Package | hl7.cda.us.ccda |
Type | StructureDefinition |
Id | Id |
FHIR Version | R5 |
Source | http://hl7.org/cda/us/ccda/https://build.fhir.org/ig/HL7/CDA-ccda/StructureDefinition-USRealmHeader.html |
Url | http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader |
Version | 4.0.0-ballot |
Status | draft |
Date | 2024-12-11T22:59:59+00:00 |
Name | USRealmHeader |
Title | US Realm Header |
Experimental | False |
Realm | us |
Authority | hl7 |
Description | This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents. Further specification, such as ClinicalDocument/code, are provided in document templates that conform to this template. In all C-CDA documents, at least one section SHALL contain clinically relevant information. A document that contains only empty sections is unhelpful to providers and fails to meet the essential purpose of conveying meaningful clinical data. Such documents contribute to inefficiencies and frustration in the healthcare process, as they do not provide the necessary information for informed decision-making. |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument |
Kind | logical |
StructureDefinition | |
CarePlan ![]() | Care Plan |
ConsultationNote ![]() | Consultation Note |
ContinuityofCareDocumentCCD ![]() | Continuity of Care Document (CCD) |
DischargeSummary ![]() | Discharge Summary |
HistoryandPhysical ![]() | History and Physical |
OperativeNote ![]() | Operative Note |
ProcedureNote ![]() | Procedure Note |
ProgressNote ![]() | Progress Note |
ReferralNote ![]() | Referral Note |
TransferSummary ![]() | Transfer Summary |
USRealmHeaderforPatientGeneratedDocument ![]() | US Realm Header for Patient Generated Document |
UnstructuredDocument ![]() | Unstructured Document |
StructureDefinition | |
http://hl7.org/cda/stds/core/StructureDefinition/AD ![]() | AD: PostalAddress (V3 Data Type) |
http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS ![]() | IVL_TS: Interval (V3 Data Type) |
http://hl7.org/cda/stds/core/StructureDefinition/PN ![]() | PN: PersonName (V3 Data Type) |
http://hl7.org/cda/stds/core/StructureDefinition/TS ![]() | TS: PointInTime (V3 Data Type) |
http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument ![]() | ClinicalDocument (CDA Class) |
USRealmAddress ![]() | US Realm Address |
USRealmDateTime ![]() | US Realm Date and Time - Point in Time |
USRealmDateTimeInterval ![]() | US Realm Date and Time - Interval |
USRealmPatientNamePTNUSFIELDED ![]() | US Realm Patient Name (PTN.US.FIELDED) |
USRealmPersonNamePNUSFIELDED ![]() | US Realm Person Name (PN.US.FIELDED) |
http://terminology.hl7.org/ValueSet/v3-Country2 ![]() | Country2 |
http://hl7.org/fhir/us/core/ValueSet/simple-language ![]() | Language codes with language and optionally a region modifier |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition USRealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
![]() ![]() | C | 1..1 | ClinicalDocument | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). 4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). should-legalAuthenticator: SHOULD contain legalAuthenticator should-relatedParticipant: Documents SHOULD contain a RelatedPerson participant |
![]() ![]() ![]() | 1..1 | CS | ||
![]() ![]() ![]() ![]() | 1..1 | cs | Required Pattern: US | |
![]() ![]() ![]() | 1..1 | II | ||
![]() ![]() ![]() ![]() | 1..1 | oid, uuid, ruid | ||
![]() ![]() ![]() ![]() | 1..1 | st | ||
![]() ![]() ![]() | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
![]() ![]() ![]() ![]() | 1..1 | II | ||
![]() ![]() ![]() ![]() ![]() | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | st | Required Pattern: 2024-05-01 | |
![]() ![]() ![]() | 1..1 | II | **SHALL** be a globally unique identifier for the document (CONF:4537-9991). | |
![]() ![]() ![]() | 1..1 | CE | **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). | |
![]() ![]() ![]() ![]() | 0..0 | |||
![]() ![]() ![]() ![]() | 1..1 | cs | ||
![]() ![]() ![]() ![]() | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() ![]() | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
![]() ![]() ![]() | 1..1 | USRealmDateTime | Base for all types and resources | |
![]() ![]() ![]() | ||||
![]() ![]() ![]() ![]() | 0..0 | |||
![]() ![]() ![]() ![]() | 1..1 | cs | Binding: HL7 BasicConfidentialityKind ![]() | |
![]() ![]() ![]() | 1..1 | CS | ||
![]() ![]() ![]() | 0..1 | II | ||
![]() ![]() ![]() | 0..1 | INT | ||
![]() ![]() ![]() | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
![]() ![]() ![]() ![]() | 1..1 | PatientRole | ||
![]() ![]() ![]() ![]() ![]() | 1..* | II | ||
![]() ![]() ![]() ![]() ![]() | 1..* | USRealmAddress | 헨헦헖헗헜: Address | |
![]() ![]() ![]() ![]() ![]() | C | 1..* | TEL | 헨헦헖헗헜: Phone Number / Email should-use: SHOULD contain @use |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | cs | Binding: Telecom Use (US Realm Header) ![]() | |
![]() ![]() ![]() ![]() ![]() | C | 1..1 | Patient | 4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present with either a @value or @nullFlavor=UNK (CONF:4537-32993). 4537-21000: If sdtc:deceasedTime/@value is present, then sdtc:deceasedInd SHALL be present with value=true should-maritalStatusCode: SHOULD contain maritalStatusCode should-us-languageCommunication: SHOULD contain languageCommunication |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | CE | Binding: Administrative Gender (HL7 V3) ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | C | 1..1 | TS | 헨헦헖헗헜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured) ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | BL | sdtc:deceasedInd | |
![]() ![]() ![]() ![]() ![]() ![]() | C | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc 헨헦헖헗헜: Date of Death XML: deceasedTime (urn:hl7-org:sdtc) should-value-att: SHOULD contain @value ts-shall-year: **SHALL** be precise to at least the year ts-should-day: **SHOULD** be precise to at least the day |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Binding: Marital Status ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Binding: Religious Affiliation ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | CE | 헨헦헖헗헜: Race Binding: Race Category Excluding Nulls ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..* | CE | XML Namespace: urn:hl7-org:sdtc 헨헦헖헗헜: Race - The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | CE | 헨헦헖헗헜: Ethnicity Binding: Ethnicity ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..* | CE | XML Namespace: urn:hl7-org:sdtc 헨헦헖헗헜: Ethnicity XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | C | 0..* | Guardian | should-us-code: SHOULD contain code should-us-addr: SHOULD contain addr should-us-telecom: SHOULD contain telecom |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Binding: Personal And Legal Relationship Role Type ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..* | USRealmAddress | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | C | 0..* | TEL | should-use: SHOULD contain @use |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | cs | Binding: Telecom Use (US Realm Header) ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | Person | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | Birthplace | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | Place | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | C | 1..1 | AD | 4537-5402: If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet US Core USPS State *DYNAMIC* (CONF:4537-5402). 4537-5403: If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). should-country: SHOULD contain country |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | ||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | ADXP | Binding: Country2 (required) | |
![]() ![]() ![]() ![]() ![]() ![]() | C | 0..* | LanguageCommunication | 헨헦헖헗헜: Preferred Language should-proficiencyLevelCode: SHOULD contain proficiencyLevelCode should-preferenceInd: SHOULD contain preferenceInd |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | CS | Binding: Language codes with language and optionally a region modifier (required) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Binding: LanguageAbilityMode ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Binding: LanguageAbilityProficiency ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | BL | ||
![]() ![]() ![]() ![]() ![]() | 0..1 | Organization | ||
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | II | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | ON | ||
![]() ![]() ![]() ![]() ![]() ![]() | C | 1..* | TEL | should-use: SHOULD contain @use |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | cs | Binding: Telecom Use (US Realm Header) ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | USRealmAddress | Base for all types and resources | |
![]() ![]() ![]() | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
![]() ![]() ![]() ![]() | 1..1 | USRealmDateTime | Base for all types and resources | |
![]() ![]() ![]() ![]() | C | 1..1 | AssignedAuthor | 4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). should-id-npi: SHOULD contain an id with root='2.16.840.1.113883.4.6' (NPI) should-us-code: SHOULD contain code |
![]() ![]() ![]() ![]() ![]() | 1..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() ![]() ![]() ![]() | C | 0..1 | II | should-extension: SHOULD contain extension |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | cs | If NPI is unknown, set @nullFlavor to UNK | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | st | ||
![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..0 | |||
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | cs | Binding: Healthcare Provider Taxonomy ![]() | |
![]() ![]() ![]() ![]() ![]() | 1..* | USRealmAddress | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() | C | 1..* | TEL | should-use: SHOULD contain @use |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | cs | Binding: Telecom Use (US Realm Header) ![]() | |
![]() ![]() ![]() ![]() ![]() | 1..1 | |||
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | Person | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | AuthoringDevice | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | SC | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | SC | ||
![]() ![]() ![]() | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | |
![]() ![]() ![]() ![]() | 0..1 | USRealmDateTime | Base for all types and resources | |
![]() ![]() ![]() ![]() | 1..1 | AssignedEntity | ||
![]() ![]() ![]() ![]() ![]() | 1..* | II | ||
![]() ![]() ![]() ![]() ![]() ![]() | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |
![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Binding: Healthcare Provider Taxonomy ![]() | |
![]() ![]() ![]() ![]() ![]() | 1..* | USRealmAddress | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() | C | 1..* | TEL | should-use: SHOULD contain @use |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | cs | Binding: Telecom Use (US Realm Header) ![]() | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Person | ||
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
![]() ![]() ![]() | 0..* | Informant | Slice: Unordered, Open by exists:relatedEntity, exists:assignedEntity | |
![]() ![]() ![]() ![]() | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
![]() ![]() ![]() ![]() ![]() | 1..1 | AssignedEntity | ||
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | II | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | CE | Binding: Healthcare Provider Taxonomy ![]() | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | USRealmAddress | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | Person | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
![]() ![]() ![]() ![]() ![]() | 0..0 | |||
![]() ![]() ![]() ![]() | 0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. | |
![]() ![]() ![]() ![]() ![]() | 0..0 | |||
![]() ![]() ![]() ![]() ![]() | 1..1 | RelatedEntity | ||
![]() ![]() ![]() | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
![]() ![]() ![]() ![]() | 1..1 | AssignedCustodian | ||
![]() ![]() ![]() ![]() ![]() | 1..1 | CustodianOrganization | ||
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | II | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | C | 0..1 | oid, uuid, ruid | should-npi: SHOULD be NPI |