Integrated Urgent Care
Domain Message Specification

Version: 3.0; Status: RC1

Integrated Urgent Care Report Tabular View

POCD_RM200001GB02
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 { CNE:CDADocumentTypeSnCT } )

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

Integrated Urgent Care will use a single SNOMED CT code to represent an Integrated Urgent Care Report

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 the value "1066271000000101"
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15"

[1..1] [M] confidentialityCode (CV { CWE:x_BasicConfidentialityKind } )

Model Attribute Description

The HL7 attribute confidentialitycode 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_RM200001GB02" }

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_MT200001GB02"
[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:

  • The XML element title shall contain the value "Integrated Urgent Care Report"

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.
[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 fixed 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 document header is conducted across to the structured body (also associated with the structured body).

Implementation in XML Instance

The XML attribute contextConductionInd is fixed to " true".
[1..1] [M] structuredBody (StructuredBody)
A link to the structured body.
[1..1] [M] 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..*] 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 fixed 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
REFT
 Referred to
 A "referred to" is a participant that receives a patient referral.

[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 fixed 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 fixed 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..1] relatedDocument
This class is a related document relationship it links the current document to a related CDA document.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } )
{ Fixed="RPLC" }

Model Attribute Description

The HL7 attribute typeCode uses a code to describe the type of relationship as one of replacement.

Implementation in XML Instance

The XML attribute typeCode is fixed to " RPLC"
[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.
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.
InformationRecipientChoice
An abstract placeholder for the templates of a recipient.
Used by: ClinicalDocument
[1..1] : Template1
A link to the templates of a recipient.
StructuredBody

The StructuredBody represents a CDA document body that is comprised of one or more document sections.
Used by: ClinicalDocument
[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-000065#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] : Template
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.
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.
ParticipantChoice
An abstract placeholder for the templates of a participant.
Used by: ClinicalDocument
[1..1] : Template14
A link to the choice of participant templates.
ParentDocument
A related CDA document which is being referenced as the document being replaced.
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 { CNE:CDADocumentTypeSnCT } )

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

Integrated Urgent Care will use a single SNOMED CT code to represent an Integrated Urgent Care Report

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 the value "1066271000000101"
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15"
[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.

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 of the document being replaced.
[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] 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.