Structured Headings - Tabular View

[1..1] [M] classCode (CS { CNE: ACT } )

Model Attribute Description

The HL7 attribute classCode describes the type of act using a value from the ActClassRoot domain of the HL7 vocabulary ActClass. This code can be any suitable subtype of "ACT"

Implementation in XML Instance

The XML attribute classCode shall carry a code from the ActClassRoot domain of the HL7 vocabulary ActClass. The recommended values to use are listed in the table below:

Code	Name	Definition
PROC	procedure	This code is used when the CDA document is about a medical procedure
CLNTRL	clinical trial	This code is used when the document is about a clinical trial to assess the effectiveness and/or safety of a biopharmaceutical product (food,drug,device, etc).
INFRM	inform	This code is used for service events related to giving information about a topic to the patient.
PCPR	patient care provision	This code is used when the CDA document is about a transfer of care.
SPCOBS	specimen observation	This code is used for CDA documents related to laboratory reports.
OBSSER	observation series	This code is used for a CDA document about observation series, for example ECG reports.
SBADM	substance administration	This code is used when the document is about a substance administration, which is a type of act that involves using, introducing or otherwise applying a substance to the patient.

[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] code (CE { CWE:SnomedCT } )

Model Attribute Description

The HL7 attribute code uses a code from any vocabulary to describe the type of service event. The vocabulary SnomedCT is a default vocabulary and contains no values.

Implementation in XML Instance

The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows:

When using a SNOMED CT code then:

The XML attribute code shall contain a SNOMED CT code
The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15"
The XML attribute displayName shall carry a description associated with the SNOMED CT code. It is recommended that the preferred term is used to populate this attribute
The XML element originalText may be used if required to carry the text or phrase used as the basis for the coding.

When using a code from an alternative vocabulary and no OID is available on the sending system then:

The XML attribute code shall contain the code
The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.335"
The XML attribute displayName shall carry a description associated with the code
The XML element originalText may be used if required to carry the text or phrase used as the basis for the coding

When using an alternative vocabulary and an OID is available on the sending system then:

The XML attribute code shall contain the code
The XML attribute codeSystem shall contain the OID from the alternative vocabulary
The XML attribute displayName shall carry a description associated with the code
The XML element originalText may be used if required to carry the text or phrase used as the basis for the coding

[0..1] effectiveTime (IVL<TS>)

Model Attribute Description

The HL7 attribute effectiveTime defines the time the actual service event (as opposed to the encounter surrounding the event) took place.

Implementation in XML Instance

The Interval of Points in Time data type flavour is used to carry this information in the XML attribute value of the XML elements low, center or high.

The date range shall be carried as follows:

The XML attribute value of the XML elements low, center and high, shall be populated (when used) 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 minute
[+|-ZZzz] is the time zone offset in hours and minutes

At least the year must be present.

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.

If a single point in time is to be carried the Date or Time Point data type shall be used:

The XML attribute value of the XML element center shall be populated with a time stamp

This datatype is used if date of the service is not fully known / available

If both a 'start date' and an 'end date' are present the Date or Time Interval Complete data type shall be used:

The XML attribute value of the XML element low shall be populated with a 'start date' time stamp

The XML attribute value of the XML element high shall be populated with an 'end date' time stamp

If only a start date is present the Date or Time Interval After data type shall be used:

The XML attribute value of the XML element low shall be populated with a 'start date' time stamp

This datatype would only be used if the service is still ongoing

The XML attribute value of the XML elements low, center or high should be populated to the level of detail that is available on the sending system.

[1..*] [M] id (SET<II>)

Model Attribute Description

The HL7 attribute id uses an identifier to identify an instance of a service event.

Implementation in XML Instance

The Identifier Global data type flavour shall be used to carry this information in the XML element id in at least one of the following ways:

When using a DCE UUID to identify the service event then:

The XML attribute root shall contain a DCE UUID.

When using a local identifier to identify the service event then:

The XML attribute root shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.40"
The XML attribute extension shall contain the local identifier
The XML attribute assigningAuthorityName shall contain the assigning organisation in the format of ODSCode:ODSName, for example:

assigningAuthorityName=" RA9:SOUTH DEVON HEALTHCARE NHS TRUST

[1..1] [M] templateId (II)
{ Fixed="COCD_TP146227GB02#ServiceEvent" }

Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:

The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
The XML attribute extension is fixed to "COCD_TP146227GB02#ServiceEvent"

[0..*] performer

This class is a performer participation.

A performer is a care professionals involved with carrying out the service.

There may multiple performers.

[1..1] [M] typeCode (CS { CNE: x_ServiceEventPerformer } )

Model Attribute Description

The HL7 attribute typeCode uses a code from the HL7 vocabulary x_ServiceEventPerformer to describe the type of service event performer. This code allows identification of the level of involvement of the personal in the service event to be indicated when required.

Implementation in XML Instance

The XML attribute typeCode shall contain a value from the x_ServiceEventPerformer vocabulary.

The recommended codes for populating the XML attribute typeCode are listed below:

Code	Name	Definition
PRF	performer	A person who actually and principally carries out an action. Need not be the principal responsible actor, e.g. a surgery resident operating under supervision of attending surgeon, and may be the patient in self-care, e.g. fingerstick blood sugar. The traditional order filler is a performer. This information should accompany every service event.
PPRF	primary performer	A primary performer is a type of performer that represents the principal or primary performer of an act that involves other performers or assistants. The primary performer is the person who undertakes the primary activity not the most senior person involved.
SPRF	secondary performer	A secondary performer is a type of performer that represents a person who assists in the performance of the act. A secondary performer must be directly involved in the act. The term secondary performer relates only to the nature of participation in the act. Neither job title nor seniority has any bearing on whether a participant is a primary performer or secondary performer.

[1..1] [M] contentId (II) { "NPFIT-000091#Role" }

Model Attribute Description

The HL7 (NHS Localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for a 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 content Id 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 local vocabulary to describe the function of the participant.

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:

When using the HL7 vocabulary ParticipationFunction then:

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).

When an alternative vocabulary is available and an OID is available then:

The XML attribute code shall contain a code from the vocabulary
The XML attribute codeSystem shall contain the OID for the vocabulary
The XML attribute displayName shall carry the name associated with the code.

When an alternative vocabulary is available and an OID is not available then:

The XML attribute code shall contain a code from the vocabulary
The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.412"
The XML attribute displayName shall carry the name associated with the code.

[1..1] [M] templateId (II)
{ Fixed="COCD_TP146227GB02#performer" }

Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:

The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
The XML attribute extension is fixed to "COCD_TP146227GB02#performer"

[0..1] time (IVL<TS>)

Model Attribute Description

The HL7 attribute time defines the time during which the performer performed (was involved) in the service event.

Implementation in XML Instance

The Interval of Points in Time data type flavour is used to carry this information in the XML attribute value of the XML elements low, center or high.

The date range shall be carried as follows:

The XML attribute value of the XML elements low, center and high, shall be populated (when used) 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 minute
[+|-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.

If a single point in time is to be carried the Date or Time Point data type shall be used. This is used when the time when or during which the person performed the service event is not fully known:

The XML attribute value of the XML element center shall contain the date.

If both a start date and an end date are present the Date or Time Interval Complete data type shall be used, this is used when the start and end times of the person's performance in the service event is known and the presence of an end date indicates that the person is no longer performing in the service event:

The XML attribute value of the XML element low shall contain the start date of the person's performance in the service event.
The XML attribute value of the XML element high shall contain the end date of the person's performance in the service event.

If only a start date is present the Date or Time Interval After data type shall be used, this is used when the person is still performing in the service event and if the service event is still ongoing.

The XML attribute value of the XML element low shall contain the start date of the person's performance in the service event.

If only an end date is present the Date or Time Interval Before data type shall be used, this is used when the person is no longer performing in the service event and the actual date they started performing in the service event is not known:

The XML attribute value of the XML element high shall contain the end date.

The XML attribute value of the XML element low, center or high should be populated to the level of detail that is available on the sending system.

[1..1] participant (PerformerChoice)

A link to the choice of performer.

[1..1] : Template1

A link to the choice of performer templates.

Structured Headings
Domain Message Specification

ServiceEvent Tabular View

Structured HeadingsDomain Message Specification

ServiceEvent Tabular View

Structured Headings
Domain Message Specification