] : Template6 | A link to templates for a custodian.
InformantChoice | An abstract placeholder for the templates of an informant
| Used by: ClinicalDocument
[1..1] : Template8 | A link to templates for an informant.
Patient | An abstract placeholder for the templates of a patient
| Used by: ClinicalDocument
[1..1] : Template5 | A link to the choice of patient templates.
AuthorChoice | An abstract placeholder for the templates for an author.
| Used by: ClinicalDocument
[1..1] : Template4 | A link to the choice of templates for an author.
AuthenticatorChoice | An abstract placeholder for the templates for an authenticator.
| Used by: ClinicalDocument
[1..1] : Template3 | A link to the choice of templates for an authenticator.
InformationRecipientChoice | An abstract placeholder for the templates of a recipient.
| Used by: ClinicalDocument
[1..1] : Template1 | A link to the templates of a recipient.
BodyChoice | A choice of XML (CDA structured text) or Non XML (other formats other than CDA structured text) bodies for the CDA document.
| Used by: ClinicalDocument
[1..1] either: StructuredBody | A body using CDA structured text (mark up).
... or ... : NonXMLBody | A body using a non XML body (formats other than CDA structured text).
StructuredBody | The StructuredBody represents a CDA document body that is comprised of one or more document sections.
| Used by: ClinicalDocument,BodyChoice
[1..1] [M] classCode (CS { CNE: ActClass } ) { Fixed="DOCBODY" } | Model Attribute Description The HL7 attribute classCode uses a code to describe this class as a clinical document body. Implementation in XML Instance The XML attribute classCode is fixed to " DOCBODY".
[1..1] [M] moodCode (CS { CNE: ActMood } ) { Fixed="EVN" } | Model Attribute Description The HL7 attribute moodCode uses a code to describe this class as a clinical document body event Implementation in XML Instance The XML attribute moodCode is fixed to " EVN".
[1..1] [M] component | This class is a component of a section (a section the nests within another section).
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } ) { Fixed="COMP" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a component. Implementation in XML Instance The XML attribute typeCode is fixed to " COMP".
[1..1] [M] contextConductionInd (BL) { Fixed="true" } | Model Attribute Description The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent section is conducted across to the child section (also associated with the child section). Implementation in XML Instance The XML attribute contextConductionInd is fixed to " true".
[1..1] [M] classificationSection (ClassificationSection) | A link to the classification section.
ClassificationSection | A section which is not rendered but is used to hold the coded entries and CRE classification in one place for ease of processing.
| Used by: StructuredBody
[1..1] [M] classCode (CS { CNE: ActClass } ) { Fixed="DOCSECT" } | Model Attribute Description The HL7 attribute classCode uses a code to describe this class document section. Implementation in XML Instance The XML attribute classCode is fixed to " DOCSECT".
[1..1] [M] moodCode (CS { CNE: ActMood } ) { Fixed="EVN" } | Model Attribute Description The HL7 attribute moodCode uses a code to describe this class as a document event. Implementation in XML Instance The XML attribute classCode is fixed to " EVN".
[1..1] [M] id (II) | Model Attribute Description The HL7 attribute id uses an identifier to identify each instance of a classification section. Implementation in XML Instance The Identifier Global data type flavour is used to carry the identifier in the XML element id as follows: The XML attribute root shall contain a DCE UUID.
[1..*] [M] component | This class is a component. It links the classification section to the text sections.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } ) { Fixed="COMP" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a component. Implementation in XML Instance The XML attribute typeCode is fixed to " COMP".
[1..1] [M] contextConductionInd (BL) { Fixed="true" } | Model Attribute Description The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent section is conducted across to the child section (also associated with the child section). Implementation in XML Instance The XML attribute contextConductionInd is fixed to " true".
[1..1] [M] contentId (II) { "NPFIT-000040#Section" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] sectionChoice (SectionChoice) | A link to the choice of section templates.
[0..*] entry | This class is an entry. It links the classification section to the component coded entries.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } ) { Fixed="COMP" } | Model Attribute Description The HL7 attribute typeCode uses a code to describe this class as a component. Implementation in XML Instance The XML attribute typeCode is fixed to " COMP".
[1..1] [M] contextConductionInd (BL) { Fixed="true" } | Model Attribute Description The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent section is conducted across to the child section (also associated with the child section). Implementation in XML Instance The XML attribute contextConductionInd is fixed to " true".
[1..1] [M] contentId (II) { "NPFIT-000066#Section" } | Model Attribute Description The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use. The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model. Implementation in XML Instance The Identifier External data type flavour is used to carry this information in the XML element contentId as follows: The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16" The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] codedEntry (CodedEntry) | A link to the coded entry.
SectionChoice | An abstract placeholder for the templates of a section.
| Used by: ClassificationSection
[1..1] : Template9 | A link to the choice of section templates.
CodedEntry | An abstract placeholder for the templates of a coded entry.
| Used by: ClassificationSection
[1..1] : Template16 | A link to the templates for a coded entry.
NonXMLBody | The NonXMLBody class represents a document body that is in some format other than CDA structured text.
| Used by: ClinicalDocument,BodyChoice
[1..1] [M] classCode (CS { CNE: ActClass } ) { Fixed="DOCBODY" } | Model Attribute Description The HL7 attribute classCode uses a code to describe this class as a document body. Implementation in XML Instance The XML attribute classCode is fixed to " DOCBODY".
[1..1] [M] moodCode (CS { CNE: ActMood } ) { Fixed="EVN" } | Model Attribute Description The HL7 attribute moodCode uses a code to describe this class as an event. Implementation in XML Instance The XML attribute moodCode is fixed to " EVN".
[1..1] [M] text (ED) | Model Attribute Description The HL7 attribute text is used for the information which makes up the document body when the standard CDA structure (mark-up) is not used. Implementation in XML Instance The XML element text is populated as follows: The XML element text shall contain the non CDA structured text body. The XML attribute mediaType of the XML element text shall contain a value to identify the mime type. The XML attribute representation of the XML element text shall contain a value to identify the representation of the non CDA structured body.
DataEntererChoice | An abstract placeholder for the templates of a data enterer.
| Used by: ClinicalDocument
[1..1] : Template2 | A link to templates for a data enterer.
EncompassingEncounter | An abstract placeholder for the templates of an Encompassing encounter.
| Used by: ClinicalDocument
[1..1] : Template7 | A link to the templates for an encompassing encounter.
ParentDocument | A related CDA document which is being referenced. Note: how this document is related to the current CDA document is dependant on the value of the parentDocument relationship typeCode. If the typeCode is "APND" then the current document is an addendum to the related document If the typeCode is "RPLC" then the current document is a replacement for the related document If the typeCode is "XFRM" then the current document is a transformation of the related document
| Used by: ClinicalDocument
[1..1] [M] classCode (CS { CNE: ActClass } ) { Fixed="DOCCLIN" } | Model Attribute Description The HL7 attribute classCode uses a code to describe this class as a clinical document. Implementation in XML Instance The XML attribute classCode is fixed to " DOCCLIN".
[1..1] [M] moodCode (CS { CNE: ActMood } ) { Fixed="EVN" } | Model Attribute Description The HL7 attribute moodCode uses a code to describe this class as a clinical document event Implementation in XML Instance The XML attribute moodCode is fixed to " EVN".
[1..1] [M] code (CV { CWE:NonCodedCDADocumentType } ) | Model Attribute Description The HL7 attribute code uses a code from any vocabulary to describe the type of CDA document. There are three possible representations for this attribute: A single code from SNOMED CT A single code from a suitable alternative vocabulary A composition grammar using multiple SNOMED CT codes. Implementation in XML Instance When using a single SNOMED CT code then: The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows: The XML attribute code shall contain a code from the subset stated in NonCodedCDADocumentType vocabulary The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15" The XML attribute displayName may carry a description associated with the code in the subset stated in the NonCodedCDADocumentType vocabulary. It is recommended that the preferred term is used to populate this attribute. When using multiple SNOMED CT codes then: The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows: The XML attribute code shall contain a string composed from codes from the subsets stated in NonCodedCDADocumentType vocabulary as per the guidance in the vocabulary The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15.1" The XML attribute displayName may contain a string composed from the codes and descriptions from the subsets stated in NonCodedCDADocumentType vocabulary as per the guidance in the vocabulary When using an alternative vocabulary code then: The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows: The XML attribute code shall contain a code from the alternative vocabulary The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.337" The XML attribute displayName may carry a description associated with the code in alternative vocabulary
[1..1] [M] id (II) | Model Attribute Description The HL7 attribute id uses an identifier to identify each unique instance of a parent clinical document. If the typeCode is "APND" then the parent document is the document that has been appended If the typeCode is "RPLC" then the parent document is the document that has been replaced If the typeCode is "XFRM" then the parent document is the document that has been transformed Implementation in XML Instance The Identifier Global data type flavour is used to carry the identifier in the XML element id as follows: The XML attribute root shall contain a DCE UUID.
[0..1] setId (II) | Model Attribute Description The HL7 attribute setId uses an identifier to identify all documents that are part of a set of documents. Implementation in XML Instance The Identifier Global data type flavour is used to carry the identifier in the XML element setId as follows: The XML attribute root shall contain a DCE UUID This element shall be populated when the XML attribute typeCode of the XML element relatedDocument contains the value "RPLC" or "APND"
[0..1] text (ED) | Model Attribute Description The HL7 attribute text is used to describe the MIME type of the parent document. This attribute is used only to express the MIME type of the parent document, it is not to be used to embed the related document. Implementation in XML Instance The XML attribute mediaType of the XML element text shall contain the MIME type.
[0..1] versionNumber (INT) | Model Attribute Description The HL7 attribute versionNumber uses an integer value to allow versioning of the CDA document. The version number here is the version number of the parent document. Implementation in XML Instance The XML element versionNumber is populated as follows: The XML attribute value should contain the version number of the parent document as an integer value.
ServiceEvent | An abstract placeholder for the templates of a service event.
| Used by: ClinicalDocument
[1..1] : Template12 | A link to choice of service event templates.