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draft Template  Minimal CDA document

Template 2.16.840.1.113883.3.1937.99.61.13.10.1 - MinimalCDAdocument
Id 2.16.840.1.113883.3.1937.99.61.13.10.1
Version valid from 2013‑02‑10 status draft Under develeopment
Classification CDA document level template
Context Pathname /
Open/Closed Open (other than defined elements are allowed)
Description A minimal CDA Release 2 document, that contains only a few attributes and relationships for the ClinicalDocument class:
  • typeId: fixed
  • id: unique id of the document instance
  • code: type of document
  • effectiveTime: creation date of the document
  • confidentialityCode: confidentiality level indication for this document
  • recordTarget: the record target (e.g. patient)
  • author: author of this document
  • custodian: custodian for this document
  • component: contains (in this case) structured body
Associated with
Associated with 0 concepts
Id Name Data Set
Used by / Uses
Used by / Uses 9 templates
Uses Template id as Name Version
2.16.840.1.113883.3.1937.99.61.13.10.900001 Include CDAtypeId DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.900002 Include CDAid DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.900003 Include CDAtitle DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.900004 Include CDAeffectiveTime DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.900005 Include CDAconfidentialityCode DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.2001 Include CDArecordTarget DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.2002 Include CDAauthor DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.2003 Include CDAcustodian DYNAMIC
2.16.840.1.113883.3.1937.99.61.13.10.3001 Containment EKGImpressionSection DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example <ClinicalDocument>
  <!-- CDA Header -->
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  <templateId root="2.16.840.1.113883.3.1937.99.61.13.10.1"/>
  <id extension="123456789" root="2.16.840.1.113883.3.1937.99.3.2.997788.1"/>
  <code code="11524-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EKG study report"/>
  <effectiveTime value="20131020122709"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <recordTarget>
    <!-- .. -->
  </recordTarget>  <author>
    <!-- .. -->
  </author>  <custodian>
    <!-- .. -->
  </custodian>  <!-- CDA Body -->
  <component>
    <structuredBody>
      <component>
        <!-- .. -->
      </component>    </structuredBody>  </component></ClinicalDocument>
Item DT Card Conf Description Label
hl7:ClinicalDocument
(MinimalCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900001 CDA typeId (DYNAMIC) ..
treetree hl7:typeId
II 1 .. 1 CDAtypeId
treeblank treetree @extension
1 .. 1 F POCD_HD000040
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.1.3
treetree hl7:templateId
II 1 .. 1 M CDA document template id for this kind of document (MinimalCDAdocument)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.3.1937.99.61.13.10.1
  Example <templateId root="2.16.840.1.113883.3.1937.99.61.13.10.1"/>
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900002 CDA id (DYNAMIC) ..
treetree hl7:id
II 1 .. 1 (MinimalCDAdocument)
treetree hl7:code
CE 1 .. 1 M (MinimalCDAdocument)
treeblank treetree @code
1 .. 1 F 11524-6
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <!-- document type -->
<code code="11524-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EKG study report"/>
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900003 CDA title (DYNAMIC) 0..1
  Example <title>EKG Report as of 1 February 2013</title>
treetree hl7:title
ST 0 .. 1 (MinimalCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900004 CDA effectiveTime (DYNAMIC) ..
treetree hl7:effectiveTime
TS.DATETIME.MIN 1 .. 1 (MinimalCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900005 CDA confidentialityCode (DYNAMIC) ..
treetree hl7:confidentialityCode
CE 1 .. 1 (MinimalCDAdocument)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 Basic Confidentiality Kind (HL7) (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.2001 CDA recordTarget (DYNAMIC) ..
treetree hl7:recordTarget
(MinimalCDAdocument)
treeblank treetree @typeCode
0 .. 1 F RCT
treeblank treetree @contextControlCode
0 .. 1 F OP
  target Associated with concepts:
asips-dataelement-1 Patient
treeblank treetree hl7:patientRole
1 .. 1 (MinimalCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F PAT
Included from 2.16.840.1.113883.3.1937.99.61.13.10.110 National Patient Identifier (DYNAMIC) 1..1 Required
treeblank treeblank treetree hl7:id
II.NL.BSN 1 .. 1 R (MinimalCDAdocument)
treeblank treeblank treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.2.4.6.3
treeblank treeblank treeblank treetree @extension
1 .. 1 R
  Burgerservicenummer (National Patient Identifier)
  target Associated with concepts:
asips-dataelement-20 National Patient Identifier
treeblank treeblank treetree hl7:patient
1 .. 1 R (MinimalCDAdocument)
treeblank treeblank treeblank treetree @classCode
0 .. 1 F PSN
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
  Example <patient classCode="PSN" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
  <birthTime value="19620219"/>
</patient>
treeblank treeblank treeblank treetree hl7:name
PN 1 .. * R (MinimalCDAdocument)
  target Associated with concepts:
asips-dataelement-10 Nom
treeblank treeblank treeblank treetree hl7:administrativeGenderCode
CE 1 .. 1 R (MinimalCDAdocument)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (HL7) (DYNAMIC)
  target Associated with concepts:
asips-dataelement-40 Sexe
treeblank treeblank treeblank treetree hl7:birthTime
TS 1 .. 1 R (MinimalCDAdocument)
  target Associated with concepts:
asips-dataelement-30 Date de naissance
Included from 2.16.840.1.113883.3.1937.99.61.13.10.2002 CDA author (DYNAMIC) ..
treetree hl7:author
1 .. * (MinimalCDAdocument)
treeblank treetree @typeCode
0 .. 1 F AUT
  target Associated with concepts:
asips-dataelement-2 Performing physician
asips-dataelement-103 Auteur du document
treeblank treetree hl7:time
TS.DATE.MIN 1 .. 1 M (MinimalCDAdocument)
treeblank treetree hl7:assignedAuthor
1 .. 1 M (MinimalCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:id
II 1 .. 1 R (MinimalCDAdocument)
treeblank treeblank treetree hl7:assignedPerson
0 .. 1 (MinimalCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900200 CDA Person Elements (2011‑12‑19) ..
treeblank treeblank treeblank treetree @classCode
0 .. 1 F PSN
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:name
PN 1 .. 1 (MinimalCDAdocument)
  target Associated with concepts:
asips-dataelement-60 Name
treeblank treeblank treetree hl7:representedOrganization
0 .. 1 (MinimalCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900201 CDA Organization Elements (DYNAMIC) ..
treeblank treeblank treeblank treetree @classCode
0 .. 1 F ORG
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:id
II 0 .. * (MinimalCDAdocument)
treeblank treeblank treeblank treetree hl7:name
ON 1 .. 1 (MinimalCDAdocument)
treeblank treeblank treeblank treetree hl7:telecom
TEL 0 .. * (MinimalCDAdocument)
treeblank treeblank treeblank treetree hl7:addr
AD 0 .. 1 (MinimalCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.2003 CDA custodian (DYNAMIC) ..
treetree hl7:custodian
1 .. 1 (MinimalCDAdocument)
treeblank treetree @typeCode
0 .. 1 F CST
treeblank treetree hl7:assignedCustodian
1 .. 1 M (MinimalCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:representedCustodianOrganization
0 .. 1 (MinimalCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.61.13.10.900201 CDA Organization Elements (DYNAMIC) ..
treeblank treeblank treeblank treetree @classCode
0 .. 1 F ORG
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:id
II 0 .. * (MinimalCDAdocument)
treeblank treeblank treeblank treetree hl7:name
ON 1 .. 1 (MinimalCDAdocument)
treeblank treeblank treeblank treetree hl7:telecom
TEL 0 .. * (MinimalCDAdocument)
treeblank treeblank treeblank treetree hl7:addr
AD 0 .. 1 (MinimalCDAdocument)
treetree hl7:component
(MinimalCDAdocument)
treeblank treetree @typeCode
0 .. 1 F COMP
treeblank treetree @contextConductionInd
0 .. 1 F true
  Example <!-- now for the study results: CDA body -->
<component typeCode="COMP" contextConductionInd="true">
  <!-- ... -->
</component>
treeblank treetree hl7:structuredBody
(MinimalCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F DOCBODY
treeblank treeblank treetree @moodCode
0 .. 1 F EVN
  Example <structuredBody classCode="DOCBODY" moodCode="EVN">
  <!-- ... -->
</structuredBody>
treeblank treeblank treetree hl7:component
where
[hl7:section [hl7:templateId/@root='2.16.840.1.113883.3.1937.99.61.13.10.3001']]
1 .. 1 M (MinimalCDAdocument)
treeblank treeblank treeblank treetree @typeCode
0 .. 1 F COMP
treeblank treeblank treeblank treetree @contextConductionInd
0 .. 1 F true
  Contains 2.16.840.1.113883.3.1937.99.61.13.10.3001 EKG impression (DYNAMIC)