Structured Headings
Domain Message Specification

Structured Headings Model Tabular View

POCD_RM000042GB01
ClinicalDocument

This template class constrains the CDA ClinicalDocument class.

This class is a clinical document class. This class and its participations are commonly known as the header of the CDA document.

This generic model is the domain model that contains all the templates for the Academy of Medical Royal Colleges (AoMRC) structured headings, along with the associated coded entry and participant templates. The model also includes templates from other sources which are not part of the AoMRC headings work.

This model itself is not meant for implementation but is constrained by a profile specification using the various artefacts contained in this specification. These artefacts contained in this specification are used in conjunction with the rules contained in a profile specification for validation and accreditation purposes.

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 the CDADocumentTypeSnCT vocabulary to describe the type of Structured Headings CDA document.

The representation of this attribute is as a compositional expression consisting of multiple codes from SNOMED CT.

Note: the vocabulary contains additional guidance for the use of this attribute with SNOMED CT.

Implementation in XML Instance

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 CDADocumentTypeSnCT 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 CDADocumentTypeSnCT vocabulary as per the guidance in the vocabulary.
[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 some form of locally agreed access control.

Implementation in XML Instance

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.

[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)

Model Attribute Description

The HL7 (NHS localisation) attribute messageType identifies the CDA document as one that complies with a particular NHS CDA conformance Refined Message Information Model structure.

The value of this attribute provides a unique identifier for the message 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 fixed value defined in the CDA Profile Specification Document.
[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 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 on 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 template class constrains the CDA authenticator class.

This class is an authenticator. An authenticator is a type of verifier who attests to the accuracy of the document, but is not authorised as a legal authenticator.
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-500084#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..1] [M] author

This template class constrains the CDA author class.

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 contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section are 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-500081#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 the time when the CDA document was authored.

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

This template class constrains the authorization class.

This class links the clinical document with any consents 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-500051#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 template class constrains the CDA component class.

This class is a component that connects the document header to the BodyChoice (containing the StructuredBody and NonXMLBody classes).

[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 classCode 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 template class constrains the CDA component class.

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-500052#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] encompassingEncounter (EncompassingEncounter)

A link to the encompassing encounter.

[1..1] [M] custodian

This template class constrains the CDA custodian class.

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-500014#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 template class constrains the CDA dataEnterer class.

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 contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section are 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-500082#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-500050#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.

[1..*] [M] informationRecipient

This template class constrains the CDA informationRecipient class.

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-500080#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

This template class constrains the CDA participant class.

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.

Note, there is guidance on how to populate this participant class and associated templates in the "Populating HSCIC CDA Document Participant Templates" document available from the Associated Specifications tab of this DMS.

[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.

[1..1] [M] contextControlCode (CS { CNE: ContextControl } )
{ Fixed="OP" }

Model Attribute Description

The HL7 attribute contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section are 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-500086#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

There is guidance on how to populate this in the "Populating HSCIC CDA Document Participant Templates" document available from the Associated Specifications tab of this DMS.

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

Model Attribute Description

The HL7 attribute participation time is used to indicate the time or duration when the participant was involved with the Structured Headings Model.

Implementation in XML Instance

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
  • ss is the seconds
  • [+|-ZZzz] is the time zone offset in hours and minutes

If a single point in time is to be carried the Date or Time Point data type shall be used. This is used for the time when or during which the participant was involved 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 participant's involvement is known and the presence of an end date indicates that the participant is no longer participating (no longer involved):

  • The XML attribute value of the XML element low shall contain the start date of the participant's involvement
  • The XML attribute value of the XML element high shall contain the end date of the participant's involvement

If only a start date is present the Date or Time Interval After data type shall be used, this is used when the participant is still participating (is still involved):

  • The XML attribute value of the XML element low shall contain the start date of the person's involvement

If only an end date is present the Date or Time Interval Before data type shall be used, this is used when the participant is no longer participating (no longer involved) and the actual date they started participating is not known:

  • The XML attribute value of the XML element high shall contain the end date
[1..1] participant (ParticipantChoice)

A link to the choice of participant templates.

[1..1] [M] recordTarget

This template class constrains the CDA recordTarget class.

A class which is a participation of the record target (i.e. 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 contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section are 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-500083#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 template class constrains the CDA relatedDocument class.

This class is a related document relationship which 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 template class constrains the CDA informationRecipient class.

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 receipt 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-500080#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.

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.

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.

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

The NonXMLBody class represents a document body that is in some format other than CDA structured text.

StructuredBody

This template class constrains the CDA StructuredBody class.

The StructuredBody class 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..*] [M] component

This template class constrains the CDA component class.

This class is a component of a section (a section that 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] contentId (II) { "NPFIT-500004#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.

SectionChoice

An abstract placeholder for the templates of a section.

Used by: StructuredBody
[1..1] : Template9

A link to the choice of section templates.

NonXMLBody

This template class constrains the CDA NonXMLBody class.

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 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 document section event.

Implementation in XML Instance

  • The XML attribute classCode 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.

ParentDocument

This template class constrains the CDA ParentDocument class.

This class is 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 SNOMED CT to describe the type of Structured Headings Model.

The representation of this attribute is as follows:

  • A compositional expression consisting of multiple codes from SNOMED CT.

Note: the vocabulary contains additional guidance for the use of this attribute with SNOMED CT.

Implementation in XML Instance

When using the compositional expression consisting of 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 CDADocumentTypeSnCT 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".
  • The XML attribute displayName may contain a string composed from the codes and descriptions from the subsets stated in CDADocumentTypeSnCT vocabulary as per the guidance in the vocabulary.

[1..1] [M] id (II)

Model Attribute Description

The HL7 attribute id uses an identifier to uniquely identify the document being replaced.

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.
[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.
[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 document being replaced.

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.