Document-Level Templates - Homepage | HL7 International

CDAR2_IG_CCDA_CLINNOTES_DSTUR2_D1_2013SEP_V2_Templates and Supporting TOC \o "1-4" \h \z \u 1Document-Level Templates PAGEREF _Toc363421096 \h 91.1US Realm Header (V2) PAGEREF _Toc363421097 \h 91.1.1Participants and Header Relationships PAGEREF _Toc363421098 \h 161.1.1.1recordTarget PAGEREF _Toc363421099 \h 161.1.1.2author PAGEREF _Toc363421100 \h 191.1.1.3dataEnterer PAGEREF _Toc363421101 \h 201.1.1.4informant PAGEREF _Toc363421102 \h 211.1.1.5informationRecipient PAGEREF _Toc363421103 \h 231.1.1.6legalAuthenticator PAGEREF _Toc363421104 \h 231.1.1.7authenticator PAGEREF _Toc363421105 \h 251.1.1.8participant PAGEREF _Toc363421106 \h 261.1.1.9inFulfillmentOf PAGEREF _Toc363421107 \h 261.1.1.10documentationOf PAGEREF _Toc363421108 \h 271.1.1.11performer PAGEREF _Toc363421109 \h 271.1.1.12authorization PAGEREF _Toc363421110 \h 281.1.1.13componentOf PAGEREF _Toc363421111 \h 281.1.2Care Plan (NEW) PAGEREF _Toc363421112 \h 351.1.3Consultation Note (V2) PAGEREF _Toc363421113 \h 391.1.3.1templateId PAGEREF _Toc363421114 \h 411.1.3.2code PAGEREF _Toc363421115 \h 421.1.3.3title PAGEREF _Toc363421116 \h 421.1.3.4inFulfillmentOf PAGEREF _Toc363421117 \h 421.1.3.5componentOf PAGEREF _Toc363421118 \h 431.1.3.6structuredBody PAGEREF _Toc363421119 \h 441.1.4Continuity of Care Document (CCD) (V2) PAGEREF _Toc363421120 \h 521.1.5Diagnostic Imaging Report (V2) PAGEREF _Toc363421121 \h 581.1.6Discharge Summary (V2) PAGEREF _Toc363421122 \h 771.1.7History and Physical (V2) PAGEREF _Toc363421123 \h 861.1.8Operative Note (V2) PAGEREF _Toc363421124 \h 951.1.9Procedure Note (V2) PAGEREF _Toc363421125 \h 1021.1.10Progress Note (V2) PAGEREF _Toc363421126 \h 1131.1.11Referral Note (NEW) PAGEREF _Toc363421127 \h 1201.1.12Transfer Summary (NEW) PAGEREF _Toc363421128 \h 1281.1.13Unstructured Document (V2) PAGEREF _Toc363421129 \h 1371.1.14US Realm Header - Patient Generated Document (NEW) PAGEREF _Toc363421130 \h 1412Section-Level Templates PAGEREF _Toc363421131 \h 1522.1Advance Directives Section (entries optional) (V2) PAGEREF _Toc363421132 \h 1532.1.1Advance Directives Section (entries required) (V2) PAGEREF _Toc363421133 \h 1542.2Allergies Section (entries optional) (V2) PAGEREF _Toc363421134 \h 1562.2.1Allergies Section (entries required) (V2) PAGEREF _Toc363421135 \h 1572.3Anesthesia Section (V2) PAGEREF _Toc363421136 \h 1582.4Assessment and Plan Section (V2) PAGEREF _Toc363421137 \h 1602.5Assessment Section PAGEREF _Toc363421138 \h 1612.6Chief Complaint and Reason for Visit Section PAGEREF _Toc363421139 \h 1622.7Chief Complaint Section PAGEREF _Toc363421140 \h 1632.8Complications (OpNote) (obsolete) PAGEREF _Toc363421141 \h 1632.9Complications Section (V2) PAGEREF _Toc363421142 \h 1642.10DICOM Object Catalog Section - DCM 121181 PAGEREF _Toc363421143 \h 1652.11Discharge Diet Section (deprecated) PAGEREF _Toc363421144 \h 1662.12Encounters Section (entries optional) (V2) PAGEREF _Toc363421145 \h 1672.12.1Encounters Section (entries required) (V2) PAGEREF _Toc363421146 \h 1682.13Family History Section PAGEREF _Toc363421147 \h 1702.14Fetus Subject Context PAGEREF _Toc363421148 \h 1712.15Findings Section (DIR) PAGEREF _Toc363421149 \h 1722.16Functional Status Section (V2) PAGEREF _Toc363421150 \h 1732.17General Status Section PAGEREF _Toc363421151 \h 1762.18Goals Section (NEW) PAGEREF _Toc363421152 \h 1772.19Health Concerns Section (NEW) PAGEREF _Toc363421153 \h 1782.20Health Status Evaluations/Outcomes Section (NEW) PAGEREF _Toc363421154 \h 1802.21History of Past Illness Section (V2) PAGEREF _Toc363421155 \h 1812.22History of Present Illness Section PAGEREF _Toc363421156 \h 1822.23Hospital Admission Diagnosis Section (V2) PAGEREF _Toc363421157 \h 1832.24Hospital Admission Medications Section (entries optional) (V2) PAGEREF _Toc363421158 \h 1842.25Hospital Consultations Section PAGEREF _Toc363421159 \h 1852.26Hospital Course Section PAGEREF _Toc363421160 \h 1852.27Hospital Discharge Diagnosis Section (V2) PAGEREF _Toc363421161 \h 1862.28Hospital Discharge Instructions Section PAGEREF _Toc363421162 \h 1872.29Hospital Discharge Medications Section (entries optional) (V2) PAGEREF _Toc363421163 \h 1882.29.1Hospital Discharge Medications Section (entries required) (V2) PAGEREF _Toc363421164 \h 1892.30Hospital Discharge Physical Section PAGEREF _Toc363421165 \h 1902.31Hospital Discharge Studies Summary Section PAGEREF _Toc363421166 \h 1912.32Immunizations Section (entries optional) (V2) PAGEREF _Toc363421167 \h 1922.32.1Immunizations Section (entries required) (V2) PAGEREF _Toc363421168 \h 1932.33Implants Section PAGEREF _Toc363421169 \h 1942.34Instructions Section (V2) PAGEREF _Toc363421170 \h 1952.35Interventions Section (V2) PAGEREF _Toc363421171 \h 1962.36Medical (General) History Section (V2) PAGEREF _Toc363421172 \h 1972.37Medical Equipment Section (V2) PAGEREF _Toc363421173 \h 1992.38Medications Administered Section (V2) PAGEREF _Toc363421174 \h 2012.39Medications Section (entries optional) (V2) PAGEREF _Toc363421175 \h 2032.39.1Medications Section (entries required) (V2) PAGEREF _Toc363421176 \h 2052.40Mental Status Section (NEW) PAGEREF _Toc363421177 \h 2072.41Nutrition Section (NEW) PAGEREF _Toc363421178 \h 2102.42Objective Section PAGEREF _Toc363421179 \h 2142.43Observer Context PAGEREF _Toc363421180 \h 2142.44Operative Note Fluids Section PAGEREF _Toc363421181 \h 2152.45Operative Note Surgical Procedure Section PAGEREF _Toc363421182 \h 2162.46Payers Section (V2) PAGEREF _Toc363421183 \h 2172.47Physical Exam Section (V2) PAGEREF _Toc363421184 \h 2192.48Physical Findings of Skin Section PAGEREF _Toc363421185 \h 2202.49Plan of Treatment Section (V2) PAGEREF _Toc363421186 \h 2212.50Planned Procedure Section (V2) PAGEREF _Toc363421187 \h 2242.51Postoperative Diagnosis Section PAGEREF _Toc363421188 \h 2252.52Postprocedure Diagnosis Section (V2) PAGEREF _Toc363421189 \h 2262.53Preoperative Diagnosis Section (V2) PAGEREF _Toc363421190 \h 2272.54Problem Section (entries optional) (V2) PAGEREF _Toc363421191 \h 2282.54.1Problem Section (entries required) (V2) PAGEREF _Toc363421192 \h 2302.55Procedure Description Section PAGEREF _Toc363421193 \h 2312.56Procedure Disposition Section PAGEREF _Toc363421194 \h 2322.57Procedure Estimated Blood Loss Section PAGEREF _Toc363421195 \h 2332.58Procedure Findings Section (V2) PAGEREF _Toc363421196 \h 2342.59Procedure Implants Section PAGEREF _Toc363421197 \h 2352.60Procedure Indications Section (V2) PAGEREF _Toc363421198 \h 2362.61Procedure Specimens Taken Section PAGEREF _Toc363421199 \h 2372.62Procedures Section (entries optional) (V2) PAGEREF _Toc363421200 \h 2382.62.1Procedures Section (entries required) (V2) PAGEREF _Toc363421201 \h 2392.63Reason for Referral Section (V2) PAGEREF _Toc363421202 \h 2412.64Reason for Visit Section PAGEREF _Toc363421203 \h 2422.65Results Section (entries optional) (V2) PAGEREF _Toc363421204 \h 2432.65.1Results Section (entries required) (V2) PAGEREF _Toc363421205 \h 2452.66Review of Systems Section PAGEREF _Toc363421206 \h 2472.67Social History Section (V2) PAGEREF _Toc363421207 \h 2482.68Subjective Section PAGEREF _Toc363421208 \h 2522.69Surgery Description Section PAGEREF _Toc363421209 \h 2532.70Surgical Drains Section PAGEREF _Toc363421210 \h 2542.71Vital Signs Section (entries optional) (V2) PAGEREF _Toc363421211 \h 2552.71.1Vital Signs Section (entries required) (V2) PAGEREF _Toc363421212 \h 2563Entry-Level Templates PAGEREF _Toc363421213 \h 2583.1Act Plan (V2) PAGEREF _Toc363421214 \h 2593.2Act Reference (NEW) PAGEREF _Toc363421215 \h 2613.3Admission Medication (V2) PAGEREF _Toc363421216 \h 2643.4Advance Directive Observation (V2) PAGEREF _Toc363421217 \h 2663.5Advance Directive Organizer PAGEREF _Toc363421218 \h 2743.6Age Observation PAGEREF _Toc363421219 \h 2763.7Allergy Problem Act (V2) PAGEREF _Toc363421220 \h 2783.8Allergy Status Observation (DEPRECATED) PAGEREF _Toc363421221 \h 2803.9Assessment Scale Observation PAGEREF _Toc363421222 \h 2823.10Assessment Scale Supporting Observation PAGEREF _Toc363421223 \h 2853.11Authorization Activity PAGEREF _Toc363421224 \h 2863.12Boundary Observation PAGEREF _Toc363421225 \h 2873.13Caregiver Characteristics PAGEREF _Toc363421226 \h 2883.14Characteristics of Home Environment (NEW) PAGEREF _Toc363421227 \h 2903.15Clinical Statement Reference PAGEREF _Toc363421228 \h 2923.16Code Observations PAGEREF _Toc363421229 \h 2933.17Cognitive Status Observation (V2) PAGEREF _Toc363421230 \h 2943.17.1Cognitive Abilities Observation (NEW) PAGEREF _Toc363421231 \h 2973.18Cognitive Status Organizer (V2) PAGEREF _Toc363421232 \h 3003.19Cognitive Status Problem Observation (DEPRECATED) PAGEREF _Toc363421233 \h 3023.20Comment Activity PAGEREF _Toc363421234 \h 3063.21Communication from Provider to Provider PAGEREF _Toc363421235 \h 3083.21.1Handoff Communication (NEW) PAGEREF _Toc363421236 \h 3103.22Coverage Activity (V2) PAGEREF _Toc363421237 \h 3133.23Cultural and Religious Observation (NEW) PAGEREF _Toc363421238 \h 3153.24Deceased Observation (V2) PAGEREF _Toc363421239 \h 3163.25Diet (NEW) PAGEREF _Toc363421240 \h 3183.26Discharge Medication (V2) PAGEREF _Toc363421241 \h 3203.27Drug Vehicle PAGEREF _Toc363421242 \h 3223.28Encounter Activity (V2) PAGEREF _Toc363421243 \h 3233.29Encounter Diagnosis (V2) PAGEREF _Toc363421244 \h 3263.30Encounter Plan (V2) PAGEREF _Toc363421245 \h 3273.31Entry Author PAGEREF _Toc363421246 \h 3313.32Estimated Date of Delivery PAGEREF _Toc363421247 \h 3333.33Family History Death Observation PAGEREF _Toc363421248 \h 3343.34Family History Observation PAGEREF _Toc363421249 \h 3363.35Family History Organizer PAGEREF _Toc363421250 \h 3393.36Functional Status Observation (V2) PAGEREF _Toc363421251 \h 3433.37Functional Status Organizer (V2) PAGEREF _Toc363421252 \h 3463.38Functional Status Problem Observation (DEPRECATED) PAGEREF _Toc363421253 \h 3483.39Health Concern Act (NEW) PAGEREF _Toc363421254 \h 3533.40Health Status Observation (V2) PAGEREF _Toc363421255 \h 3643.41Highest Pressure Ulcer Stage PAGEREF _Toc363421256 \h 3663.42Hospital Admission Diagnosis (V2) PAGEREF _Toc363421257 \h 3673.43Hospital Discharge Diagnosis (V2) PAGEREF _Toc363421258 \h 3683.44Immunization Activity (V2) PAGEREF _Toc363421259 \h 3703.45Immunization Medication Information PAGEREF _Toc363421260 \h 3793.46Immunization Medication Information (V2) PAGEREF _Toc363421261 \h 3813.47Immunization Refusal Reason PAGEREF _Toc363421262 \h 3843.48Indication (V2) PAGEREF _Toc363421263 \h 3853.49Instruction (V2) PAGEREF _Toc363421264 \h 3883.50Intervention Act (NEW) PAGEREF _Toc363421265 \h 3903.51Medical Equipment Organizer (NEW) PAGEREF _Toc363421266 \h 3963.52Medication Activity (V2) PAGEREF _Toc363421267 \h 3993.53Medication Dispense (V2) PAGEREF _Toc363421268 \h 4093.54Medication Information (V2) PAGEREF _Toc363421269 \h 4123.55Medication Supply Order (V2) PAGEREF _Toc363421270 \h 4133.56Medication Use - None Known (obsolete) PAGEREF _Toc363421271 \h 4153.57Mental Status Observation (NEW) PAGEREF _Toc363421272 \h 4163.58Non-Medicinal Supply Activity PAGEREF _Toc363421273 \h 4183.59Non-Medicinal Supply Activity (V2) PAGEREF _Toc363421274 \h 4203.60Number of Pressure Ulcers Observation PAGEREF _Toc363421275 \h 4223.61Nutritional Status Observation (NEW) PAGEREF _Toc363421276 \h 4243.62Observation Plan (V2) PAGEREF _Toc363421277 \h 4273.62.1Goal Observation (NEW) PAGEREF _Toc363421278 \h 4303.63Patient Preference PAGEREF _Toc363421279 \h 4373.64Patient Priority Preference (NEW) PAGEREF _Toc363421280 \h 4383.65Patient Referral Activity Observation (NEW) PAGEREF _Toc363421281 \h 4403.66Physician of Record Participant (V2) PAGEREF _Toc363421282 \h 4433.67Policy Activity (V2) PAGEREF _Toc363421283 \h 4453.68Postprocedure Diagnosis (V2) PAGEREF _Toc363421284 \h 4533.69Precondition for Substance Administration PAGEREF _Toc363421285 \h 4543.70Pregnancy Observation PAGEREF _Toc363421286 \h 4543.71Preoperative Diagnosis (V2) PAGEREF _Toc363421287 \h 4563.72Pressure Ulcer Observation (DEPRECATED) PAGEREF _Toc363421288 \h 4573.73Problem Concern Act (Condition) (V2) PAGEREF _Toc363421289 \h 4633.74Problem Observation (V2) PAGEREF _Toc363421290 \h 4663.74.1Wound Observation (NEW) PAGEREF _Toc363421291 \h 4723.75Problem Status (DEPRECATED) PAGEREF _Toc363421292 \h 4773.76Procedure Activity Act (V2) PAGEREF _Toc363421293 \h 4793.77Procedure Activity Observation (V2) PAGEREF _Toc363421294 \h 4853.78Procedure Activity Procedure (V2) PAGEREF _Toc363421295 \h 4933.78.1Medical Device Applied (NEW) PAGEREF _Toc363421296 \h 5033.79Procedure Context PAGEREF _Toc363421297 \h 5073.80Procedure Plan (V2) PAGEREF _Toc363421298 \h 5093.80.1Nutrition Recommendations (NEW) PAGEREF _Toc363421299 \h 5123.81Product Instance PAGEREF _Toc363421300 \h 5143.82Prognosis Observation PAGEREF _Toc363421301 \h 5153.83Progress Toward Goal Observation PAGEREF _Toc363421302 \h 5173.84Provider Preference PAGEREF _Toc363421303 \h 5193.85Provider Priority Preference (NEW) PAGEREF _Toc363421304 \h 5203.86Purpose of Reference Observation PAGEREF _Toc363421305 \h 5223.87Quantity Measurement Observation PAGEREF _Toc363421306 \h 5243.88Reaction Observation (V2) PAGEREF _Toc363421307 \h 5273.89Reason PAGEREF _Toc363421308 \h 5323.90Referenced Frames Observation PAGEREF _Toc363421309 \h 5333.91Result Observation (V2) PAGEREF _Toc363421310 \h 5353.91.1Outcome Observation (NEW) PAGEREF _Toc363421311 \h 5383.92Result Organizer (V2) PAGEREF _Toc363421312 \h 5403.93Self-Care Activities (ADL and IADL) (NEW) PAGEREF _Toc363421313 \h 5423.94Sensory and Speech Status (NEW) PAGEREF _Toc363421314 \h 5443.95Series Act PAGEREF _Toc363421315 \h 5473.96Service Delivery Location PAGEREF _Toc363421316 \h 5503.97Severity Observation (V2) PAGEREF _Toc363421317 \h 5523.98Social History Observation (V2) PAGEREF _Toc363421318 \h 5543.99SOP Instance Observation PAGEREF _Toc363421319 \h 5573.100Study Act PAGEREF _Toc363421320 \h 5603.101Substance Administered Act (NEW) PAGEREF _Toc363421321 \h 5623.102Substance Administration Plan (V2) PAGEREF _Toc363421322 \h 5643.102.1Drug Monitoring Act (NEW) PAGEREF _Toc363421323 \h 5663.103Substance or Device Allergy - Intolerance Observation (V2) PAGEREF _Toc363421324 \h 5703.103.1Allergy - Intolerance Observation (V2) PAGEREF _Toc363421325 \h 5753.104Supply Plan (V2) PAGEREF _Toc363421326 \h 5823.105Text Observation PAGEREF _Toc363421327 \h 5843.106Tobacco Use (V2) PAGEREF _Toc363421328 \h 5873.106.1Current Smoking Status (V2) PAGEREF _Toc363421329 \h 5903.107Vital Sign Observation (V2) PAGEREF _Toc363421330 \h 5933.108Vital Signs Organizer (V2) PAGEREF _Toc363421331 \h 5953.109Wound Characteristics (NEW) PAGEREF _Toc363421332 \h 5983.110Wound Measurement Observation (NEW) PAGEREF _Toc363421333 \h 6004Participant and Other Templates PAGEREF _Toc363421334 \h 6034.1Author Participant (NEW) PAGEREF _Toc363421335 \h 6034.2Physician Reading Study Performer (V2) PAGEREF _Toc363421336 \h 6064.3US Realm Address (AD.US.FIELDED) PAGEREF _Toc363421337 \h 6084.4US Realm Date and Time (DT.US.FIELDED) (obsolete) PAGEREF _Toc363421338 \h 6104.5US Realm Date and Time (DTM.US.FIELDED) PAGEREF _Toc363421339 \h 6104.6US Realm Patient Name (PTN.US.FIELDED) PAGEREF _Toc363421340 \h 6114.7US Realm Person Name (PN.US.FIELDED) PAGEREF _Toc363421341 \h 6135Template Ids in This Guide PAGEREF _Toc363421342 \h 6146Value Sets In This Guide PAGEREF _Toc363421343 \h 622Document-Level TemplatesDocument-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and refer to section-level templates. Each document-level template contains the following information:???Scope and intended use of the document type???Description and explanatory narrative.???Template metadata (e.g., templateId, etc.)???Header constraints: this includes a reference to the US Realm Clinical Document Header template and additional constraints specific to each document type???Required and optional section-level templates??US Realm Header (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.1.2 (open)]SEQ Table \* ARABIC1: US Realm Header (V2) ContextsContained By:Contains:This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents. Further specification, such as documentCode, are provided in document templates that conform to this template.SEQ Table \* ARABIC2: US Realm Header (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.1.2']realmCode1..1SHALL16791UStypeId1..1SHALL5361@root1..1SHALL52502.16.840.1.113883.1.3@extension1..1SHALL5251POCD_HD000040templateId1..1SHALL5252@root1..1SHALL100362.16.840.1.113883.10.20.22.1.1.2id1..1SHALL5363code1..1SHALL5253title1..1SHALL5254effectiveTime1..1SHALL5256confidentialityCode1..1SHALL52592.16.840.1.113883.1.11.16926 (HL7 BasicConfidentialityKind)languageCode1..1SHALL53722.16.840.1.113883.1.11.11526 (Language)setId0..1MAY5261versionNumber0..1MAY5264recordTarget1..*SHALL5266patientRole1..1SHALL5267id1..*SHALL5268addr1..*SHALL5271telecom1..*SHALL5280@use0..1SHOULD53752.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))patient1..1SHALL5283name1..*SHALL5284administrativeGenderCode1..1SHALL63942.16.840.1.113883.1.11.1 (Administrative Gender (HL7 V3))birthTime1..1SHALL5298maritalStatusCode0..1SHOULD53032.16.840.1.113883.1.11.12212 (Marital Status Value Set)religiousAffiliationCode0..1MAY53172.16.840.1.113883.1.11.19185 (Religious Affiliation Value Set)raceCode0..1SHOULD53222.16.840.1.113883.1.11.14914 (Race Value Set)sdtc:raceCode0..*MAY72632.16.840.1.113883.1.11.14914 (Race Value Set)ethnicGroupCode0..1SHOULD53232.16.840.1.114222.4.11.837 (EthnicityGroup)guardian0..*MAY5325code0..1SHOULD53262.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)addr0..*SHOULD5359telecom0..*MAY5382@use0..1SHOULD79932.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))guardianPerson1..1SHALL5385name1..*SHALL5386birthplace0..1MAY5395place1..1SHALL5396addr1..1SHALL5397country0..1SHOULD54042.16.840.1.113883.3.88.12.80.63 (CountryValueSet)postalCode0..1MAY54032.16.840.1.113883.3.88.12.80.2 (PostalCodeValueSet)languageCommunication0..*SHOULD5406languageCode1..1SHALL54072.16.840.1.113883.1.11.11526 (Language)modeCode0..1MAY54092.16.840.1.113883.1.11.12249 (LanguageAbilityMode Value Set)proficiencyLevelCode0..1SHOULD99652.16.840.1.113883.1.11.12199 (LanguageAbilityProficiency)preferenceInd0..1SHOULD5414providerOrganization0..1MAY5416id1..*SHALL5417@root0..1SHOULD168202.16.840.1.113883.4.6name1..*SHALL5419telecom1..*SHALL5420@use0..1SHOULD79942.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))addr1..*SHALL5422author1..*SHALL5444time1..1SHALL5445assignedAuthor1..1SHALL5448id1..*SHALL5449code0..1SHOULD16787@code1..1SHALL167882.16.840.1.114222.4.11.1066 (Healthcare Provider Taxonomy (HIPAA))addr1..*SHALL5452telecom1..*SHALL5428@use0..1SHOULD79952.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))assignedPerson0..1SHOULD5430name1..*SHALL16789assignedAuthoringDevice0..1SHOULD16783manufacturerModelName1..1SHALL16784softwareName1..1SHALL16785dataEnterer0..1MAY5441assignedEntity1..1SHALL5442id1..*SHALL5443@root0..1SHOULD168212.16.840.1.113883.4.6addr1..*SHALL5460telecom1..*SHALL5466@use0..1SHOULD79962.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))assignedPerson1..1SHALL5469name1..*SHALL5470informant0..*MAY8001assignedEntity1..1SHALL8002id1..*SHALL9945addr1..*SHALL8220assignedPerson1..1SHALL8221name1..*SHALL8222custodian1..1SHALL5519assignedCustodian1..1SHALL5520representedCustodianOrganization1..1SHALL5521id1..*SHALL5522@root0..1SHOULD168222.16.840.1.113883.4.6name1..1SHALL5524telecom1..1SHALL5525@use0..1SHOULD79982.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))addr1..1SHALL5559informationRecipient0..*MAY5565intendedRecipient1..1SHALL5566informationRecipient0..1MAY5567name1..*SHALL5568receivedOrganization0..1MAY5577name1..1SHALL5578legalAuthenticator0..1SHOULD5579time1..1SHALL5580signatureCode1..1SHALL5583@code1..1SHALL55842.16.840.1.113883.5.89 (Participationsignature) = Ssdtc:signatureText0..1MAY30810assignedEntity1..1SHALL5585id1..*SHALL5586@root0..1MAY168232.16.840.1.113883.4.6code0..1MAY170002.16.840.1.114222.4.11.1066 (Healthcare Provider Taxonomy (HIPAA))addr1..*SHALL5589telecom1..*SHALL5595@use0..1SHOULD79992.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))assignedPerson1..1SHALL5597name1..*SHALL5598authenticator0..*MAY5607time1..1SHALL5608signatureCode1..1SHALL5610@code1..1SHALL56112.16.840.1.113883.5.89 (Participationsignature) = Ssdtc:signatureText0..1MAY30811assignedEntity1..1SHALL5612id1..*SHALL5613@root0..1SHOULD168242.16.840.1.113883.4.6code0..1MAY16825@code0..1MAY168262.16.840.1.114222.4.11.1066 (Healthcare Provider Taxonomy (HIPAA))addr1..*SHALL5616telecom1..*SHALL5622@use0..1SHOULD80002.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))assignedPerson1..1SHALL5624name1..*SHALL5625participant0..*MAY10003time0..1MAY10004inFulfillmentOf0..*MAY9952order1..1SHALL9953id1..*SHALL9954documentationOf0..*MAY14835serviceEvent1..1SHALL14836effectiveTime1..1SHALL14837low1..1SHALL14838performer0..*SHOULD14839@typeCode1..1SHALL148402.16.840.1.113883.5.90 (HL7ParticipationType)functionCode0..1MAY16818@codeSystem0..1SHOULD168192.16.840.1.113883.5.88 (participationFunction)assignedEntity1..1SHALL14841id1..*SHALL14846@root0..1SHOULD148472.16.840.1.113883.4.6code0..1SHOULD14842@code1..1SHALL148432.16.840.1.113883.6.101 (NUCCProviderTaxonomy)authorization0..*MAY16792consent1..1SHALL16793id0..*MAY16794code0..1MAY16795statusCode1..1SHALL16797@code1..1SHALL167982.16.840.1.113883.5.6 (HL7ActClass) = completedcomponentOf0..1MAY9955encompassingEncounter1..1SHALL9956id1..*SHALL9959effectiveTime1..1SHALL9958informant0..*MAY31355relatedEntity1..1SHALL31356SHALL contain exactly one [1..1] realmCode="US" (CONF:16791).SHALL contain exactly one [1..1] typeId (CONF:5361).This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" (CONF:5250).This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:5251).SHALL contain exactly one [1..1] templateId (CONF:5252) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1.2" (CONF:10036).SHALL contain exactly one [1..1] id (CONF:5363).This id SHALL be a globally unique identifier for the document (CONF:9991).SHALL contain exactly one [1..1] code (CONF:5253).This code SHALL specify the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note) (CONF:9992).SHALL contain exactly one [1..1] title (CONF:5254).Note: The title can either be a locally defined name or the displayName corresponding to clinicalDocument/codeSHALL contain exactly one [1..1] effectiveTime (CONF:5256).The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:29287).SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC 2010-04-21 (CONF:5259).SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language 2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:5372).MAY contain zero or one [0..1] setId (CONF:5261).If??setId is present versionNumber SHALL be present (CONF:6380).MAY contain zero or one [0..1] versionNumber (CONF:5264).If versionNumber is present setId SHALL be present (CONF:6387).Participants and Header RelationshipsrecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole elementSHALL contain at least one [1..*] recordTarget (CONF:5266).Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:5267).This patientRole SHALL contain at least one [1..*] id (CONF:5268).This patientRole SHALL contain at least one [1..*] addr (CONF:5271).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10412).This patientRole SHALL contain at least one [1..*] telecom (CONF:5280).Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:5375).This patientRole SHALL contain exactly one [1..1] patient (CONF:5283).This patient SHALL contain at least one [1..*] name (CONF:5284).The content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1) (CONF:10411).This patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC (CONF:6394).This patient SHALL contain exactly one [1..1] birthTime (CONF:5298).SHALL be precise to year (CONF:5299).SHOULD be precise to day (CONF:5300).This patient SHOULD contain zero or one [0..1] maritalStatusCode, which SHALL be selected from ValueSet Marital Status Value Set 2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:5303).This patient MAY contain zero or one [0..1] religiousAffiliationCode, which SHALL be selected from ValueSet Religious Affiliation Value Set 2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:5317).This patient SHOULD contain zero or one [0..1] raceCode, which SHALL be selected from ValueSet Race Value Set 2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:5322).The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races.This patient MAY contain zero or more [0..*] sdtc:raceCode, which SHALL be selected from ValueSet Race Value Set 2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:7263).If sdtc:raceCode is present, then the patient SHALL contain 1..1] raceCode (CONF:31347).This patient SHOULD contain zero or one [0..1] ethnicGroupCode, which SHALL be selected from ValueSet EthnicityGroup 2.16.840.1.114222.4.11.837 DYNAMIC (CONF:5323).This patient MAY contain zero or more [0..*] guardian (CONF:5325).The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:5326).The guardian, if present, SHOULD contain zero or more [0..*] addr (CONF:5359).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10413).The guardian, if present, MAY contain zero or more [0..*] telecom (CONF:5382).The telecom, if present, SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7993).The guardian, if present, SHALL contain exactly one [1..1] guardianPerson (CONF:5385).This guardianPerson SHALL contain at least one [1..*] name (CONF:5386).The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:10414).This patient MAY contain zero or one [0..1] birthplace (CONF:5395).The birthplace, if present, SHALL contain exactly one [1..1] place (CONF:5396).This place SHALL contain exactly one [1..1] addr (CONF:5397).This addr SHOULD contain zero or one [0..1] country, which SHALL be selected from ValueSet CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:5404).This addr MAY contain zero or one [0..1] postalCode, which SHALL be selected from ValueSet PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC (CONF:5403).If country is US, this addr SHALL contain exactly one 1..1] state, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.1 StateValueSet DYNAMIC (CONF:5402).This patient SHOULD contain zero or more [0..*] languageCommunication (CONF:5406).The languageCommunication, if present, SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language 2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:5407).The languageCommunication, if present, MAY contain zero or one [0..1] modeCode, which SHALL be selected from ValueSet LanguageAbilityMode Value Set 2.16.840.1.113883.1.11.12249 DYNAMIC (CONF:5409).The languageCommunication, if present, SHOULD contain zero or one [0..1] proficiencyLevelCode, which SHALL be selected from ValueSet LanguageAbilityProficiency 2.16.840.1.113883.1.11.12199 DYNAMIC (CONF:9965).The languageCommunication, if present, SHOULD contain zero or one [0..1] preferenceInd (CONF:5414).This patientRole MAY contain zero or one [0..1] providerOrganization (CONF:5416).The providerOrganization, if present, SHALL contain at least one [1..*] id (CONF:5417).Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:16820).The providerOrganization, if present, SHALL contain at least one [1..*] name (CONF:5419).The providerOrganization, if present, SHALL contain at least one [1..*] telecom (CONF:5420).Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7994).The providerOrganization, if present, SHALL contain at least one [1..*] addr (CONF:5422).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10415).authorThe author element represents the creator of the clinical document.??The author may be a device or a person. SHALL contain at least one [1..*] author (CONF:5444).Such authors SHALL contain exactly one [1..1] time (CONF:5445).The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:16866).Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:5448).This assignedAuthor SHALL contain at least one [1..*] id (CONF:5449).If this assignedAuthor is an assignedPerson, the assignedAuthor/id SHOULD contain zero to one 0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:31135).This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:16787).The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:16788).This assignedAuthor SHALL contain at least one [1..*] addr (CONF:5452).The content SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:16871).This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:5428).Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7995).This assignedAuthor SHOULD contain zero or one [0..1] assignedPerson (CONF:5430).The assignedPerson, if present, SHALL contain at least one [1..*] name (CONF:16789).The content SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:16872).This assignedAuthor SHOULD contain zero or one [0..1] assignedAuthoringDevice (CONF:16783).The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] manufacturerModelName (CONF:16784).The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] softwareName (CONF:16785).There SHALL be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:16790).dataEntererThe dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.MAY contain zero or one [0..1] dataEnterer (CONF:5441).The dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:5442).This assignedEntity SHALL contain at least one [1..*] id (CONF:5443).Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:16821).This assignedEntity SHALL contain at least one [1..*] addr (CONF:5460).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10417).This assignedEntity SHALL contain at least one [1..*] telecom (CONF:5466).Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7996).This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:5469).This assignedPerson SHALL contain at least one [1..*] name (CONF:5470).The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:10418).This assignedEntity MAY contain zero or one 0..1] code which SHOULD be selected from coding system NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101 (CONF:9944).informantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.MAY contain zero or more [0..*] informant (CONF:8001) such that itSHALL contain exactly one [1..1] assignedEntity (CONF:8002).This assignedEntity SHALL contain at least one [1..*] id (CONF:9945).If assignedEntity/id is a provider then this id, SHOULD include zero or one 0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:9946).This assignedEntity SHALL contain at least one [1..*] addr (CONF:8220).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10419).This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:8221).This assignedPerson SHALL contain at least one [1..*] name (CONF:8222).The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:10420).This assignedEntity MAY contain zero or one 0..1] code which SHOULD be selected from coding system NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101 (CONF:9947).The informant element describes an information source for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient. MAY contain zero or more [0..*] informant (CONF:31355) such that itSHALL contain exactly one [1..1] relatedEntity (CONF:31356).The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.There may only be exactly one custodian per CDA document. Allowing that CDA is an exchange standard and may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.SHALL contain exactly one [1..1] custodian (CONF:5519).This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:5520).This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:5521).This representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:5522).Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:16822).This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:5524).This representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:5525).This telecom SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7998).This representedCustodianOrganization SHALL contain exactly one [1..1] addr (CONF:5559).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10421).informationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.MAY contain zero or more [0..*] informationRecipient (CONF:5565).The informationRecipient, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:5566).This intendedRecipient MAY contain zero or one [0..1] informationRecipient (CONF:5567).The informationRecipient, if present, SHALL contain at least one [1..*] name (CONF:5568).The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:10427).This intendedRecipient MAY contain zero or one [0..1] receivedOrganization (CONF:5577).The receivedOrganization, if present, SHALL contain exactly one [1..1] name (CONF:5578).legalAuthenticatorThe legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated.The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication.??All clinical documents have the potential for legal authentication, given the appropriate credentials.Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system.Note that the legal authenticator, if present, must be a person.SHOULD contain zero or one [0..1] legalAuthenticator (CONF:5579).The legalAuthenticator, if present, SHALL contain exactly one [1..1] time (CONF:5580).The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:29402).The legalAuthenticator, if present, SHALL contain exactly one [1..1] signatureCode (CONF:5583).This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: Participationsignature 2.16.840.1.113883.5.89 STATIC) (CONF:5584).The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013..The legalAuthenticator, if present, MAY contain zero or one [0..1] sdtc:signatureText (CONF:30810).Note: The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are:1) Electronic signature: this attribute can represent virtually any electronic signature scheme.2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.The legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:5585).This assignedEntity SHALL contain at least one [1..*] id (CONF:5586).Such ids MAY contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:16823).This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066 STATIC (CONF:17000).This assignedEntity SHALL contain at least one [1..*] addr (CONF:5589).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10429).This assignedEntity SHALL contain at least one [1..*] telecom (CONF:5595).Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7999).This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:5597).This assignedPerson SHALL contain at least one [1..*] name (CONF:5598).The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:10430).authenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.MAY contain zero or more [0..*] authenticator (CONF:5607).The authenticator, if present, SHALL contain exactly one [1..1] time (CONF:5608).The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:16874).The authenticator, if present, SHALL contain exactly one [1..1] signatureCode (CONF:5610).This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: Participationsignature 2.16.840.1.113883.5.89 STATIC) (CONF:5611).The sdtc:signatureText extension provides a location in CDA for a textual or multimedia depiction of the signature by which the participant endorses and accepts responsibility for his or her participation in the Act as specified in the Participation.typeCode. Details of what goes in the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013..The authenticator, if present, MAY contain zero or one [0..1] sdtc:signatureText (CONF:30811).Note: The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are:1) Electronic signature: this attribute can represent virtually any electronic signature scheme.2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.The authenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:5612).This assignedEntity SHALL contain at least one [1..*] id (CONF:5613).Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:16824).This assignedEntity MAY contain zero or one [0..1] code (CONF:16825).The code, if present, MAY contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066 STATIC (CONF:16826).This assignedEntity SHALL contain at least one [1..*] addr (CONF:5616).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10425).This assignedEntity SHALL contain at least one [1..*] telecom (CONF:5622).Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:8000).This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:5624).This assignedPerson SHALL contain at least one [1..*] name (CONF:5625).The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:10424).participantThe participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).MAY contain zero or more [0..*] participant (CONF:10003) such that itMAY contain zero or one [0..1] time (CONF:10004).SHALL contain associatedEntity/associatedPerson AND/OR associatedEntity/scopingOrganization (CONF:10006).When participant/@typeCode is IND, associatedEntity/@classCode SHOULD be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:10007).inFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists’ report of an x-ray.MAY contain zero or more [0..*] inFulfillmentOf (CONF:9952).The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:9953).This order SHALL contain at least one [1..*] id (CONF:9954).documentationOfA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.MAY contain zero or more [0..*] documentationOf (CONF:14835).The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:14836).This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:14837).This effectiveTime SHALL contain exactly one [1..1] low (CONF:14838).performerThis serviceEvent SHOULD contain zero or more [0..*] performer (CONF:14839).The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors The performer, if present, SHALL contain exactly one [1..1] @typeCode (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:14840).The performer, if present, MAY contain zero or one [0..1] functionCode (CONF:16818).The functionCode, if present, SHOULD contain zero or one [0..1] @codeSystem, which SHOULD be selected from CodeSystem participationFunction (2.16.840.1.113883.5.88) STATIC (CONF:16819).The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:14841).This assignedEntity SHALL contain at least one [1..*] id (CONF:14846).Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:14847).This assignedEntity SHOULD contain zero or one [0..1] code (CONF:14842).The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from CodeSystem NUCCProviderTaxonomy (2.16.840.1.113883.6.101) STATIC (CONF:14843).authorizationThe authorization element represents information about the patient’s consent.The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ‘Privacy Consent’.MAY contain zero or more [0..*] authorization (CONF:16792) such that itSHALL contain exactly one [1..1] consent (CONF:16793).This consent MAY contain zero or more [0..*] id (CONF:16794).The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code This consent MAY contain zero or one [0..1] code (CONF:16795).This consent SHALL contain exactly one [1..1] statusCode (CONF:16797).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:16798).componentOfThe componentOf element contains the encompassing encounter for the document. The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred.In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants.In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.MAY contain zero or one [0..1] componentOf (CONF:9955).The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:9956).This encompassingEncounter SHALL contain at least one [1..*] id (CONF:9959).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:9958).SEQ Table \* ARABIC3: HL7 BasicConfidentialityKindValue Set: HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926CodeCode SystemPrint NameNConfidentialityCodenormalRConfidentialityCoderestrictedVConfidentialityCodevery restrictedSEQ Table \* ARABIC4: LanguageValue Set: Language 2.16.840.1.113883.1.11.11526CodeCode SystemPrint NameaaLanguageAfarabLanguageAbkhazianaceLanguageAchineseachLanguageAcoliadaLanguageAdangmeadyLanguageAdyghe; AdygeiaeLanguageAvestanafLanguageAfrikaansafaLanguageAfro-Asiatic (Other)afhLanguageAfrihiliainLanguageAinuakLanguageAkanakkLanguageAkkadianaleLanguageAleutalgLanguageAlgonquian languagesaltLanguageSouthern AltaiamLanguageAmharicanLanguageAragoneseangLanguageEnglish, Old (ca.450-1100)anpLanguageAngika...SEQ Table \* ARABIC5: Telecom Use (US Realm Header)Value Set: Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20CodeCode SystemPrint NameHPAddressUsePrimary homeHVAddressUseVacation homeWPAddressUseWork placeMCAddressUseMobile contactSEQ Table \* ARABIC6: Administrative Gender (HL7 V3)Value Set: Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1Administrative Gender based upon HL7 V3 vocabulary. This value set contains only male, female and undifferentiated concepts.CodeCode SystemPrint NameFAdministrativeGenderFemaleMAdministrativeGenderMaleUNAdministrativeGenderUndifferentiatedSEQ Table \* ARABIC7: Marital Status Value SetValue Set: Marital Status Value Set 2.16.840.1.113883.1.11.12212Marital Status is the domestic partnership status of a person.CodeCode SystemPrint NameAMaritalStatusAnnulledDMaritalStatusDivorcedTMaritalStatusDomestic partnerIMaritalStatusInterlocutoryLMaritalStatusLegally SeparatedMMaritalStatusMarriedSMaritalStatusNever MarriedPMaritalStatusPolygamousWMaritalStatusWidowedSEQ Table \* ARABIC8: Religious Affiliation Value SetValue Set: Religious Affiliation Value Set 2.16.840.1.113883.1.11.19185CodeCode SystemPrint Name1001ReligiousAffiliationAdventist1002ReligiousAffiliationAfrican Religions1003ReligiousAffiliationAfro-Caribbean Religions1004ReligiousAffiliationAgnosticism1005ReligiousAffiliationAnglican1006ReligiousAffiliationAnimism1007ReligiousAffiliationAtheism1008ReligiousAffiliationBabi & Baha'I faiths1009ReligiousAffiliationBaptist1010ReligiousAffiliationBon1011ReligiousAffiliationCao Dai1012ReligiousAffiliationCelticism1013ReligiousAffiliationChristian (non-Catholic, non-specific)1014ReligiousAffiliationConfucianism1015ReligiousAffiliationCyberculture Religions1016ReligiousAffiliationDivination1017ReligiousAffiliationFourth Way1018ReligiousAffiliationFree Daism1019ReligiousAffiliationGnosis1020ReligiousAffiliationHinduism...SEQ Table \* ARABIC9: Race Value SetValue Set: Race Value Set 2.16.840.1.113883.1.11.14914Concepts in the race value set include the OMB minimum categories, 5 races, along with a sixth race category, Other race, and a more detailed set of race categories used by the Bureau of Census. CodeCode SystemPrint Name1006-6Race & Ethnicity - CDCAbenaki1579-2Race & Ethnicity - CDCAbsentee Shawnee1490-2Race & Ethnicity - CDCAcoma2126-1Race & Ethnicity - CDCAfghanistani2060-2Race & Ethnicity - CDCAfrican2058-6Race & Ethnicity - CDCAfrican American1994-3Race & Ethnicity - CDCAgdaagux1212-0Race & Ethnicity - CDCAgua Caliente1045-4Race & Ethnicity - CDCAgua Caliente Cahuilla1740-0Race & Ethnicity - CDCAhtna1654-3Race & Ethnicity - CDCAk-Chin1993-5Race & Ethnicity - CDCAkhiok1897-8Race & Ethnicity - CDCAkiachak1898-6Race & Ethnicity - CDCAkiak2007-3Race & Ethnicity - CDCAkutan1187-4Race & Ethnicity - CDCAlabama Coushatta1194-0Race & Ethnicity - CDCAlabama Creek1195-7Race & Ethnicity - CDCAlabama Quassarte1899-4Race & Ethnicity - CDCAlakanuk1383-9Race & Ethnicity - CDCAlamo Navajo...SEQ Table \* ARABIC10: EthnicityGroupValue Set: EthnicityGroup 2.16.840.1.114222.4.11.837CodeCode SystemPrint Name2135-2Race & Ethnicity - CDCHispanic or Latino2186-5Race & Ethnicity - CDCNot Hispanic or LatinoSEQ Table \* ARABIC11: Personal And Legal Relationship Role TypeValue Set: Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1A personal or legal relationship records the role of a person in relation to another person, or a person to himself or herself. This value set is to be used when recording relationships based on personal or family ties or through legal assignment of responsibility. Direct URL PendingValueset Source: SystemPrint NameHUSBRoleCodehusbandWIFERoleCodewifeFRNDRoleCodefriendSISINLAWRoleCodesister-in-lawSELFRoleCodeselfPUNCLERoleCodepaternal uncle...SEQ Table \* ARABIC12: CountryValueSetValue Set: CountryValueSet 2.16.840.1.113883.3.88.12.80.63This identifies the codes for the representation of names of countries, territories and areas of geographical interest.CodeCode SystemPrint NameSEQ Table \* ARABIC13: PostalCodeValueSetValue Set: PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2This identifies the postal (ZIP) Code of an address in the United StatesCodeCode SystemPrint NameSEQ Table \* ARABIC14: LanguageAbilityMode Value SetValue Set: LanguageAbilityMode Value Set 2.16.840.1.113883.1.11.12249This identifies the language ability of the individual. A value representing the method of expression of the language.CodeCode SystemPrint NameESGNLanguageAbilityModeExpressed signedESPLanguageAbilityModeExpressed spokenEWRLanguageAbilityModeExpressed writtenRSGNLanguageAbilityModeReceived signedRSPLanguageAbilityModeReceived spokenRWRLanguageAbilityModeReceived writtenSEQ Table \* ARABIC15: LanguageAbilityProficiencyValue Set: LanguageAbilityProficiency 2.16.840.1.113883.1.11.12199CodeCode SystemPrint NameELanguageAbilityProficiencyExcellentFLanguageAbilityProficiencyFairGLanguageAbilityProficiencyGoodPLanguageAbilityProficiencyPoorSEQ Table \* ARABIC16: Healthcare Provider Taxonomy (HIPAA)Value Set: Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066The Health Care Provider Taxonomy code set is a collection of unique alphanumeric codes, ten characters in length. The code set is structured into three distinct Levels including Provider Type, Classification, and Area of Specialization. The Health Care Provider Taxonomy code set allows a single provider (individual, group, or institution) to identify their specialty category. Providers may have one or more than one value associated to them. When determining what value or valuess to associate with a provider, the user needs to review the requirements of the trading partner with which the value(s) are being used.CodeCode SystemPrint Name171100000XHealthcare Provider Taxonomy (HIPAA)Acupuncturist363LA2100XHealthcare Provider Taxonomy (HIPAA)Acute Care364SA2100XHealthcare Provider Taxonomy (HIPAA)Acute Care101YA0400XHealthcare Provider Taxonomy (HIPAA)Addiction (Substance Use Disorder)103TA0400XHealthcare Provider Taxonomy (HIPAA)Addiction (Substance Use Disorder)163WA0400XHealthcare Provider Taxonomy (HIPAA)Addiction (Substance Use Disorder)207LA0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine207QA0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine207RA0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine2084A0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine2084P0802XHealthcare Provider Taxonomy (HIPAA)Addiction Psychiatry163WA2000XHealthcare Provider Taxonomy (HIPAA)Administrator261QM0855XHealthcare Provider Taxonomy (HIPAA)Adolescent and Children Mental Health2080A0000XHealthcare Provider Taxonomy (HIPAA)Adolescent Medicine207RA0000XHealthcare Provider Taxonomy (HIPAA)Adolescent Medicine207QA0000XHealthcare Provider Taxonomy (HIPAA)Adolescent Medicine311ZA0620XHealthcare Provider Taxonomy (HIPAA)Adult Care Home372600000XHealthcare Provider Taxonomy (HIPAA)Adult Companion261QA0600XHealthcare Provider Taxonomy (HIPAA)Adult Day Care103TA0700XHealthcare Provider Taxonomy (HIPAA)Adult Development & Aging...SEQ Table \* ARABIC17: INDRoleclassCodesValue Set: INDRoleclassCodes 2.16.840.1.113883.11.20.9.33CodeCode SystemPrint NamePRSRoleClasspersonal relationshipNOKRoleClassnext of kinCAREGIVERRoleClasscaregiverAGNTRoleClassagentGUARRoleClassguarantorECONRoleClassemergency contactCare Plan (NEW)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.15 (open)]SEQ Table \* ARABIC18: Care Plan (NEW) ContextsContained By:Contains:Goals Section (NEW)Health Concerns Section (NEW)Health Status Evaluations/Outcomes Section (NEW)Interventions Section (V2)CARE PLAN FRAMEWORKA Care Plan is a consensus-driven dynamic plan that represents all of a patient’s and Care Team Members’ prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members, including the patient, to guide the Care Team Members (including Patients, their caregivers, providers and patient’s care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patient’s life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care.The CDA Care Plan represents an instance of this dynamic Care Plan. The CDA document itself is NOT dynamic.SEQ Table \* ARABIC19: Care Plan (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.15']templateId1..1SHALL28741@root1..1SHALL287422.16.840.1.113883.10.20.22.1.15id1..1SHALL28743@root1..1SHALL28744code1..1SHALL28745@code1..1SHALL28746XXXXX-X@codeSystem1..1SHALL287472.16.840.1.113883.6.1title1..1SHALL28748custodian1..1SHALL28749assignedCustodian1..1SHALL28750representedCustodianOrganization1..1SHALL28751name1..1SHALL28752component1..1SHALL28753structuredBody1..1SHALL28754component1..1SHALL28755section1..1SHALL28756component1..1SHALL28761section1..1SHALL28762component1..1SHALL28763section1..1SHALL28764component1..1SHALL29596section1..1SHALL29597relatedDocument0..*MAY29893parentDocument1..1SHALL29894setId1..1SHALL29895versionNumber1..1SHALL29896Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:28741) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.15" (CONF:28742).SHALL contain exactly one [1..1] id (CONF:28743).This id SHALL contain exactly one [1..1] @root (CONF:28744).SHALL contain exactly one [1..1] code (CONF:28745).This code SHALL contain exactly one [1..1] @code="XXXXX-X" **TODO** (CONF:28746).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:28747).SHALL contain exactly one [1..1] title (CONF:28748).SHALL contain exactly one [1..1] custodian (CONF:28749).This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:28750).This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:28751).This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:28752).MAY contain zero or more [0..*] relatedDocument (CONF:29893).The relatedDocument, if present, SHALL contain exactly one [1..1] parentDocument (CONF:29894).This parentDocument SHALL contain exactly one [1..1] setId (CONF:29895).This parentDocument SHALL contain exactly one [1..1] versionNumber (CONF:29896).SHALL contain exactly one [1..1] component (CONF:28753).This component SHALL contain exactly one [1..1] structuredBody (CONF:28754).This structuredBody SHALL contain exactly one [1..1] component (CONF:28755) such that itSHALL contain exactly one [1..1] Health Concerns Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.58) (CONF:28756).This structuredBody SHALL contain exactly one [1..1] component (CONF:28761) such that itSHALL contain exactly one [1..1] Goals Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.60) (CONF:28762).This structuredBody SHALL contain exactly one [1..1] component (CONF:28763) such that itSHALL contain exactly one [1..1] Interventions Section (V2) (templateId:2.16.840.1.113883.10.20.21.2.3.2) (CONF:28764).This structuredBody SHALL contain exactly one [1..1] component (CONF:29596) such that itSHALL contain exactly one [1..1] Health Status Evaluations/Outcomes Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.61) (CONF:29597).This structuredBody SHALL NOT contain Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:31044).Consultation Note (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.4.2 (open)]SEQ Table \* ARABIC20: Consultation Note (V2) ContextsContained By:Contains:Advance Directives Section (entries optional) (V2)Allergies Section (entries required) (V2)Assessment and Plan Section (V2)Assessment SectionChief Complaint and Reason for Visit SectionChief Complaint SectionFamily History SectionFunctional Status Section (V2)General Status SectionHistory of Past Illness Section (V2)History of Present Illness SectionImmunizations Section (entries optional) (V2)Medical Equipment Section (V2)Medications Section (entries required) (V2)Mental Status Section (NEW)Nutrition Section (NEW)Physical Exam Section (V2)Plan of Treatment Section (V2)Problem Section (entries required) (V2)Procedures Section (entries optional) (V2)Reason for Referral Section (V2)Reason for Visit SectionResults Section (entries required) (V2)Review of Systems SectionSocial History Section (V2)Vital Signs Section (entries required) (V2)Consultation Note is generated as a result of a request from a clinician for an opinion or advice from another clinician. Consultations involve face-to-face time with the patient or may fall under the guidelines for tele-medicine visits. A consultation note includes the reason for the referral, history of present illness, physical examination, and decision-making component (Assessment and Plan). SEQ Table \* ARABIC21: Consultation Note (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.4.2']templateId1..1SHALL8375@root1..1SHALL100402.16.840.1.113883.10.20.22.1.4.2code1..1SHALL171762.16.840.1.113883.11.20.9.31 (ConsultDocumentType)inFulfillmentOf1..*SHALL8382order1..1SHALL29923id1..*SHALL29924componentOf1..1SHALL8386encompassingEncounter1..1SHALL8387id1..1SHALL8388effectiveTime1..1SHALL8389responsibleParty0..1MAY8391encounterParticipant0..*MAY8392component1..1SHALL8397structuredBody1..1SHALL28895component0..1MAY28896section1..1SHALL28897component0..1MAY28898section1..1SHALL28899component0..1MAY28900section1..1SHALL28901component0..1MAY28902section1..1SHALL28903component0..1MAY28904section1..1SHALL28905component1..1SHALL28906section1..1SHALL28907component1..1SHALL28908section1..1SHALL28909component1..1SHALL28910section1..1SHALL28911component0..1MAY28912section1..1SHALL28913component0..1MAY28915section1..1SHALL28916component0..1MAY28917section1..1SHALL28918component0..1MAY28919section1..1SHALL28920component0..1MAY28921section1..1SHALL28922component0..1MAY28923section1..1SHALL28924component0..1SHOULD28925section1..1SHALL28926component1..1SHALL28928section1..1SHALL28929component0..1SHOULD28930section1..1SHALL28931component0..1SHOULD28932section1..1SHALL28933component0..1SHOULD28934section1..1SHALL28935component0..1SHOULD28936section1..1SHALL28937component0..1MAY28942section1..1SHALL28943component0..1MAY28944section1..1SHALL28945component0..1MAY30237section1..1SHALL30238component0..1MAY30904section1..1SHALL30905component0..1MAY30906section1..1SHALL30907component0..1MAY30909section1..1SHALL30910title1..1SHALL29837Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).templateIdSHALL contain exactly one [1..1] templateId (CONF:8375) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.4.2" (CONF:10040).codeThe Consultation Note recommends use of??the document type code 11488-4 "Consultation Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, a Cardiology Consultation Note would not be authored by an Obstetrician. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ConsultDocumentType 2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:17176).Figure SEQ Table \* ARABIC1: Document Type Code Sample<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="11488-4" displayName="Consultation Note" />titleSHALL contain exactly one [1..1] title (CONF:29837).Figure SEQ Table \* ARABIC2: Consult Note Title Sample<title>Community Health Consult Note</title>inFulfillmentOfThe inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note.??For example, a prior order might be the the consultation that is being reported in the note.SHALL contain at least one [1..*] inFulfillmentOf (CONF:8382).Such inFulfillmentOfs SHALL contain exactly one [1..1] order (CONF:29923).This order SHALL contain at least one [1..*] id (CONF:29924).Figure SEQ Table \* ARABIC3: InFulfillmentOf Sample<inFulfillmentOf typeCode="FLFS"> <order classCode="ACT" moodCode="RQO"> <id root="2.16.840.1.113883.6.96" extension="1298989898" /> <code code="388975008" displayName="Weight Reduction Consultation" codeSystem="2.16.840.1.113883.6.96" codeSystemName="CPT4" /> </order></inFulfillmentOf>componentOfA Consultation Note is always associated with an encounter; the componentOf element must be present and the encounter must be identified.SHALL contain exactly one [1..1] componentOf (CONF:8386).CDA R2 requires encompasingEncounter and the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8387).This encompassingEncounter SHALL contain exactly one [1..1] id (CONF:8388).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8389).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:10132).This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8391).The responsibleParty element records??only the party responsible for the encounter, not necessarily the entire episode of care (CONF:8393).The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:8394).The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:8392).The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care (CONF:8395).An encounterParticipant element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element,??a representedOrganization element, or both (CONF:8396).Figure SEQ Table \* ARABIC4: ComponentOf Sample<componentOf> <encompassingEncounter> <id extension="9937012" root="2.16.840.1.113883.19" /> <code codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" code="99213" displayName="Evaluation and Management" /> <effectiveTime> <low value="20130203" /> <high value="20130203" /> </effectiveTime> <location> <healthCareFacility> <id root="2.16.540.1.113883.19.2" /> </healthCareFacility> </location> </encompassingEncounter></componentOf>SHALL contain exactly one [1..1] component (CONF:8397).structuredBodyThis component SHALL contain exactly one [1..1] structuredBody (CONF:28895).This structuredBody MAY contain zero or one [0..1] component (CONF:28896) such that itSHALL contain exactly one [1..1] Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) (CONF:28897).This structuredBody MAY contain zero or one [0..1] component (CONF:28898) such that itSHALL contain exactly one [1..1] Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) (CONF:28899).This structuredBody MAY contain zero or one [0..1] component (CONF:28900) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:28901).This structuredBody MAY contain zero or one [0..1] component (CONF:28902) such that itSHALL contain exactly one [1..1] Reason for Referral Section (V2) (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.1.2) (CONF:28903).This structuredBody MAY contain zero or one [0..1] component (CONF:28904) such that itSHALL contain exactly one [1..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) (CONF:28905).This structuredBody SHALL contain exactly one [1..1] component (CONF:28906) such that itSHALL contain exactly one [1..1] History of Present Illness Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:28907).This structuredBody SHALL contain exactly one [1..1] component (CONF:28908) such that itSHALL contain exactly one [1..1] Physical Exam Section (V2) (templateId:2.16.840.1.113883.10.20.2.10.2) (CONF:28909).This structuredBody SHALL contain exactly one [1..1] component (CONF:28910) such that itSHALL contain exactly one [1..1] Allergies Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.1.2) (CONF:28911).This structuredBody MAY contain zero or one [0..1] component (CONF:28912) such that itSHALL contain exactly one [1..1] Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:28913).This structuredBody MAY contain zero or one [0..1] component (CONF:28915) such that itSHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13) (CONF:28916).This structuredBody MAY contain zero or one [0..1] component (CONF:28917) such that itSHALL contain exactly one [1..1] Family History Section (templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:28918).This structuredBody MAY contain zero or one [0..1] component (CONF:28919) such that itSHALL contain exactly one [1..1] General Status Section (templateId:2.16.840.1.113883.10.20.2.5) (CONF:28920).This structuredBody MAY contain zero or one [0..1] component (CONF:28921) such that itSHALL contain exactly one [1..1] History of Past Illness Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.20.2) (CONF:28922).This structuredBody MAY contain zero or one [0..1] component (CONF:28923) such that itSHALL contain exactly one [1..1] Immunizations Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.2.2) (CONF:28924).This structuredBody SHOULD contain zero or one [0..1] component (CONF:28925) such that itSHALL contain exactly one [1..1] Medications Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.1.1.2) (CONF:28926).This structuredBody SHALL contain exactly one [1..1] component (CONF:28928) such that itSHALL contain exactly one [1..1] Problem Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.5.1.2) (CONF:28929).This structuredBody SHOULD contain zero or one [0..1] component (CONF:28930) such that itSHALL contain exactly one [1..1] Procedures Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.7.2) (CONF:28931).This structuredBody SHOULD contain zero or one [0..1] component (CONF:28932) such that itSHALL contain exactly one [1..1] Results Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.3.1.2) (CONF:28933).This structuredBody SHOULD contain zero or one [0..1] component (CONF:28934) such that itSHALL contain exactly one [1..1] Social History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.17.2) (CONF:28935).This structuredBody SHOULD contain zero or one [0..1] component (CONF:28936) such that itSHALL contain exactly one [1..1] Vital Signs Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.4.1.2) (CONF:28937).This structuredBody MAY contain zero or one [0..1] component (CONF:28942) such that itSHALL contain exactly one [1..1] Advance Directives Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.21.2) (CONF:28943).This structuredBody MAY contain zero or one [0..1] component (CONF:28944) such that itSHALL contain exactly one [1..1] Functional Status Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.14.2) (CONF:28945).This structuredBody MAY contain zero or one [0..1] component (CONF:30237) such that itSHALL contain exactly one [1..1] Review of Systems Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:30238).This structuredBody MAY contain zero or one [0..1] component (CONF:30904) such that itSHALL contain exactly one [1..1] Medical Equipment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.23.2) (CONF:30905).This structuredBody MAY contain zero or one [0..1] component (CONF:30906) such that itSHALL contain exactly one [1..1] Mental Status Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.56) (CONF:30907).This structuredBody MAY contain zero or one [0..1] component (CONF:30909) such that itSHALL contain exactly one [1..1] Nutrition Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.57) (CONF:30910).SHALL include an Assessment and Plan Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.9.2) OR both an Assessment Section (templateId: 2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.10.2) (CONF:28938).SHALL NOT include an Assessment and Plan Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.9.2) when an Assessment Section (templateId: 2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.10.2) are present (CONF:28939).SHALL NOT include a Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) with a Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13) (CONF:28940).SHALL include either a Reason for Referral Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.1) or Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) (CONF:28941).Figure SEQ Table \* ARABIC5: Consult Note StructuredBody Sample<component><structuredBody><component><section><templateId root="2.16.840.1.113883.10.20.22.2.6.1.2"/><code code="48765-2" codeSystem="2.16.840.1.113883.6.1"displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/><title>Allergies, Adverse Reactions, Alerts</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.8"/> <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="51848-0"displayName="ASSESSMENT"/><title>ASSESSMENT</title>...</section></component><component><section><templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/> <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="10164-2"displayName="HISTORY OF PRESENT ILLNESS"/><title>HISTORY OF PRESENT ILLNESS</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.1.1.2"/><code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"displayName="HISTORY OF MEDICATION USE"/><title>MEDICATIONS</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.2.10.2"/> <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="29545-1"displayName="PHYSICAL FINDINGS"/><title>PHYSICAL EXAMINATION</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.10.2"/><code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"displayName="Treatment plan"/><title>PLAN OF CARE</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.5.1.2"/><code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"displayName="PROBLEM LIST"/><title>PROBLEMS</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.7.2"/><code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"displayName="HISTORY OF PROCEDURES"/><title>PROCEDURES</title>...</section></component><component><section><templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1.2"/><code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="42349-1"displayName="REASON FOR REFERRAL"/><title>REASON FOR REFERRAL</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.3.1.2"/><code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"displayName="RESULTS"/><title>RESULTS</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.17.2"/> <code code="29762-2" codeSystem="2.16.840.1.113883.6.1"displayName="Social History"/><title>SOCIAL HISTORY</title>...</section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.4.1.2"/> <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"displayName="VITAL SIGNS"/><title>VITAL SIGNS</title>...</section></component></structuredBody></component></ClinicalDocument>SEQ Table \* ARABIC22: ConsultDocumentTypeValue Set: ConsultDocumentType 2.16.840.1.113883.11.20.9.31A Consultation Note is provided to a referring physician or provider and contains reason for the referral, history of present illness, physical examination, and decision-making components. CodeCode SystemPrint Name11488-4LOINC{Provider}34100-8LOINC{Provider}34104-0LOINC{Provider}51845-6LOINC{Provider}51853-0LOINC{Provider}51846-4LOINC{Provider}34101-6LOINCGeneral medicine34749-2LOINCAnesthesia34102-4LOINCPsychiatry34099-2LOINCCardiology34756-7LOINCDentistry34758-3LOINCDermatology34760-9LOINCDiabetology34879-7LOINCEndocrinology34761-7LOINCGastroenterology34764-1LOINCGeneral medicine34771-6LOINCGeneral surgery34776-5LOINCGerontology34777-3LOINCGynecology34779-9LOINCHematology+Oncology...Continuity of Care Document (CCD) (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.2.2 (open)]SEQ Table \* ARABIC23: Continuity of Care Document (CCD) (V2) ContextsContained By:Contains:Advance Directives Section (entries optional) (V2)Allergies Section (entries required) (V2)Encounters Section (entries optional) (V2)Family History SectionFunctional Status Section (V2)Immunizations Section (entries required) (V2)Medical Equipment Section (V2)Medications Section (entries required) (V2)Payers Section (V2)Plan of Treatment Section (V2)Problem Section (entries required) (V2)Procedures Section (entries required) (V2)Results Section (entries required) (V2)Social History Section (V2)Vital Signs Section (entries required) (V2)The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another to support the continuity of care. The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, and administrative data for a specific patient. More specific use cases, such as a Discharge Summary or Progress Note, are available as alternative documents in this guide.SEQ Table \* ARABIC24: Continuity of Care Document (CCD) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.2.2']templateId1..1SHALL8450@root1..1SHALL100382.16.840.1.113883.10.20.22.1.2.2code1..1SHALL17180@code1..1SHALL171812.16.840.1.113883.6.1 (LOINC) = 34133-9author1..*SHALL9442assignedAuthor1..1SHALL9443documentationOf1..1SHALL8452serviceEvent1..1SHALL8480@classCode1..1SHALL84532.16.840.1.113883.5.6 (HL7ActClass) = PCPReffectiveTime1..1SHALL8481low1..1SHALL8454high1..1SHALL8455performer0..*SHOULD8482@typeCode1..1SHALL84582.16.840.1.113883.5.90 (HL7ParticipationType) = PRFassignedEntity0..1MAY8459id1..*SHALL8460id0..1SHOULD30882@root1..1SHALL308832.16.840.1.113883.4.6code0..1MAY8461component1..1SHALL30659structuredBody1..1SHALL30660component1..1SHALL30661section1..1SHALL30662component1..1SHALL30663section1..1SHALL30664component1..1SHALL30665section1..1SHALL30666component1..1SHALL30667section1..1SHALL30668component1..1SHALL30669section1..1SHALL30670component0..1MAY30671section1..1SHALL30672component0..1MAY30673section1..1SHALL30674component0..1MAY30675section1..1SHALL30676component0..1MAY30677section1..1SHALL30678component0..1MAY30679section1..1SHALL30680component0..1MAY30681section1..1SHALL30682component0..1MAY30683section1..1SHALL30684component0..1SHOULD30685section1..1SHALL30686component1..1SHALL30687section1..1SHALL30688component1..1SHALL30689section1..1SHALL30690Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:8450) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.2.2" (CONF:10038).In accordance with the CDA specification, the ClinicalDocument/code element must be present and specify the type of the clinical document. CCD requires the document type code 34133-9 "Summarization of Episode Note". SHALL contain exactly one [1..1] code (CONF:17180).This code SHALL contain exactly one [1..1] @code="34133-9" Summarization of Episode Note (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:17181).SHALL contain at least one [1..*] author (CONF:9442).Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:9443).SHALL contain exactly one 1..1] assignedPerson or exactly one 1..1]??representedOrganization (CONF:8456).If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” SHALL be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:8457).SHALL contain exactly one [1..1] documentationOf (CONF:8452).This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:8480).This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8453).This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8481).This effectiveTime SHALL contain exactly one [1..1] low (CONF:8454).This effectiveTime SHALL contain exactly one [1..1] high (CONF:8455).serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselorsThis serviceEvent SHOULD contain zero or more [0..*] performer (CONF:8482).The performer, if present, SHALL contain exactly one [1..1] @typeCode="PRF" Participation physical performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8458).The performer, if present, MAY contain zero or one [0..1] assignedEntity (CONF:8459).The assignedEntity, if present, SHALL contain at least one [1..*] id (CONF:8460).SHOULD include zero or one 0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:10027).The assignedEntity, if present, SHOULD contain zero or one [0..1] id (CONF:30882) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:30883).The assignedEntity, if present, MAY contain zero or one [0..1] code (CONF:8461).I.??The code MAY be the NUCC Health Care Provider Taxonomy (CodeSystem: 2.16.840.1.113883.6.101). (See ) (CONF:8462).SHALL contain exactly one [1..1] component (CONF:30659).This component SHALL contain exactly one [1..1] structuredBody (CONF:30660).This structuredBody SHALL contain exactly one [1..1] component (CONF:30661) such that itSHALL contain exactly one [1..1] Allergies Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.1.2) (CONF:30662).This structuredBody SHALL contain exactly one [1..1] component (CONF:30663) such that itSHALL contain exactly one [1..1] Medications Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.1.1.2) (CONF:30664).This structuredBody SHALL contain exactly one [1..1] component (CONF:30665) such that itSHALL contain exactly one [1..1] Problem Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.5.1.2) (CONF:30666).This structuredBody SHALL contain exactly one [1..1] component (CONF:30667) such that itSHALL contain exactly one [1..1] Procedures Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.7.1.2) (CONF:30668).This structuredBody SHALL contain exactly one [1..1] component (CONF:30669) such that itSHALL contain exactly one [1..1] Results Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.3.1.2) (CONF:30670).This structuredBody MAY contain zero or one [0..1] component (CONF:30671) such that itSHALL contain exactly one [1..1] Advance Directives Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.21.2) (CONF:30672).This structuredBody MAY contain zero or one [0..1] component (CONF:30673) such that itSHALL contain exactly one [1..1] Encounters Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.22.2) (CONF:30674).This structuredBody MAY contain zero or one [0..1] component (CONF:30675) such that itSHALL contain exactly one [1..1] Family History Section (templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:30676).This structuredBody MAY contain zero or one [0..1] component (CONF:30677) such that itSHALL contain exactly one [1..1] Functional Status Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.14.2) (CONF:30678).This structuredBody MAY contain zero or one [0..1] component (CONF:30679) such that itSHALL contain exactly one [1..1] Immunizations Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.2.1.2) (CONF:30680).This structuredBody MAY contain zero or one [0..1] component (CONF:30681) such that itSHALL contain exactly one [1..1] Medical Equipment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.23.2) (CONF:30682).This structuredBody MAY contain zero or one [0..1] component (CONF:30683) such that itSHALL contain exactly one [1..1] Payers Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.18.2) (CONF:30684).This structuredBody SHOULD contain zero or one [0..1] component (CONF:30685) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30686).This structuredBody SHALL contain exactly one [1..1] component (CONF:30687) such that itSHALL contain exactly one [1..1] Social History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.17.2) (CONF:30688).This structuredBody SHALL contain exactly one [1..1] component (CONF:30689) such that itSHALL contain exactly one [1..1] Vital Signs Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.4.1.2) (CONF:30690).Diagnostic Imaging Report (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.5.2 (open)]SEQ Table \* ARABIC25: Diagnostic Imaging Report (V2) ContextsContained By:Contains:Code ObservationsDICOM Object Catalog Section - DCM 121181Fetus Subject ContextFindings Section (DIR)Observer ContextPhysician of Record Participant (V2)Physician Reading Study Performer (V2)Procedure ContextQuantity Measurement ObservationSOP Instance ObservationText ObservationUS Realm Person Name (PN.US.FIELDED)A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist’s interpretation of image data.??It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record.??It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.SEQ Table \* ARABIC26: Diagnostic Imaging Report (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.5.2']templateId1..1SHALL8404@root1..1SHALL100422.16.840.1.113883.10.20.22.1.5.2code1..1SHALL14833@code0..1SHOULD148342.16.840.1.113883.11.20.9.32 (DIRDocumentTypeCodes)informant0..0SHALL NOT8410informationRecipient0..*MAY8411participant0..1MAY8414associatedEntity1..1SHALL31198associatedPerson1..1SHALL31199name1..1SHALL31200documentationOf1..1SHALL8416serviceEvent1..1SHALL8431@classCode1..1SHALL84302.16.840.1.113883.5.6 (HL7ActClass) = ACTid0..*SHOULD8418code1..1SHALL8419performer0..*SHOULD8422relatedDocument0..1MAY8432id1..1SHALL10030component1..1SHALL14907structuredBody1..1SHALL30695component1..1SHALL30696section1..1SHALL30697component0..1SHOULD30698section1..1SHALL30699component0..*MAY31055section1..1SHALL31056code1..1SHALL31057@code1..1SHALL312072.16.840.1.113883.11.20.9.59 (DIRSectionTypeCodes)title0..1SHOULD31058text0..1SHOULD31059subject0..*MAY31215relatedSubject1..1SHALL31216author0..*MAY31217assignedAuthor1..1SHALL31218entry0..*MAY31213act1..1SHALL31214entry0..*MAY31357observation1..1SHALL31358entry0..*MAY31359observation1..1SHALL31360entry0..*MAY31361observation1..1SHALL31362entry0..*MAY31363observation1..1SHALL31364component0..*MAY31208id1..1SHALL30932@root1..1SHALLOID30933inFulfillmentOf0..*MAY30936order1..1SHALL30937id1..*SHALL30938componentOf0..1MAY30939encompassingEncounter1..1SHALL30940id1..*SHALL30941effectiveTime1..1SHALL30943responsibleParty0..1MAY30945assignedEntity1..1SHALL30946encounterParticipant0..1SHOULD30948Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:8404) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.5.2" (CONF:10042).SHALL contain exactly one [1..1] id (CONF:30932).This id SHALL contain exactly one [1..1] @root (CONF:30933).OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form (0-2])(.(1-9]0-9]*|0))+ The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:30934).OIDs SHALL be no more than 64 characters in length (CONF:30935).Given that DIR documents may be transformed from established collections of imaging reports already stored with their own type codes, there is no static set of Document Type codes. The set of LOINC codes listed in the DIR LOINC Document Type Codes table may be extended by additions to LOINC and supplemented by local codes as translations.The DIR document recommends use of a single document type code, 18748-4 "Diagnostic Imaging Report", with further specification provided by author or performer, setting, or specialty. Some of these codes in the DIR LOINC Document Type Codes table are pre-coordinated with either the imaging modality, body part examined, or specific imaging method such as the view. Use of these codes is not recommended, as this duplicates information potentially present with the header. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. This table is drawn from LOINC Version 2.36, June 30, 2011, and consists of codes whose scale is DOC and that refer to reports for diagnostic imaging procedures.SHALL contain exactly one [1..1] code (CONF:14833).This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet DIRDocumentTypeCodes 2.16.840.1.113883.11.20.9.32 DYNAMIC (CONF:14834).SHALL NOT contain [0..0] informant (CONF:8410).MAY contain zero or more [0..*] informationRecipient (CONF:8411).The physician requesting the imaging procedure (ClincalDocument/participant@typeCode=REF]/associatedEntity), if present, SHOULD also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:8412).When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient MAY be absent. The intendedRecipient MAY also be the health chart of the patient, in which case the receivedOrganization SHALL be the scoping organization of that chart (CONF:8413).??If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF).MAY contain zero or one [0..1] participant (CONF:8414) such that itSHALL contain exactly one [1..1] associatedEntity (CONF:31198).This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:31199).This associatedPerson SHALL contain exactly one [1..1] US Realm Person Name (PN.US.FIELDED) (templateId:2.16.840.1.113883.10.20.22.5.1.1) (CONF:31200).An inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below.In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data.A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.MAY contain zero or more [0..*] inFulfillmentOf (CONF:30936).The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:30937).inFulfillmentOf/order/id is mapped to the DICOM Accession Number in the imaging data.This order SHALL contain at least one [1..*] id (CONF:30938).Each documentationOf/serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event.In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent.The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time.Service events map to DICOM Requested Procedures. That is, documentationOf/serviceEvent/id is the ID of the Requested Procedure.SHALL contain exactly one [1..1] documentationOf (CONF:8416) such that itSHALL contain exactly one [1..1] serviceEvent (CONF:8431).This serviceEvent SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8430).This serviceEvent SHOULD contain zero or more [0..*] id (CONF:8418).This serviceEvent SHALL contain exactly one [1..1] code (CONF:8419).The value of serviceEvent/code SHALL NOT conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor SHALL be used on serviceEvent/code (CONF:8420).This serviceEvent SHOULD contain zero or more [0..*] Physician Reading Study Performer (V2) (templateId:2.16.840.1.113883.10.20.6.2.1.2) (CONF:8422).A DIR may have three types of parent document:? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report.? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original.? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document.MAY contain zero or one [0..1] relatedDocument (CONF:8432) such that itWhen a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode SHALL be XFRM, and relatedDocument/parentDocument/id SHALL contain the SOP Instance UID of the original DICOM SR document (CONF:8433).SHALL contain exactly one [1..1] id (CONF:10030).OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form (0-2])(.(1-9]0-9]|0))+ (CONF:10031).OIDs SHALL be no more than 64 characters in length (CONF:10032).The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter.The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.MAY contain zero or one [0..1] componentOf (CONF:30939).The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:30940).This encompassingEncounter SHALL contain at least one [1..*] id (CONF:30941).In the case of transformed DICOM SR documents, an appropriate null flavor MAY be used if the id is unavailable (CONF:30942).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:30943).This effectiveTime SHALL contain exactly one 1..1] US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:30944).This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:30945).The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:30946).SHOULD contain zero or one 0..1] assignedPerson OR contain zero or one 0..1] representedOrganization (CONF:30947).This encompassingEncounter SHOULD contain zero or one [0..1] Physician of Record Participant (V2) (templateId:2.16.840.1.113883.10.20.6.2.2.2) (CONF:30948).SHALL contain exactly one [1..1] component (CONF:14907).This component SHALL contain exactly one [1..1] structuredBody (CONF:30695).This structuredBody SHALL contain exactly one [1..1] component (CONF:30696) such that itSHALL contain exactly one [1..1] Findings Section (DIR) (templateId:2.16.840.1.113883.10.20.6.1.2) (CONF:30697).This structuredBody SHOULD contain zero or one [0..1] component (CONF:30698) such that itSHALL contain exactly one [1..1] DICOM Object Catalog Section - DCM 121181 (templateId:2.16.840.1.113883.10.20.6.1.1) (CONF:30699).The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, SHALL be the first section in the document Body (CONF:31206).A Diagnostic Imaging Report may contain CDA entries that represent, in coded form findings, image references, annotation, and numeric measurements based on DICOM Basic Diagnostic Imaging Report (Template 2000) and Transcribed Diagnostic Imaging Report (Template 2005). Most of the constraints for this document have been inherited from the DICOM PS 3.20 “Transformation of DICOM to and from HL7 Standards”. This document type and the companion DICOM PS 3.20 “Transformation of DICOM to and from HL7 Standards??guidefurther constrain the transformation because image Spatial Coordinates region of interest (SCOORD) for linear, area, and volume measurements are not encoded in the CDA document.??If it is desired to show images with such graphical annotations, the annotations should be encoded in DICOM Softcopy Presentation State objects that reference the image.??Report applications that display referenced images and annotation should retrieve a rendered image using a WADO reference, including the image and Presentation State, or other DICOM retrieval and rendering methods.??This approach avoids the risks of errors in registering a region of interest annotation with DICOM images.DICOM Template 2000 defines imaging report documents that are comprised of a number of optional sections.This structuredBody MAY contain zero or more [0..*] component (CONF:31055) such that itSHALL contain exactly one [1..1] section (CONF:31056).This section SHALL contain exactly one [1..1] code (CONF:31057).For sections listed in the DIR Section Type Codes table, the code element must contain a LOINC code or DCM code for sections that have no LOINC equivalentThis code SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet DIRSectionTypeCodes 2.16.840.1.113883.11.20.9.59 DYNAMIC (CONF:31207).Note: The section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes tableThere is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.This section SHOULD contain zero or one [0..1] title (CONF:31058).This section SHOULD contain zero or one [0..1] text (CONF:31059).If clinical statements are present, the section/text SHALL represent faithfully all such statements and MAY contain additional text (CONF:31060).All text elements SHALL contain content. Text elements SHALL contain PCDATA or child elements (CONF:31061).The text elements (and their children) MAY contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:31062).This subject is used if the subject of a section is a fetus. The information on the mother is in the CDA header. This section MAY contain zero or more [0..*] subject (CONF:31215) such that itSHALL contain exactly one [1..1] Fetus Subject Context (templateId:2.16.840.1.113883.10.20.6.2.3) (CONF:31216).This author element is used when the author of a section is different from the author(s) listed in the HeaderThis section MAY contain zero or more [0..*] author (CONF:31217) such that itSHALL contain exactly one [1..1] Observer Context (templateId:2.16.840.1.113883.10.20.6.2.4) (CONF:31218).If the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elementsThis section MAY contain zero or more [0..*] entry (CONF:31213) such that itSHALL contain exactly one [1..1] Procedure Context (templateId:2.16.840.1.113883.10.20.6.2.5) (CONF:31214).This section MAY contain zero or more [0..*] entry (CONF:31357) such that itSHALL contain exactly one [1..1] Text Observation (templateId:2.16.840.1.113883.10.20.6.2.12) (CONF:31358).This section MAY contain zero or more [0..*] entry (CONF:31359) such that itSHALL contain exactly one [1..1] Code Observations (templateId:2.16.840.1.113883.10.20.6.2.13) (CONF:31360).This section MAY contain zero or more [0..*] entry (CONF:31361) such that itSHALL contain exactly one [1..1] Quantity Measurement Observation (templateId:2.16.840.1.113883.10.20.6.2.14) (CONF:31362).This section MAY contain zero or more [0..*] entry (CONF:31363) such that itSHALL contain exactly one [1..1] SOP Instance Observation (templateId:2.16.840.1.113883.10.20.6.2.8) (CONF:31364).This section MAY contain zero or more [0..*] component (CONF:31208).SHALL contain child elements (CONF:31210).All sections defined in the DIR Section Type Codes table SHALL be top-level sections (CONF:31211).SHALL contain at least one text element or one or more component elements (CONF:31212).SEQ Table \* ARABIC27: DIRDocumentTypeCodesValue Set: DIRDocumentTypeCodes 2.16.840.1.113883.11.20.9.32This is the set of LOINC () codes used for DIR Document Types. The set of LOINC codes listed in this table may be extended by additions to LOINC and supplemented by local codes as translations. This table is drawn from LOINC Version 2.36, June 30, 2011, and consists of codes whose scale is DOC and that refer to reports for diagnostic imaging procedures.Valueset Source: SystemPrint Name18748-4LOINCDiagnostic Imaging Report18747-6LOINCCT Report18755-9LOINCMRI Report18760-9LOINCUltrasound Report18757-5LOINCNuclear Medicine Report18758-3LOINCPET Scan Report18745-0LOINCCardiac Catheterization Report11522-0LOINCEchocardiography Report18746-8LOINCColonoscopy Report18751-8LOINCEndoscopy Report11525-3LOINCObstetrical Ultrasound Report...SEQ Table \* ARABIC28: DIRSectionTypeCodesValue Set: DIRSectionTypeCodes 2.16.840.1.113883.11.20.9.59The Section Type codes used by DIR are all narrative document sections. The codes in this table are drawn from LOINC () and DICOM (). The section/code should be selected from LOINC or DICOM for sections not listed in this table.Valueset Source: SystemPrint Name121181DCMDICOM Object Catalog121060DCMHistory121062DCMRequest121064DCMCurrent Procedure Descriptions121066DCMPrior Procedure Descriptions121068DCMPrevious Findings121070DCMFindings (DIR)121072DCMImpressions121074DCMRecommendations121076DCMConclusions121078DCMAddendum121109DCMIndications for Procedure121110DCMPatient Presentation121113DCMComplications121111DCMSummary121180DCMKey Images11329-0LOINCHISTORY GENERAL55115-0LOINCREQUESTED IMAGING STUDIES INFORMATION55111-9LOINCCURRENT IMAGING PROCEDURE DESCRIPTIONS55114-3LOINCPRIOR IMAGING PROCEDURE DESCRIPTIONS...Figure SEQ Table \* ARABIC6: Sample  <realmCode code="US"/> <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <templateId root="2.16.840.1.113883.10.20.22.1.1.2"/>  <templateId root="2.16.840.1.113883.10.20.22.1.5.2"/> <id root="2.16.840.1.113883.19.4.27" extension="20060828170821659"/> <code code="18748-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnostic Imaging Report"/> <title>Chest X-Ray, PA and LAT View</title> <effectiveTime value="20050329171504+0500"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="en-US"/> <setId extension="111199021" root="2.16.840.1.113883.19"/> <versionNumber value="1"/> <recordTarget>  <patientRole> <id extension="12345" root="2.16.840.1.113883.19.5"/> <addr use="HP"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> <telecom value="tel:(781)555-1212" use="HP"/> <patient> <name use="L"> <given>Adam</given> <family>Everyman</family> </name> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19541125"/> <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/> <religiousAffiliationCode code="1013" displayName="Christian" codeSystemName="HL7 Religious Affiliation " codeSystem="2.16.840.1.113883.5.1076"/> <raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/> <ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/> <guardian> <code code="GRFTH" displayName="Grandfather" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code"/> <addr use="HP"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> <telecom value="tel:(781)555-1212" use="HP"/> <guardianPerson> <name> <given>Ralph</given> <family>Relative</family> </name> </guardianPerson> </guardian> <birthplace> <place> <addr> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> </place> </birthplace> <languageCommunication> <languageCode code="fr-CN"/> <modeCode code="RWR" displayName="Received Written" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/> <proficiencyLevelCode code="G" displayName="Good" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/> <preferenceInd value="true"/> </languageCommunication> </patient> <providerOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> <telecom value="tel:(781)555-1212" use="WP"/> <addr> <streetAddressLine>21 North Ave</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> </providerOrganization> </patientRole> </recordTarget> <author> <time value="20050329224411+0500"/> <assignedAuthor> <id extension="KP00017" root="2.16.840.1.113883.4.6"/> <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic & Osteopathic Physicians"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> <telecom value="tel:(555)555-1003" use="WP"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor> </author> <dataEnterer> <assignedEntity> <id root="2.16.840.1.113883.19.5" extension="43252"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> <telecom value="tel:(555)555-1003" use="WP"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </dataEnterer> <custodian> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> <telecom value="tel:(555)555-1212" use="WP"/> <addr use="WP"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> </representedCustodianOrganization> </assignedCustodian> </custodian> <informationRecipient> <intendedRecipient> <informationRecipient> <name> <given>Henry</given> <family>Seven</family> </name> </informationRecipient> <receivedOrganization> <name>Good Health Clinic</name> </receivedOrganization> </intendedRecipient> </informationRecipient> <legalAuthenticator> <time value="20050329224411+0500"/> <signatureCode code="S"/> <assignedEntity> <id extension="KP00017" root="2.16.840.1.113883.19.5"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> <telecom value="tel:(555)555-1003" use="WP"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </legalAuthenticator> <authenticator> <time value="20050329224411+0500"/> <signatureCode code="S"/> <assignedEntity> <id extension="KP00017" root="2.16.840.1.113883.19.5"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>USA</country> </addr> <telecom value="tel:(555)555-1003" use="WP"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </authenticator> <participant typeCode="REF"> <associatedEntity classCode="PROV"> <id nullFlavor="NI"/> <addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <associatedPerson> <name> <given>Amanda</given> <family>Assigned</family> <suffix>MD</suffix> </name> </associatedPerson> </associatedEntity> </participant> <inFulfillmentOf> <order> <id extension="10523475" root="1.2.840.113619.2.62.994044785528.27"/>  <id extension="123452" root="1.2.840.113619.2.62.994044785528.28"/>  <id extension="123451" root="1.2.840.113619.2.62.994044785528.29"/>  </order> </inFulfillmentOf> <documentationOf> <serviceEvent classCode="ACT"> <id root="1.2.840.113619.2.62.994044785528.114289542805"/>  <id extension="123453" root="1.2.840.113619.2.62.994044785528.26"/>  <code code="70544" displayName="Magnetic resonance angiography, head; without contrast material(s)" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4"/> <effectiveTime> <low value="20060823222400"/> </effectiveTime> <performer typeCode="PRF"> <templateId root="2.16.840.1.113883.10.20.6.2.1"/> <assignedEntity> <id extension="121008" root="2.16.840.1.113883.19.5"/> <code code="2085R0202X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Diagnostic Radiology"/> <addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <assignedPerson> <name> <given>Christine</given> <family>Cure</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity> </performer> </serviceEvent> </documentationOf>  <relatedDocument typeCode="XFRM"> <parentDocument> <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.9"/>  </parentDocument> </relatedDocument> <componentOf> <encompassingEncounter> <id extension="9937012" root="1.3.6.4.1.4.1.2835.12"/> <effectiveTime value="20060828170821"/> <encounterParticipant typeCode="ATND"> <templateId root="2.16.840.1.113883.10.20.6.2.2"/> <assignedEntity> <id extension="44444444" root="2.16.840.1.113883.4.6"/> <code code="208D00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="General Practice"/> <addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Fay</given> <family>Family</family> </name> </assignedPerson> </assignedEntity> </encounterParticipant> </encompassingEncounter> </componentOf> <component> <structuredBody> <component>  <section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.1.1"/> <code code="121181" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="DICOM Object Catalog"/> <entry>  <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.6"/> ... </act> </entry> </section>  </component> <component>  <section> <code code="121109" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Indications for Procedure"/> <title>Indications for Procedure</title> <text>Suspected lung tumor</text> </section>  </component> <component>  <section> <code code="11329-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History"/> <title>History</title> <text> <paragraph> <caption>History</caption> <content ID="Fndng1">Sore throat.</content> </paragraph> </text> <entry>  <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.12"/> ... </observation> </entry> </section>  </component> <component>  <section> <templateId root="2.16.840.1.113883.10.20.6.1.2"/> <code code="121070" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Findings"/> <title>Findings</title> <text> <paragraph> <caption>Finding</caption> <content ID="Fndng2">The cardiomediastinum is within normal limits. The trachea is midline. The previously described opacity at the medial right lung base has cleared. There are no new infiltrates. There is a new round density at the left hilus, superiorly (diameter about 45mm). A CT scan is recommended for further evaluation. The pleural spaces are clear. The visualized musculoskeletal structures and the upper abdomen are stable and unremarkable.</content> </paragraph> <paragraph> <caption>Diameter</caption> <content ID="Diam2">45mm</content> </paragraph> <paragraph> <caption>Source of Measurement</caption> <content ID="SrceOfMeas2"> <linkHtml href="" >Chest_PA </linkHtml> </content> </paragraph> </text> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.6.2.12"/> ... </observation> </entry> </section>  </component> <component>  <section> <code code="121072" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Impressions"/> <title>Impressions</title> <text> <paragraph> <caption>Impression</caption> <content ID="Fndng3">No acute cardiopulmonary process. Round density in left superior hilus, further evaluation with CT is recommended as underlying malignancy is not excluded.</content> </paragraph> </text> <entry>  <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.6.2.12"/> ... </observation> </entry> <entry> <act moodCode="EVN" classCode="ACT"> <templateId root="2.16.840.1.113883.10.20.6.2.5"/>  ... </act> </entry> </section>  </component> </structuredBody> </component>Discharge Summary (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.8.2 (open)]SEQ Table \* ARABIC29: Discharge Summary (V2) ContextsContained By:Contains:Allergies Section (entries optional) (V2)Chief Complaint and Reason for Visit SectionChief Complaint SectionFamily History SectionFunctional Status Section (V2)History of Past Illness Section (V2)History of Present Illness SectionHospital Admission Diagnosis Section (V2)Hospital Admission Medications Section (entries optional) (V2)Hospital Consultations SectionHospital Course SectionHospital Discharge Diagnosis Section (V2)Hospital Discharge Instructions SectionHospital Discharge Medications Section (entries optional) (V2)Hospital Discharge Physical SectionHospital Discharge Studies Summary SectionImmunizations Section (entries optional) (V2)Nutrition Section (NEW)Plan of Treatment Section (V2)Problem Section (entries optional) (V2)Procedures Section (entries optional) (V2)Reason for Visit SectionReview of Systems SectionSocial History Section (V2)Vital Signs Section (entries optional) (V2)The Discharge Summary is a document that is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge.??The Joint Commission requires the following information to be included in the Discharge Summary:???The reason for hospitalization???The procedures performed???The care, treatment, and services provided???The patient’s condition and disposition at discharge???Information provided to the patient and family???Provisions for follow-up careSEQ Table \* ARABIC30: Discharge Summary (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.8.2']templateId1..1SHALL8463@root1..1SHALL100442.16.840.1.113883.10.20.22.1.8.2code1..1SHALL17178@code1..1SHALL171792.16.840.1.113883.11.20.4.1 (DischargeSummaryDocumentTypeCode)participant0..*MAY8467componentOf1..1SHALL8471encompassingEncounter1..1SHALL8472effectiveTime/low1..1SHALL8473effectiveTime/high1..1SHALL8475component1..1SHALL9539structuredBody1..1SHALL30518component1..1SHALL30519section1..1SHALL30520component1..1SHALL30521section1..1SHALL30522component1..1SHALL30523section1..1SHALL30524component1..1SHALL30525section1..1SHALL30526component1..1SHALL30527section1..1SHALL30528component0..1MAY30529section1..1SHALL30530component0..1MAY30531section1..1SHALL30532component0..1MAY30533section1..1SHALL30534component0..1MAY30535section1..1SHALL30536component0..1MAY30537section1..1SHALL30538component0..1MAY30539section1..1SHALL30540component0..1MAY30541section1..1SHALL30542component0..1MAY30543section1..1SHALL30544component0..1MAY30545section1..1SHALL30546component0..1MAY30547section1..1SHALL30548component0..1MAY30549section1..1SHALL30550component0..1MAY30551section1..1SHALL30552component0..1MAY30553section1..1SHALL30554component0..1MAY30555section1..1SHALL30556component0..1MAY30557section1..1SHALL30558component0..1MAY30559section1..1SHALL30560component0..1MAY30561section1..1SHALL30562component0..1MAY30563section1..1SHALL30564component0..1MAY30565section1..1SHALL30566component0..1MAY30567section1..1SHALL30568Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:8463) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.8.2" (CONF:10044).SHALL contain exactly one [1..1] code (CONF:17178).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet DischargeSummaryDocumentTypeCode 2.16.840.1.113883.11.20.4.1 DYNAMIC (CONF:17179).MAY contain zero or more [0..*] participant (CONF:8467).If present, the participant/associatedEntity element SHALL have an associatedPerson or scopingOrganization element (CONF:8468).B.??When participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:8469).SHALL contain exactly one [1..1] componentOf (CONF:8471).This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8472).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/low (CONF:8473).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/high (CONF:8475).The dischargeDispositionCode SHALL be present where the value of code SHOULD be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status DYNAMIC () (CONF:8476).The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, SHALL be displayed when the document is rendered (CONF:8477).The encounterParticipant elements MAY be present. If present, the encounterParticipant/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present (CONF:8478).The responsibleParty element MAY be present. If present, the responsibleParty/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present (CONF:8479).SHALL contain exactly one [1..1] component (CONF:9539).In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional.This component SHALL contain exactly one [1..1] structuredBody (CONF:30518).This structuredBody SHALL contain exactly one [1..1] component (CONF:30519) such that itSHALL contain exactly one [1..1] Allergies Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.2) (CONF:30520).This structuredBody SHALL contain exactly one [1..1] component (CONF:30521) such that itSHALL contain exactly one [1..1] Hospital Course Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.5) (CONF:30522).This structuredBody SHALL contain exactly one [1..1] component (CONF:30523) such that itSHALL contain exactly one [1..1] Hospital Discharge Diagnosis Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.24.2) (CONF:30524).This structuredBody SHALL contain exactly one [1..1] component (CONF:30525) such that itSHALL contain exactly one [1..1] Hospital Discharge Medications Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.11.2) (CONF:30526).This structuredBody SHALL contain exactly one [1..1] component (CONF:30527) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30528).This structuredBody MAY contain zero or one [0..1] component (CONF:30529) such that itSHALL contain exactly one [1..1] Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:30530).This structuredBody MAY contain zero or one [0..1] component (CONF:30531) such that itSHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13) (CONF:30532).This structuredBody MAY contain zero or one [0..1] component (CONF:30533) such that itSHALL contain exactly one [1..1] Nutrition Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.57) (CONF:30534).This structuredBody MAY contain zero or one [0..1] component (CONF:30535) such that itSHALL contain exactly one [1..1] Family History Section (templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:30536).This structuredBody MAY contain zero or one [0..1] component (CONF:30537) such that itSHALL contain exactly one [1..1] Functional Status Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.14.2) (CONF:30538).This structuredBody MAY contain zero or one [0..1] component (CONF:30539) such that itSHALL contain exactly one [1..1] History of Past Illness Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.20.2) (CONF:30540).This structuredBody MAY contain zero or one [0..1] component (CONF:30541) such that itSHALL contain exactly one [1..1] History of Present Illness Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:30542).This structuredBody MAY contain zero or one [0..1] component (CONF:30543) such that itSHALL contain exactly one [1..1] Hospital Admission Diagnosis Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.43.2) (CONF:30544).This structuredBody MAY contain zero or one [0..1] component (CONF:30545) such that itSHALL contain exactly one [1..1] Hospital Admission Medications Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.44.2) (CONF:30546).This structuredBody MAY contain zero or one [0..1] component (CONF:30547) such that itSHALL contain exactly one [1..1] Hospital Consultations Section (templateId:2.16.840.1.113883.10.20.22.2.42) (CONF:30548).This structuredBody MAY contain zero or one [0..1] component (CONF:30549) such that itSHALL contain exactly one [1..1] Hospital Discharge Instructions Section (templateId:2.16.840.1.113883.10.20.22.2.41) (CONF:30550).This structuredBody MAY contain zero or one [0..1] component (CONF:30551) such that itSHALL contain exactly one [1..1] Hospital Discharge Physical Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.26) (CONF:30552).This structuredBody MAY contain zero or one [0..1] component (CONF:30553) such that itSHALL contain exactly one [1..1] Hospital Discharge Studies Summary Section (templateId:2.16.840.1.113883.10.20.22.2.16) (CONF:30554).This structuredBody MAY contain zero or one [0..1] component (CONF:30555) such that itSHALL contain exactly one [1..1] Immunizations Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.2.2) (CONF:30556).This structuredBody MAY contain zero or one [0..1] component (CONF:30557) such that itSHALL contain exactly one [1..1] Problem Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.5.2) (CONF:30558).This structuredBody MAY contain zero or one [0..1] component (CONF:30559) such that itSHALL contain exactly one [1..1] Procedures Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.7.2) (CONF:30560).This structuredBody MAY contain zero or one [0..1] component (CONF:30561) such that itSHALL contain exactly one [1..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) (CONF:30562).This structuredBody MAY contain zero or one [0..1] component (CONF:30563) such that itSHALL contain exactly one [1..1] Review of Systems Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:30564).This structuredBody MAY contain zero or one [0..1] component (CONF:30565) such that itSHALL contain exactly one [1..1] Social History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.17.2) (CONF:30566).This structuredBody MAY contain zero or one [0..1] component (CONF:30567) such that itSHALL contain exactly one [1..1] Vital Signs Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.4.2) (CONF:30568).SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section (CONF:30569).SEQ Table \* ARABIC31: DischargeSummaryDocumentTypeCodeValue Set: DischargeSummaryDocumentTypeCode 2.16.840.1.113883.11.20.4.1CodeCode SystemPrint Name18842-5LOINC{Provider}11490-0LOINCPhysician28655-9LOINCAttending physician29761-4LOINCDentistry34745-0LOINCNursing34105-7LOINC{Provider}34106-5LOINCPhysicianHistory and Physical (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.3.2 (open)]SEQ Table \* ARABIC32: History and Physical (V2) ContextsContained By:Contains:Allergies Section (entries optional) (V2)Assessment and Plan Section (V2)Assessment SectionChief Complaint and Reason for Visit SectionChief Complaint SectionFamily History SectionGeneral Status SectionHistory of Past Illness Section (V2)History of Present Illness SectionImmunizations Section (entries optional) (V2)Instructions Section (V2)Medications Section (entries optional) (V2)Physical Exam Section (V2)Plan of Treatment Section (V2)Problem Section (entries optional) (V2)Procedures Section (entries optional) (V2)Reason for Visit SectionResults Section (entries optional) (V2)Review of Systems SectionSocial History Section (V2)Vital Signs Section (entries optional) (V2)A History and Physical (H&P) Note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The first portion of the report is a current collection of organized information unique to an individual, typically supplied by the patient or their caregiver, about the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures. The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues. A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P Note.SEQ Table \* ARABIC33: History and Physical (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.3.2']templateId1..1SHALL8283@root1..1SHALL100462.16.840.1.113883.10.20.22.1.3.2code1..1SHALL17185@code1..1SHALL171862.16.840.1.113883.1.11.20.22 (HPDocumentType)participant0..*MAY8286inFulfillmentOf0..*MAY8336componentOf1..1SHALL8338encompassingEncounter1..1SHALL8339id1..1SHALL8340effectiveTime1..1SHALL8341responsibleParty0..1MAY8345encounterParticipant0..*MAY8342location0..1MAY8344component1..1SHALL8349structuredBody1..1SHALL30570component1..1SHALL30571section1..1SHALL30572component0..1MAY30573section1..1SHALL30574component0..1MAY30575section1..1SHALL30576component0..1MAY30577section1..1SHALL30578component0..1MAY30579section1..1SHALL30580component0..1MAY30581section1..1SHALL30582component1..1SHALL30583section1..1SHALL30584component1..1SHALL30585section1..1SHALL30586component1..1SHALL30587section1..1SHALL30588component0..1SHOULD30589section1..1SHALL30590component0..1MAY30591section1..1SHALL30592component0..1MAY30593section1..1SHALL31385component1..1SHALL30595section1..1SHALL30596component1..1SHALL30597section1..1SHALL30598component0..1MAY30599section1..1SHALL30600component0..1MAY30601section1..1SHALL30602component0..1MAY30603section1..1SHALL30604component1..1SHALL30605section1..1SHALL30606component1..1SHALL30607section1..1SHALL30608component1..1SHALL30609section1..1SHALL30610component1..1SHALL30611section1..1SHALL30612Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:8283) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.3.2" (CONF:10046).SHALL contain exactly one [1..1] code (CONF:17185).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet HPDocumentType 2.16.840.1.113883.1.11.20.22 DYNAMIC (CONF:17186).MAY contain zero or more [0..*] participant (CONF:8286).A participant element, if present, SHALL contain an associatedEntity element which SHALL contain either an associatedPerson or scopingOrganization element (CONF:8287).A special class of participant is the supporting person or organization:??an individual or an organization that has a relationship to the patient, including??parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded (CONF:8288).C.??When participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:8333).MAY contain zero or more [0..*] inFulfillmentOf (CONF:8336).An inFulfillmentOf element records the prior orders that are fulfilled (in whole or part) by the service events described in this document.??For example, the prior order might be a referral and this H&P Note may be in partial fulfillment of that referral (CONF:8337).SHALL contain exactly one [1..1] componentOf (CONF:8338).This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8339).This encompassingEncounter SHALL contain exactly one [1..1] id (CONF:8340).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8341).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:10135).This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8345).The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care (CONF:8347).The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:8348).This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:8342).An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:8343).The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care (CONF:8346).This encompassingEncounter MAY contain zero or one [0..1] location (CONF:8344).SHALL contain exactly one [1..1] component (CONF:8349).In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional.This component SHALL contain exactly one [1..1] structuredBody (CONF:30570).This structuredBody SHALL contain exactly one [1..1] component (CONF:30571) such that itSHALL contain exactly one [1..1] Allergies Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.2) (CONF:30572).This structuredBody MAY contain zero or one [0..1] component (CONF:30573) such that itSHALL contain exactly one [1..1] Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) (CONF:30574).This structuredBody MAY contain zero or one [0..1] component (CONF:30575) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30576).This structuredBody MAY contain zero or one [0..1] component (CONF:30577) such that itSHALL contain exactly one [1..1] Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) (CONF:30578).This structuredBody MAY contain zero or one [0..1] component (CONF:30579) such that itSHALL contain exactly one [1..1] Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:30580).This structuredBody MAY contain zero or one [0..1] component (CONF:30581) such that itSHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13) (CONF:30582).This structuredBody SHALL contain exactly one [1..1] component (CONF:30583) such that itSHALL contain exactly one [1..1] Family History Section (templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:30584).This structuredBody SHALL contain exactly one [1..1] component (CONF:30585) such that itSHALL contain exactly one [1..1] General Status Section (templateId:2.16.840.1.113883.10.20.2.5) (CONF:30586).This structuredBody SHALL contain exactly one [1..1] component (CONF:30587) such that itSHALL contain exactly one [1..1] History of Past Illness Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.20.2) (CONF:30588).This structuredBody SHOULD contain zero or one [0..1] component (CONF:30589) such that itSHALL contain exactly one [1..1] History of Present Illness Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:30590).This structuredBody MAY contain zero or one [0..1] component (CONF:30591) such that itSHALL contain exactly one [1..1] Immunizations Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.2.2) (CONF:30592).This structuredBody MAY contain zero or one [0..1] component (CONF:30593) such that itSHALL contain exactly one [1..1] Instructions Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.45.2) (CONF:31385).This structuredBody SHALL contain exactly one [1..1] component (CONF:30595) such that itSHALL contain exactly one [1..1] Medications Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.1.2) (CONF:30596).This structuredBody SHALL contain exactly one [1..1] component (CONF:30597) such that itSHALL contain exactly one [1..1] Physical Exam Section (V2) (templateId:2.16.840.1.113883.10.20.2.10.2) (CONF:30598).This structuredBody MAY contain zero or one [0..1] component (CONF:30599) such that itSHALL contain exactly one [1..1] Problem Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.5.2) (CONF:30600).This structuredBody MAY contain zero or one [0..1] component (CONF:30601) such that itSHALL contain exactly one [1..1] Procedures Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.7.2) (CONF:30602).This structuredBody MAY contain zero or one [0..1] component (CONF:30603) such that itSHALL contain exactly one [1..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) (CONF:30604).This structuredBody SHALL contain exactly one [1..1] component (CONF:30605) such that itSHALL contain exactly one [1..1] Results Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.3.2) (CONF:30606).This structuredBody SHALL contain exactly one [1..1] component (CONF:30607) such that itSHALL contain exactly one [1..1] Review of Systems Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:30608).This structuredBody SHALL contain exactly one [1..1] component (CONF:30609) such that itSHALL contain exactly one [1..1] Social History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.17.2) (CONF:30610).This structuredBody SHALL contain exactly one [1..1] component (CONF:30611) such that itSHALL contain exactly one [1..1] Vital Signs Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.4.2) (CONF:30612).SHALL include a Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13), a Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1), or a Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) (CONF:30613).SHALL include an Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2), or an Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) and a??Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30614).SHALL NOT include an Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) when an Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) are present (CONF:30615).SHALL NOT contain a Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) is present (CONF:30616).SEQ Table \* ARABIC34: HPDocumentTypeValue Set: HPDocumentType 2.16.840.1.113883.1.11.20.22CodeCode SystemPrint Name34117-2LOINCHistory & Physical11492-6LOINCHistory & Physical: Hospital28626-0LOINCPhysician34774-0LOINCGeneral surgery34115-6LOINCHistory & Physical: Hospital: Medical Student34116-4LOINCHistory & Physical: Nursing Home: Physician34095-0LOINCComprehensive History & Physical34096-8LOINCComprehensive History & Physical: Nursing Home51849-8LOINCAdmission History & Physical47039-3LOINCAdmission History & Physical: Inpatient34763-3LOINCAdmission History & Physical: General medicine34094-3LOINCAdmission History & Physical: Cardiology34138-8LOINCTargeted History & PhysicalOperative Note (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.7.2 (open)]SEQ Table \* ARABIC35: Operative Note (V2) ContextsContained By:Contains:Anesthesia Section (V2)Complications Section (V2)Operative Note Fluids SectionOperative Note Surgical Procedure SectionPlan of Treatment Section (V2)Planned Procedure Section (V2)Postoperative Diagnosis SectionPreoperative Diagnosis Section (V2)Procedure Description SectionProcedure Disposition SectionProcedure Estimated Blood Loss SectionProcedure Findings Section (V2)Procedure Implants SectionProcedure Indications Section (V2)Procedure Specimens Taken SectionSurgical Drains SectionThe Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note or Report is created immediately following a surgical or other high-risk procedure and records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure.??The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.SEQ Table \* ARABIC36: Operative Note (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.7.2']templateId1..1SHALL8483@root1..1SHALL100482.16.840.1.113883.10.20.22.1.7.2code1..1SHALL17187@code1..1SHALL171882.16.840.1.113883.11.20.1.1 (SurgicalOperationNoteDocumentTypeCode)documentationOf1..*SHALL8486serviceEvent1..1SHALL8493effectiveTime1..1SHALL8494performer1..1SHALL8489@typeCode1..1SHALL84952.16.840.1.113883.5.90 (HL7ParticipationType) = PPRFassignedEntity1..1SHALL10917code1..1SHALL8490@code0..1SHOULD84912.16.840.1.113883.3.88.12.3221.4 (Provider Role Value Set)component1..1SHALL9585structuredBody1..1SHALL30485component1..1SHALL30486section1..1SHALL30487component1..1SHALL30488section1..1SHALL30489component1..1SHALL30490section1..1SHALL30491component1..1SHALL30492section1..1SHALL30493component1..1SHALL30494section1..1SHALL30495component1..1SHALL30496section1..1SHALL30497component1..1SHALL30498section1..1SHALL30499component1..1SHALL30500section1..1SHALL30501component0..1MAY30502section1..1SHALL30503component0..1MAY30504section1..1SHALL30505component0..1MAY30506section1..1SHALL30507component0..1MAY30508section1..1SHALL30509component0..1MAY30510section1..1SHALL30511component0..1MAY30512section1..1SHALL30513component0..1MAY30514section1..1SHALL30515component0..1MAY30516section1..1SHALL30517Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:8483) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.7.2" (CONF:10048).SHALL contain exactly one [1..1] code (CONF:17187).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet SurgicalOperationNoteDocumentTypeCode 2.16.840.1.113883.11.20.1.1 DYNAMIC (CONF:17188).SHALL contain at least one [1..*] documentationOf (CONF:8486).Such documentationOfs SHALL contain exactly one [1..1] serviceEvent (CONF:8493).This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8494).The serviceEvent/effectiveTime SHALL be present with effectiveTime/low (CONF:8488).If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high (CONF:10058).When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present (CONF:10060).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:10136).This serviceEvent SHALL contain exactly one [1..1] performer (CONF:8489) such that itSHALL contain exactly one [1..1] @typeCode="PPRF" Primary performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8495).SHALL contain exactly one [1..1] assignedEntity (CONF:10917).This assignedEntity SHALL contain exactly one [1..1] code (CONF:8490).This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Provider Role Value Set 2.16.840.1.113883.3.88.12.3221.4 DYNAMIC (CONF:8491).The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC (CONF:8487).Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF) (CONF:8512).SHALL contain exactly one [1..1] component (CONF:9585).This component SHALL contain exactly one [1..1] structuredBody (CONF:30485).This structuredBody SHALL contain exactly one [1..1] component (CONF:30486) such that itSHALL contain exactly one [1..1] Anesthesia Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.25.2) (CONF:30487).This structuredBody SHALL contain exactly one [1..1] component (CONF:30488) such that itSHALL contain exactly one [1..1] Complications Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.37.2) (CONF:30489).This structuredBody SHALL contain exactly one [1..1] component (CONF:30490) such that itSHALL contain exactly one [1..1] Preoperative Diagnosis Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.34.2) (CONF:30491).This structuredBody SHALL contain exactly one [1..1] component (CONF:30492) such that itSHALL contain exactly one [1..1] Procedure Estimated Blood Loss Section (templateId:2.16.840.1.113883.10.20.18.2.9) (CONF:30493).This structuredBody SHALL contain exactly one [1..1] component (CONF:30494) such that itSHALL contain exactly one [1..1] Procedure Findings Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.28.2) (CONF:30495).This structuredBody SHALL contain exactly one [1..1] component (CONF:30496) such that itSHALL contain exactly one [1..1] Procedure Specimens Taken Section (templateId:2.16.840.1.113883.10.20.22.2.31) (CONF:30497).This structuredBody SHALL contain exactly one [1..1] component (CONF:30498) such that itSHALL contain exactly one [1..1] Procedure Description Section (templateId:2.16.840.1.113883.10.20.22.2.27) (CONF:30499).This structuredBody SHALL contain exactly one [1..1] component (CONF:30500) such that itSHALL contain exactly one [1..1] Postoperative Diagnosis Section (templateId:2.16.840.1.113883.10.20.22.2.35) (CONF:30501).This structuredBody MAY contain zero or one [0..1] component (CONF:30502) such that itSHALL contain exactly one [1..1] Procedure Implants Section (templateId:2.16.840.1.113883.10.20.22.2.40) (CONF:30503).This structuredBody MAY contain zero or one [0..1] component (CONF:30504) such that itSHALL contain exactly one [1..1] Operative Note Fluids Section (templateId:2.16.840.1.113883.10.20.7.12) (CONF:30505).This structuredBody MAY contain zero or one [0..1] component (CONF:30506) such that itSHALL contain exactly one [1..1] Operative Note Surgical Procedure Section (templateId:2.16.840.1.113883.10.20.7.14) (CONF:30507).This structuredBody MAY contain zero or one [0..1] component (CONF:30508) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30509).This structuredBody MAY contain zero or one [0..1] component (CONF:30510) such that itSHALL contain exactly one [1..1] Planned Procedure Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.30.2) (CONF:30511).This structuredBody MAY contain zero or one [0..1] component (CONF:30512) such that itSHALL contain exactly one [1..1] Procedure Disposition Section (templateId:2.16.840.1.113883.10.20.18.2.12) (CONF:30513).This structuredBody MAY contain zero or one [0..1] component (CONF:30514) such that itSHALL contain exactly one [1..1] Procedure Indications Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.29.2) (CONF:30515).This structuredBody MAY contain zero or one [0..1] component (CONF:30516) such that itSHALL contain exactly one [1..1] Surgical Drains Section (templateId:2.16.840.1.113883.10.20.7.13) (CONF:30517).A consent, if present, SHALL be represented as ClinicalDocument/authorization/consent (CONF:8485).SEQ Table \* ARABIC37: SurgicalOperationNoteDocumentTypeCodeValue Set: SurgicalOperationNoteDocumentTypeCode 2.16.840.1.113883.11.20.1.1CodeCode SystemPrint Name11504-8LOINC{Provider}34137-0LOINC{Provider}28583-3LOINCDentistry28624-5LOINCPodiatry28573-4LOINCPhysician34877-1LOINCUrology34874-8LOINCSurgery34870-6LOINCPlastic surgery34868-0LOINCOrthopedics34818-5LOINCOtorhinolaryngologySEQ Table \* ARABIC38: Provider Role Value SetValue Set: Provider Role Value Set 2.16.840.1.113883.3.88.12.3221.4The Provider type vocabulary classifies providers according to the type of license or accreditation they hold or the service they provide. CodeCode SystemPrint NameCPProvider Role (HL7)Consulting ProviderPPProvider Role (HL7)Primary Care ProviderRPProvider Role (HL7)Referring ProviderProcedure Note (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.6.2 (open)]SEQ Table \* ARABIC39: Procedure Note (V2) ContextsContained By:Contains:Allergies Section (entries optional) (V2)Anesthesia Section (V2)Assessment and Plan Section (V2)Assessment SectionChief Complaint and Reason for Visit SectionChief Complaint SectionComplications Section (V2)Family History SectionHistory of Past Illness Section (V2)History of Present Illness SectionMedical (General) History Section (V2)Medications Administered Section (V2)Medications Section (entries optional) (V2)Physical Exam Section (V2)Plan of Treatment Section (V2)Planned Procedure Section (V2)Postprocedure Diagnosis Section (V2)Procedure Description SectionProcedure Disposition SectionProcedure Estimated Blood Loss SectionProcedure Findings Section (V2)Procedure Implants SectionProcedure Indications Section (V2)Procedure Specimens Taken SectionProcedures Section (entries optional) (V2)Reason for Visit SectionReview of Systems SectionSocial History Section (V2)Procedure Note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are documents that are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act.??The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient’s tolerance of the procedure. The document should be sufficiently detailed to justify the procedure, describe the course of the procedure, and provide continuity of care.SEQ Table \* ARABIC40: Procedure Note (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.6.2']templateId1..1SHALL8496@root1..1SHALL100502.16.840.1.113883.10.20.22.1.6.2code1..1SHALL17182@code1..1SHALL171832.16.840.1.113883.11.20.6.1 (ProcedureNoteDocumentTypeCodes)participant0..*MAY8504@typeCode1..1SHALL85052.16.840.1.113883.5.88 (participationFunction) = INDfunctionCode1..1SHALL85062.16.840.1.113883.5.88 (participationFunction) = PCPassociatedEntity/@classCode1..1SHALL85072.16.840.1.113883.5.90 (HL7ParticipationType) = PROVassociatedPerson1..1SHALL8508documentationOf1..*SHALL8510serviceEvent1..1SHALL10061effectiveTime1..1SHALL10062low1..1SHALL26449performer1..1SHALL8520@typeCode1..1SHALL85212.16.840.1.113883.5.90 (HL7ParticipationType) = PPRFassignedEntity1..1SHALL14911code0..1SHOULD14912@code0..1SHOULD149132.16.840.1.114222.4.11.1066 (Healthcare Provider Taxonomy (HIPAA))component1..1SHALL9588structuredBody1..1SHALL30352component1..1SHALL30353section1..1SHALL30387component1..1SHALL30355section1..1SHALL30356component1..1SHALL30357section1..1SHALL30358component1..1SHALL30359section1..1SHALL30360component0..1MAY30361section1..1SHALL30362component0..1MAY30363section1..1SHALL30364component0..1MAY30365section1..1SHALL30366component0..1MAY30367section1..1SHALL30368component0..1MAY30369section1..1SHALL30370component0..1MAY30371section1..1SHALL30372component0..1MAY30373section1..1SHALL30374component0..1MAY30375section1..1SHALL30376component0..1MAY30377section1..1SHALL30378component0..1MAY30379section1..1SHALL30380component0..1MAY30381section1..1SHALL30382component0..1MAY30383section1..1SHALL30384component0..1MAY30388section1..1SHALL30389component0..1MAY30390section1..1SHALL30391component0..1MAY30392section1..1SHALL30393component0..1MAY30394section1..1SHALL30395component0..1MAY30396section1..1SHALL30397component0..1MAY30398section1..1SHALL30399component0..1MAY30400section1..1SHALL30401component0..1MAY30402section1..1SHALL30403component0..1MAY30404section1..1SHALL30405component0..1MAY30406section1..1SHALL30407component0..1MAY30408section1..1SHALL30409component0..1MAY30410section1..1SHALL30411componentOf0..1SHOULD30871encompassingEncounter1..1SHALL30872code1..1SHALL30873encounterParticipant0..1MAY30874@typeCode1..1SHALL30875REFlocation1..*SHALL30876healthCareFacility1..1SHALL30877id1..*SHALL30878Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:8496) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.6.2" (CONF:10050).SHALL contain exactly one [1..1] code (CONF:17182).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureNoteDocumentTypeCodes 2.16.840.1.113883.11.20.6.1 DYNAMIC (CONF:17183).MAY contain zero or more [0..*] participant (CONF:8504) such that itSHALL contain exactly one [1..1] @typeCode="IND" Individual (CodeSystem: participationFunction 2.16.840.1.113883.5.88 STATIC) (CONF:8505).SHALL contain exactly one [1..1] functionCode="PCP" Primary Care Physician (CodeSystem: participationFunction 2.16.840.1.113883.5.88 STATIC) (CONF:8506).SHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8507).This associatedEntity/@classCode SHALL contain exactly one [1..1] associatedPerson (CONF:8508).SHALL contain at least one [1..*] documentationOf (CONF:8510) such that itSHALL contain exactly one [1..1] serviceEvent (CONF:10061).This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:10062).This effectiveTime SHALL contain exactly one [1..1] low (CONF:26449).The serviceEvent/effectiveTime SHALL be present with effectiveTime/low (CONF:8513).If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high (CONF:8514).When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present (CONF:8515).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:10063).This serviceEvent SHALL contain exactly one [1..1] performer (CONF:8520).This performer SHALL contain exactly one [1..1] @typeCode="PPRF" Primary Performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8521).This performer SHALL contain exactly one [1..1] assignedEntity (CONF:14911).This assignedEntity SHOULD contain zero or one [0..1] code (CONF:14912).The code, if present, SHOULD contain zero or one [0..1] @code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:14913).The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:8511).Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF) (CONF:8524).SHOULD contain zero or one [0..1] componentOf (CONF:30871).The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:30872).This encompassingEncounter SHALL contain exactly one [1..1] code (CONF:30873).This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (CONF:30874) such that itSHALL contain exactly one [1..1] @typeCode="REF" Referrer (CONF:30875).This encompassingEncounter SHALL contain at least one [1..*] location (CONF:30876).Such locations SHALL contain exactly one [1..1] healthCareFacility (CONF:30877).This healthCareFacility SHALL contain at least one [1..*] id (CONF:30878).SHALL contain exactly one [1..1] component (CONF:9588).This component SHALL contain exactly one [1..1] structuredBody (CONF:30352).This structuredBody SHALL contain exactly one [1..1] component (CONF:30353) such that itSHALL contain exactly one [1..1] Complications Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.37.2) (CONF:30387).This structuredBody SHALL contain exactly one [1..1] component (CONF:30355) such that itSHALL contain exactly one [1..1] Procedure Description Section (templateId:2.16.840.1.113883.10.20.22.2.27) (CONF:30356).This structuredBody SHALL contain exactly one [1..1] component (CONF:30357) such that itSHALL contain exactly one [1..1] Procedure Indications Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.29.2) (CONF:30358).This structuredBody SHALL contain exactly one [1..1] component (CONF:30359) such that itSHALL contain exactly one [1..1] Postprocedure Diagnosis Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.36.2) (CONF:30360).This structuredBody MAY contain zero or one [0..1] component (CONF:30361) such that itSHALL contain exactly one [1..1] Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) (CONF:30362).This structuredBody MAY contain zero or one [0..1] component (CONF:30363) such that itSHALL contain exactly one [1..1] Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) (CONF:30364).This structuredBody MAY contain zero or one [0..1] component (CONF:30365) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30366).This structuredBody MAY contain zero or one [0..1] component (CONF:30367) such that itSHALL contain exactly one [1..1] Allergies Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.2) (CONF:30368).This structuredBody MAY contain zero or one [0..1] component (CONF:30369) such that itSHALL contain exactly one [1..1] Anesthesia Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.25.2) (CONF:30370).This structuredBody MAY contain zero or one [0..1] component (CONF:30371) such that itSHALL contain exactly one [1..1] Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:30372).This structuredBody MAY contain zero or one [0..1] component (CONF:30373) such that itSHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13) (CONF:30374).This structuredBody MAY contain zero or one [0..1] component (CONF:30375) such that itSHALL contain exactly one [1..1] Family History Section (templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:30376).This structuredBody MAY contain zero or one [0..1] component (CONF:30377) such that itSHALL contain exactly one [1..1] History of Past Illness Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.20.2) (CONF:30378).This structuredBody MAY contain zero or one [0..1] component (CONF:30379) such that itSHALL contain exactly one [1..1] History of Present Illness Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:30380).This structuredBody MAY contain zero or one [0..1] component (CONF:30381) such that itSHALL contain exactly one [1..1] Medical (General) History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.39.2) (CONF:30382).This structuredBody MAY contain zero or one [0..1] component (CONF:30383) such that itSHALL contain exactly one [1..1] Medications Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.1.2) (CONF:30384).This structuredBody MAY contain zero or one [0..1] component (CONF:30388) such that itSHALL contain exactly one [1..1] Medications Administered Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.38.2) (CONF:30389).This structuredBody MAY contain zero or one [0..1] component (CONF:30390) such that itSHALL contain exactly one [1..1] Physical Exam Section (V2) (templateId:2.16.840.1.113883.10.20.2.10.2) (CONF:30391).This structuredBody MAY contain zero or one [0..1] component (CONF:30392) such that itSHALL contain exactly one [1..1] Planned Procedure Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.30.2) (CONF:30393).This structuredBody MAY contain zero or one [0..1] component (CONF:30394) such that itSHALL contain exactly one [1..1] Procedure Disposition Section (templateId:2.16.840.1.113883.10.20.18.2.12) (CONF:30395).This structuredBody MAY contain zero or one [0..1] component (CONF:30396) such that itSHALL contain exactly one [1..1] Procedure Estimated Blood Loss Section (templateId:2.16.840.1.113883.10.20.18.2.9) (CONF:30397).This structuredBody MAY contain zero or one [0..1] component (CONF:30398) such that itSHALL contain exactly one [1..1] Procedure Findings Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.28.2) (CONF:30399).This structuredBody MAY contain zero or one [0..1] component (CONF:30400) such that itSHALL contain exactly one [1..1] Procedure Implants Section (templateId:2.16.840.1.113883.10.20.22.2.40) (CONF:30401).This structuredBody MAY contain zero or one [0..1] component (CONF:30402) such that itSHALL contain exactly one [1..1] Procedure Specimens Taken Section (templateId:2.16.840.1.113883.10.20.22.2.31) (CONF:30403).This structuredBody MAY contain zero or one [0..1] component (CONF:30404) such that itSHALL contain exactly one [1..1] Procedures Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.7.2) (CONF:30405).This structuredBody MAY contain zero or one [0..1] component (CONF:30406) such that itSHALL contain exactly one [1..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) (CONF:30407).This structuredBody MAY contain zero or one [0..1] component (CONF:30408) such that itSHALL contain exactly one [1..1] Review of Systems Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:30409).This structuredBody MAY contain zero or one [0..1] component (CONF:30410) such that itSHALL contain exactly one [1..1] Social History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.17.2) (CONF:30411).SHALL include an Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2), or an Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) and a??Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30412).Each section SHALL have a title and the title SHALL NOT be empty (CONF:30413).SHALL NOT include an Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) when an Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) are present (CONF:30414).SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section (CONF:30415).A consent, if present, SHALL be represented as ClinicalDocument/authorization/consent (CONF:8509).SEQ Table \* ARABIC41: ProcedureNoteDocumentTypeCodesValue Set: ProcedureNoteDocumentTypeCodes 2.16.840.1.113883.11.20.6.1CodeCode SystemPrint Name28570-0LOINC{Setting}11505-5LOINC{Setting}18744-3LOINCRespiratory system18745-0LOINCHeart18746-8LOINCLower GI tract18751-8LOINCUpper GI tract18753-4LOINCLower GI tract18836-7LOINCCardiac stress study28577-5LOINC{Setting}28625-2LOINC{Setting}29757-2LOINCCvx/Vag33721-2LOINCBone mar34121-4LOINC{Setting}34896-1LOINC{Setting}34899-5LOINC{Setting}47048-4LOINC{Setting}48807-2LOINCBone marSEQ Table \* ARABIC42: Healthcare Provider Taxonomy (HIPAA)Value Set: Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066The Health Care Provider Taxonomy code set is a collection of unique alphanumeric codes, ten characters in length. The code set is structured into three distinct Levels including Provider Type, Classification, and Area of Specialization. The Health Care Provider Taxonomy code set allows a single provider (individual, group, or institution) to identify their specialty category. Providers may have one or more than one value associated to them. When determining what value or valuess to associate with a provider, the user needs to review the requirements of the trading partner with which the value(s) are being used.CodeCode SystemPrint Name171100000XHealthcare Provider Taxonomy (HIPAA)Acupuncturist363LA2100XHealthcare Provider Taxonomy (HIPAA)Acute Care364SA2100XHealthcare Provider Taxonomy (HIPAA)Acute Care101YA0400XHealthcare Provider Taxonomy (HIPAA)Addiction (Substance Use Disorder)103TA0400XHealthcare Provider Taxonomy (HIPAA)Addiction (Substance Use Disorder)163WA0400XHealthcare Provider Taxonomy (HIPAA)Addiction (Substance Use Disorder)207LA0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine207QA0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine207RA0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine2084A0401XHealthcare Provider Taxonomy (HIPAA)Addiction Medicine2084P0802XHealthcare Provider Taxonomy (HIPAA)Addiction Psychiatry163WA2000XHealthcare Provider Taxonomy (HIPAA)Administrator261QM0855XHealthcare Provider Taxonomy (HIPAA)Adolescent and Children Mental Health2080A0000XHealthcare Provider Taxonomy (HIPAA)Adolescent Medicine207RA0000XHealthcare Provider Taxonomy (HIPAA)Adolescent Medicine207QA0000XHealthcare Provider Taxonomy (HIPAA)Adolescent Medicine311ZA0620XHealthcare Provider Taxonomy (HIPAA)Adult Care Home372600000XHealthcare Provider Taxonomy (HIPAA)Adult Companion261QA0600XHealthcare Provider Taxonomy (HIPAA)Adult Day Care103TA0700XHealthcare Provider Taxonomy (HIPAA)Adult Development & Aging...Progress Note (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.9.2 (open)]SEQ Table \* ARABIC43: Progress Note (V2) ContextsContained By:Contains:Allergies Section (entries optional) (V2)Assessment and Plan Section (V2)Assessment SectionChief Complaint SectionInstructions Section (V2)Interventions Section (V2)Medications Section (entries optional) (V2)Objective SectionPhysical Exam Section (V2)Plan of Treatment Section (V2)Problem Section (entries optional) (V2)Results Section (entries optional) (V2)Review of Systems SectionSubjective SectionVital Signs Section (entries optional) (V2)A Progress Note documents a patient’s clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.Taber’s??medical dictionary defines a Progress Note as “An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.” Mosby’s??medical dictionary defines a Progress Note as “Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned.”A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report.SEQ Table \* ARABIC44: Progress Note (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.9.2']templateId1..1SHALL7588@root1..1SHALL100522.16.840.1.113883.10.20.22.1.9.2code1..1SHALL17189@code1..1SHALL171902.16.840.1.113883.11.20.8.1 (ProgressNoteDocumentTypeCode)documentationOf0..1SHOULD7603serviceEvent1..1SHALL7604@classCode1..1SHALL264202.16.840.1.113883.5.6 (HL7ActClass) = PCPRtemplateId1..1SHALL9480@root1..1SHALL100682.16.840.1.113883.10.20.21.3.1effectiveTime0..1SHOULD9481componentOf1..1SHALL7595encompassingEncounter1..1SHALL7596id1..*SHALL7597effectiveTime1..1SHALL7598low1..1SHALL7599location1..1SHALL30879healthCareFacility1..1SHALL30880id1..*SHALL30881component1..1SHALL9591structuredBody1..1SHALL30617component0..1MAY30618section1..1SHALL30619component0..1MAY30620section1..1SHALL30621component0..1MAY30622section1..1SHALL30623component0..1MAY30624section1..1SHALL30625component0..1MAY30626section1..1SHALL30627component0..1MAY30628section1..1SHALL30629component0..1MAY30639section1..1SHALL31386component0..1MAY30641section1..1SHALL30642component0..1MAY30643section1..1SHALL30644component0..1MAY30645section1..1SHALL30646component0..1MAY30647section1..1SHALL30648component0..1MAY30649section1..1SHALL30650component0..1MAY30651section1..1SHALL30652component0..1MAY30653section1..1SHALL30654component0..1MAY30655section1..1SHALL30656Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:7588) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.9.2" (CONF:10052).SHALL contain exactly one [1..1] code (CONF:17189).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProgressNoteDocumentTypeCode 2.16.840.1.113883.11.20.8.1 DYNAMIC (CONF:17190).SHOULD contain zero or one [0..1] documentationOf (CONF:7603).The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:7604).This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:26420).This serviceEvent SHALL contain exactly one [1..1] templateId (CONF:9480) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.21.3.1" (CONF:10068).This serviceEvent SHOULD contain zero or one [0..1] effectiveTime (CONF:9481).The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element (CONF:9482).If a width element is not present, the serviceEvent SHALL include effectiveTime/high (CONF:10066).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:10137).SHALL contain exactly one [1..1] componentOf (CONF:7595).This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:7596).This encompassingEncounter SHALL contain at least one [1..*] id (CONF:7597).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:7598).This effectiveTime SHALL contain exactly one [1..1] low (CONF:7599).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:10138).This encompassingEncounter SHALL contain exactly one [1..1] location (CONF:30879).This location SHALL contain exactly one [1..1] healthCareFacility (CONF:30880).This healthCareFacility SHALL contain at least one [1..*] id (CONF:30881).SHALL contain exactly one [1..1] component (CONF:9591).In this template (templateId 2.16.840.1.113883.10.20.22.1.9.2), coded entries are optionalThis component SHALL contain exactly one [1..1] structuredBody (CONF:30617).This structuredBody MAY contain zero or one [0..1] component (CONF:30618) such that itSHALL contain exactly one [1..1] Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) (CONF:30619).This structuredBody MAY contain zero or one [0..1] component (CONF:30620) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30621).This structuredBody MAY contain zero or one [0..1] component (CONF:30622) such that itSHALL contain exactly one [1..1] Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) (CONF:30623).This structuredBody MAY contain zero or one [0..1] component (CONF:30624) such that itSHALL contain exactly one [1..1] Allergies Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.2) (CONF:30625).This structuredBody MAY contain zero or one [0..1] component (CONF:30626) such that itSHALL contain exactly one [1..1] Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:30627).This structuredBody MAY contain zero or one [0..1] component (CONF:30628) such that itSHALL contain exactly one [1..1] Interventions Section (V2) (templateId:2.16.840.1.113883.10.20.21.2.3.2) (CONF:30629).This structuredBody MAY contain zero or one [0..1] component (CONF:30639) such that itSHALL contain exactly one [1..1] Instructions Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.45.2) (CONF:31386).This structuredBody MAY contain zero or one [0..1] component (CONF:30641) such that itSHALL contain exactly one [1..1] Medications Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.1.2) (CONF:30642).This structuredBody MAY contain zero or one [0..1] component (CONF:30643) such that itSHALL contain exactly one [1..1] Objective Section (templateId:2.16.840.1.113883.10.20.21.2.1) (CONF:30644).This structuredBody MAY contain zero or one [0..1] component (CONF:30645) such that itSHALL contain exactly one [1..1] Physical Exam Section (V2) (templateId:2.16.840.1.113883.10.20.2.10.2) (CONF:30646).This structuredBody MAY contain zero or one [0..1] component (CONF:30647) such that itSHALL contain exactly one [1..1] Problem Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.5.2) (CONF:30648).This structuredBody MAY contain zero or one [0..1] component (CONF:30649) such that itSHALL contain exactly one [1..1] Results Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.3.2) (CONF:30650).This structuredBody MAY contain zero or one [0..1] component (CONF:30651) such that itSHALL contain exactly one [1..1] Review of Systems Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:30652).This structuredBody MAY contain zero or one [0..1] component (CONF:30653) such that itSHALL contain exactly one [1..1] Subjective Section (templateId:2.16.840.1.113883.10.20.21.2.2) (CONF:30654).This structuredBody MAY contain zero or one [0..1] component (CONF:30655) such that itSHALL contain exactly one [1..1] Vital Signs Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.4.2) (CONF:30656).SHALL include an Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2), or an Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) and a??Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:30657).SHALL NOT include an Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) when an Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) are present (CONF:30658).SEQ Table \* ARABIC45: ProgressNoteDocumentTypeCodeValue Set: ProgressNoteDocumentTypeCode 2.16.840.1.113883.11.20.8.1CodeCode SystemPrint Name11506-3LOINC{Provider}18733-6LOINCAttending physician18762-5LOINCChiropractor28569-2LOINCConsulting physician28617-9LOINCDentistry34900-1LOINCGeneral medicine34904-3LOINCMental health18764-1LOINCNurse practitioner28623-7LOINCNursing11507-1LOINCOccupational therapy11508-9LOINCPhysical therapy11509-7LOINCPodiatry28627-8LOINCPsychiatry11510-5LOINCPsychology28656-7LOINCSocial service11512-1LOINCSpeech therapy34126-3LOINC{Provider}15507-7LOINC{Provider}34129-7LOINC{Provider}34125-5LOINCCase manager...Referral Note (NEW)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.14 (open)]SEQ Table \* ARABIC46: Referral Note (NEW) ContextsContained By:Contains:Advance Directives Section (entries optional) (V2)Allergies Section (entries required) (V2)Assessment and Plan Section (V2)Assessment SectionChief Complaint and Reason for Visit SectionChief Complaint SectionFamily History SectionFunctional Status Section (V2)General Status SectionHistory of Past Illness Section (V2)History of Present Illness SectionImmunizations Section (entries required) (V2)Medical Equipment Section (V2)Medications Section (entries required) (V2)Mental Status Section (NEW)Nutrition Section (NEW)Physical Exam Section (V2)Plan of Treatment Section (V2)Problem Section (entries required) (V2)Procedures Section (entries optional) (V2)Reason for Referral Section (V2)Results Section (entries required) (V2)Review of Systems SectionSocial History Section (V2)Vital Signs Section (entries required) (V2)This clinical document communicates pertinent patient information to the consulting provider from a referring provider. The information in this document would include the reason for the referral and additional medical information that would augment care delivery. Examples of referral situations are when a patient is referred from a family physician to a cardiologist for follow up for a cardiac condition or a when patient is sent by a??primary care provider to an emergency department.SEQ Table \* ARABIC47: Referral Note (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.14']templateId1..1SHALL28947@root1..1SHALL289482.16.840.1.113883.10.20.22.1.14code1..1SHALL289492.16.840.1.113883.1.11.20.2.3 (ReferralDocumentType)inFulfillmentOf1..*SHALL28952order1..1SHALL28953id1..*SHALL28954componentOf0..1MAY28955encompassingEncounter1..1SHALL28956id1..1SHALL28957effectiveTime1..1SHALL28958responsibleParty0..1MAY28960encounterParticipant0..*MAY28963component1..1SHALL29062structuredBody1..1SHALL29063component0..1MAY29066section1..1SHALL29067component0..1MAY29068section1..1SHALL29069component0..1MAY29070section1..1SHALL29073component1..1SHALL29071section1..1SHALL29072component0..1MAY29074section1..1SHALL29075component0..1SHOULD29076section1..1SHALL29077component0..1SHOULD29082section1..1SHALL29083component1..1SHALL29086section1..1SHALL29087component0..1SHOULD29088section1..1SHALL29089component1..1SHALL29090section1..1SHALL29091component0..1SHOULD29092section1..1SHALL29093component0..1SHOULD29094section1..1SHALL29095component0..1SHOULD29096section1..1SHALL29097component1..1SHALL29098section1..1SHALL29099component0..1MAY29100section1..1SHALL29101component0..1MAY29564section1..1SHALL29565component0..1SHOULD30780section1..1SHALL30781component0..1MAY30796section1..1SHALL30926component0..1MAY30798section1..1SHALL30799component1..1SHALL30911section1..1SHALL30912component0..1MAY30913section1..1SHALL30914component0..1MAY30915section1..1SHALL30916component0..1MAY30917section1..1SHALL30918component0..1MAY30919section1..1SHALL30920component1..1SHALL30922section1..1SHALL30923component1..1SHALL30924section1..1SHALL30925title1..1SHALL29840Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).Conformant documents must carry the document-level templateId asserting conformance with specific constraints of a Referral Summary as well as the templateId for the US Realm Clinical Document Header template. SHALL contain exactly one [1..1] templateId (CONF:28947) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.14" (CONF:28948).The Referral note recommends use of the document type code 57113-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist.SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ReferralDocumentType 2.16.840.1.113883.1.11.20.2.3 DYNAMIC (CONF:28949).SHALL contain exactly one [1..1] title (CONF:29840).The inFulfillmentOf element describes the prior orders that are fulfilled (in whole or part) by the service events described in the Referral Note.??For example, prior orders are listed in the Referral Summary.SHALL contain at least one [1..*] inFulfillmentOf (CONF:28952).Such inFulfillmentOfs SHALL contain exactly one [1..1] order (CONF:28953).This order SHALL contain at least one [1..*] id (CONF:28954).MAY contain zero or one [0..1] componentOf (CONF:28955).The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:28956).This encompassingEncounter SHALL contain exactly one [1..1] id (CONF:28957).This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:28958).The content of effectiveTime SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:28959).This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:28960).The responsibleParty element records??only the party responsible for the encounter, not necessarily the entire episode of care (CONF:28961).The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:28962).This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:28963).The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care (CONF:28964).An encounterParticipant element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element,??a representedOrganization element, or both (CONF:28965).SHALL contain exactly one [1..1] component (CONF:29062).This component SHALL contain exactly one [1..1] structuredBody (CONF:29063).This structuredBody MAY contain zero or one [0..1] component (CONF:29066) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:29067).This structuredBody MAY contain zero or one [0..1] component (CONF:29068) such that itSHALL contain exactly one [1..1] Advance Directives Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.21.2) (CONF:29069).This structuredBody MAY contain zero or one [0..1] component (CONF:29070) such that itSHALL contain exactly one [1..1] Chief Complaint Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:29073).This structuredBody SHALL contain exactly one [1..1] component (CONF:29071) such that itSHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.13) (CONF:29072).This structuredBody MAY contain zero or one [0..1] component (CONF:29074) such that itSHALL contain exactly one [1..1] History of Present Illness Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:29075).This structuredBody SHOULD contain zero or one [0..1] component (CONF:29076) such that itSHALL contain exactly one [1..1] Family History Section (templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:29077).This structuredBody SHOULD contain zero or one [0..1] component (CONF:29082) such that itSHALL contain exactly one [1..1] Immunizations Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.2.1.2) (CONF:29083).This structuredBody SHALL contain exactly one [1..1] component (CONF:29086) such that itSHALL contain exactly one [1..1] Problem Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.5.1.2) (CONF:29087).This structuredBody SHOULD contain zero or one [0..1] component (CONF:29088) such that itSHALL contain exactly one [1..1] Procedures Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.7.2) (CONF:29089).This structuredBody SHALL contain exactly one [1..1] component (CONF:29090) such that itSHALL contain exactly one [1..1] Results Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.3.1.2) (CONF:29091).This structuredBody SHOULD contain zero or one [0..1] component (CONF:29092) such that itSHALL contain exactly one [1..1] Review of Systems Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:29093).This structuredBody SHOULD contain zero or one [0..1] component (CONF:29094) such that itSHALL contain exactly one [1..1] Social History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.17.2) (CONF:29095).This structuredBody SHOULD contain zero or one [0..1] component (CONF:29096) such that itSHALL contain exactly one [1..1] Vital Signs Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.4.1.2) (CONF:29097).This structuredBody SHALL contain exactly one [1..1] component (CONF:29098) such that itSHALL contain exactly one [1..1] Functional Status Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.14.2) (CONF:29099).This structuredBody MAY contain zero or one [0..1] component (CONF:29100) such that itSHALL contain exactly one [1..1] Physical Exam Section (V2) (templateId:2.16.840.1.113883.10.20.2.10.2) (CONF:29101).This structuredBody MAY contain zero or one [0..1] component (CONF:29564) such that itSHALL contain exactly one [1..1] Advance Directives Section (entries optional) (V2) (templateId:2.16.840.1.113883.10.20.22.2.21.2) (CONF:29565).This structuredBody SHOULD contain zero or one [0..1] component (CONF:30780) such that itSHALL contain exactly one [1..1] Nutrition Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.57) (CONF:30781).This structuredBody MAY contain zero or one [0..1] component (CONF:30796) such that itSHALL contain exactly one [1..1] Mental Status Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.56) (CONF:30926).This structuredBody MAY contain zero or one [0..1] component (CONF:30798) such that itSHALL contain exactly one [1..1] Medical Equipment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.23.2) (CONF:30799).This structuredBody SHALL contain exactly one [1..1] component (CONF:30911) such that itSHALL contain exactly one [1..1] Allergies Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.1.2) (CONF:30912).This structuredBody MAY contain zero or one [0..1] component (CONF:30913) such that itSHALL contain exactly one [1..1] Assessment Section (templateId:2.16.840.1.113883.10.20.22.2.8) (CONF:30914).This structuredBody MAY contain zero or one [0..1] component (CONF:30915) such that itSHALL contain exactly one [1..1] Assessment and Plan Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.9.2) (CONF:30916).This structuredBody MAY contain zero or one [0..1] component (CONF:30917) such that itSHALL contain exactly one [1..1] History of Past Illness Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.20.2) (CONF:30918).This structuredBody MAY contain zero or one [0..1] component (CONF:30919) such that itSHALL contain exactly one [1..1] General Status Section (templateId:2.16.840.1.113883.10.20.2.5) (CONF:30920).This structuredBody SHALL contain exactly one [1..1] component (CONF:30922) such that itSHALL contain exactly one [1..1] Medications Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.1.1.2) (CONF:30923).This structuredBody SHALL contain exactly one [1..1] component (CONF:30924) such that itSHALL contain exactly one [1..1] Reason for Referral Section (V2) (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.1.2) (CONF:30925).SHALL include an Assessment and Plan Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.9.2) OR an Assessment Section (templateId: 2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.10.2) (CONF:29102).SHALL NOT include an Assessment and Plan Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.9.2) when an Assessment Section (templateId: 2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (templateId: 2.16.840.1.113883.10.20.22.2.10.2) are present (CONF:29103).SEQ Table \* ARABIC48: ReferralDocumentTypeValue Set: ReferralDocumentType 2.16.840.1.113883.1.11.20.2.3A referral note provides a consulting physician specified patient information about the patient referred.CodeCode SystemPrint Name57133-1LOINCReferral note57170-3LOINCCardiovascular disease Referral note57178-6LOINCCritical Care Medicine Referral note57134-9LOINCDentistry Referral note57135-6LOINCDermatology Referral note57136-4LOINCDiabetology Referral note57137-2LOINCEndocrinology Referral note57138-0LOINCGastroenterology Referral note57139-8LOINCGeneral medicine Referral note57140-6LOINCGeneral surgery Referral note57171-1LOINCGeriatric medicine Referral note57172-9LOINCHematology+Oncology Referral note57141-4LOINCInfectious disease Referral note57142-2LOINCKinesiotherapy Referral note57143-0LOINCMental health Referral note57144-8LOINCNephrology Referral note57146-3LOINCNeurological surgery Referral note57145-5LOINCNeurology Referral note57173-7LOINCNutrition and dietetics Referral note57179-4LOINCObstetrics and Gynecology Referral note...Transfer Summary (NEW)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.13 (open)]SEQ Table \* ARABIC49: Transfer Summary (NEW) ContextsContained By:Contains:Advance Directives Section (entries required) (V2)Allergies Section (entries required) (V2)Encounters Section (entries required) (V2)Family History SectionFunctional Status Section (V2)General Status SectionHistory of Past Illness Section (V2)History of Present Illness SectionHospital Discharge Diagnosis Section (V2)Immunizations Section (entries required) (V2)Medical Equipment Section (V2)Medications Section (entries required) (V2)Mental Status Section (NEW)Nutrition Section (NEW)Payers Section (V2)Physical Exam Section (V2)Plan of Treatment Section (V2)Problem Section (entries required) (V2)Procedures Section (entries required) (V2)Reason for Referral Section (V2)Results Section (entries required) (V2)Review of Systems SectionSocial History Section (V2)Vital Signs Section (entries required) (V2)This document describes constraints on the??Clinical Document Architecture (CDA) header and body elements for a Transfer Summary. The Transfer summary standardizes critical information for exchange of information between providers of care when a patient moves between health care settings. Standardization of information used in this form will promote interoperability; create information suitable for reuse in quality measurement, public health, research, and for reimbursement.SEQ Table \* ARABIC50: Transfer Summary (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.13']templateId1..1SHALL28239@root1..1SHALL282402.16.840.1.113883.10.20.22.1.13id1..1SHALL28241@root1..1SHALL28242code1..1SHALL282432.16.840.1.113883.1.11.20.2.4 (TransferDocumentType)custodian1..1SHALL28247assignedCustodian1..1SHALL28248representedCustodianOrganization1..1SHALL28249name1..1SHALL28250component1..1SHALL28251structuredBody1..1SHALL28252component1..1SHALL28253section1..1SHALL28254component1..1SHALL28255section1..1SHALL28256component0..1SHOULD28257section1..1SHALL28258component0..1SHOULD28261section1..1SHALL28262component0..1SHOULD28263section1..1SHALL28264component0..1SHOULD28265section1..1SHALL28266component0..1SHOULD28267section1..1SHALL28268component0..1SHOULD28269section1..1SHALL28270component0..1SHOULD28271section1..1SHALL28272component0..1SHOULD28273section1..1SHALL28274component0..1SHOULD28275section1..1SHALL28276component1..1SHALL28277section1..1SHALL28278component0..1SHOULD28279section1..1SHALL28280component0..1SHOULD28281section1..1SHALL28282component1..1SHALL28283section1..1SHALL28284component0..1SHOULD28285templateId0..*MAY31348section1..1SHALL28286component1..1SHALL28287section1..1SHALL28288component0..1SHOULD28289section1..1SHALL28290component1..1SHALL28291section1..1SHALL28292component0..1SHOULD28327section1..1SHALL28328component0..1MAY28838section1..1SHALL28839component0..1SHOULD30239section1..1SHALL30240component0..0SHOULD30776section1..1SHALL30777component0..1SHALL31342section1..1SHALL31343title1..1SHALL29838componentOf0..1MAY30241encompassingEncounter1..1SHALL30242effectiveTime1..1SHALL30243responsibleParty0..*MAY30249location1..1SHALL30244healthCareFacility1..1SHALL30245id1..*SHALL30246code1..1SHALL30247@nullFlavor0..1MAY30248Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:28239) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.13" (CONF:28240).SHALL contain exactly one [1..1] id (CONF:28241).This id SHALL contain exactly one [1..1] @root (CONF:28242).The Transfer Summary recommends use of the document type code 18761-7 "Provider Unspecified Transfer Summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Transfer Summary note would not be authored by a Pediatric Cardiologist.SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet TransferDocumentType 2.16.840.1.113883.1.11.20.2.4 DYNAMIC (CONF:28243).SHALL contain exactly one [1..1] title (CONF:29838).SHALL contain exactly one [1..1] custodian (CONF:28247).This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:28248).This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:28249).This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:28250).MAY contain zero or one [0..1] componentOf (CONF:30241) such that itSHALL contain exactly one [1..1] encompassingEncounter (CONF:30242).Note: The encompassing encounter also represents the sending site information, such as 'name of the sending site', 'sending site type' and 'individual providing transfer'.The sending site can be represented in ‘encompassingEncounter/location’, the sending type can be coded in ‘location/code’.The sending individual can be represented in encompassingEncounter/responsibleParty.This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:30243).This encompassingEncounter MAY contain zero or more [0..*] responsibleParty (CONF:30249).This encompassingEncounter SHALL contain exactly one [1..1] location (CONF:30244) such that itSHALL contain exactly one [1..1] healthCareFacility (CONF:30245).This healthCareFacility SHALL contain at least one [1..*] id (CONF:30246).This healthCareFacility SHALL contain exactly one [1..1] code (CONF:30247).This code MAY contain zero or one [0..1] @nullFlavor (CONF:30248).SHALL contain exactly one [1..1] component (CONF:28251).This component SHALL contain exactly one [1..1] structuredBody (CONF:28252) such that itSHALL contain exactly one [1..1] component (CONF:28253) such that itSHALL contain exactly one [1..1] Advance Directives Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.21.1.2) (CONF:28254).SHALL contain exactly one [1..1] component (CONF:28255) such that itSHALL contain exactly one [1..1] Allergies Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.6.1.2) (CONF:28256).SHOULD contain zero or one [0..1] component (CONF:28257) such that itSHALL contain exactly one [1..1] Physical Exam Section (V2) (templateId:2.16.840.1.113883.10.20.2.10.2) (CONF:28258).SHOULD contain zero or one [0..1] component (CONF:28261) such that itSHALL contain exactly one [1..1] Encounters Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.22.1.2) (CONF:28262).SHOULD contain zero or one [0..1] component (CONF:28263) such that itSHALL contain exactly one [1..1] Family History Section (templateId:2.16.840.1.113883.10.20.22.2.15) (CONF:28264).SHOULD contain zero or one [0..1] component (CONF:28265) such that itSHALL contain exactly one [1..1] Functional Status Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.14.2) (CONF:28266).SHOULD contain zero or one [0..1] component (CONF:28267) such that itSHALL contain exactly one [1..1] History of Present Illness Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:28268).SHOULD contain zero or one [0..1] component (CONF:28269) such that itSHALL contain exactly one [1..1] History of Past Illness Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.20.2) (CONF:28270).SHOULD contain zero or one [0..1] component (CONF:28271) such that itRequired for hospital discharges.SHALL contain exactly one [1..1] Hospital Discharge Diagnosis Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.24.2) (CONF:28272).SHOULD contain zero or one [0..1] component (CONF:28273) such that itSHALL contain exactly one [1..1] Immunizations Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.2.1.2) (CONF:28274).SHOULD contain zero or one [0..1] component (CONF:28275) such that itSHALL contain exactly one [1..1] Medical Equipment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.23.2) (CONF:28276).SHALL contain exactly one [1..1] component (CONF:28277) such that itSHALL contain exactly one [1..1] Medications Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.1.1.2) (CONF:28278).SHOULD contain zero or one [0..1] component (CONF:28279) such that itSHALL contain exactly one [1..1] Payers Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.18.2) (CONF:28280).SHOULD contain zero or one [0..1] component (CONF:28281) such that itSHALL contain exactly one [1..1] Plan of Treatment Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.10.2) (CONF:28282).SHALL contain exactly one [1..1] component (CONF:28283) such that itSHALL contain exactly one [1..1] Problem Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.5.1.2) (CONF:28284).SHOULD contain zero or one [0..1] component (CONF:28285) such that itRequired for hospitals.MAY contain zero or more [0..*] templateId (CONF:31348).SHALL contain exactly one [1..1] Procedures Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.7.1.2) (CONF:28286).SHALL contain exactly one [1..1] component (CONF:28287) such that itSHALL contain exactly one [1..1] Results Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.3.1.2) (CONF:28288).SHOULD contain zero or one [0..1] component (CONF:28289) such that itSHALL contain exactly one [1..1] Social History Section (V2) (templateId:2.16.840.1.113883.10.20.22.2.17.2) (CONF:28290).SHALL contain exactly one [1..1] component (CONF:28291) such that itSHALL contain exactly one [1..1] Vital Signs Section (entries required) (V2) (templateId:2.16.840.1.113883.10.20.22.2.4.1.2) (CONF:28292).SHOULD contain zero or one [0..1] component (CONF:28327) such that itSHALL contain exactly one [1..1] Mental Status Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.56) (CONF:28328).MAY contain zero or one [0..1] component (CONF:28838) such that itSHALL contain exactly one [1..1] General Status Section (templateId:2.16.840.1.113883.10.20.2.5) (CONF:28839).SHOULD contain zero or one [0..1] component (CONF:30239) such that itSHALL contain exactly one [1..1] Review of Systems Section (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:30240).SHOULD contain [0..0] component (CONF:30776) such that itSHALL contain exactly one [1..1] Nutrition Section (NEW) (templateId:2.16.840.1.113883.10.20.22.2.57) (CONF:30777).SHALL contain zero or one [0..1] component (CONF:31342) such that itSHALL contain exactly one [1..1] Reason for Referral Section (V2) (templateId:1.3.6.1.4.1.19376.1.5.3.1.3.1.2) (CONF:31343).SEQ Table \* ARABIC51: TransferDocumentTypeValue Set: TransferDocumentType 2.16.840.1.113883.1.11.20.2.4A transfer document is exchanged between care providers when a patient transfers from one care setting to another.CodeCode SystemPrint Name18761-7LOINCProvider-unspecified Transfer summary68618-8LOINCAdolescent medicine Transfer summarization note68632-9LOINCAllergy and immunology Transfer summarization note68647-7LOINCChild and adolescent psychiatry Transfer summarization note68660-0LOINCClinical genetics Transfer summarization note34755-9LOINCCritical Care Medicine Transfer summarization note68669-1LOINCDevelopmental-behavioral pediatrics Transfer summarization note34770-8LOINCGeneral medicine Transfer summarization note68680-8LOINCMulti-specialty program Transfer summarization note68704-6LOINCNeurology w special qualifications in child neuro Transfer summarization note28651-8LOINCNurse Transfer note68565-1LOINCObstetrics and Gynecology Transfer summarization note68569-3LOINCOccupational therapy Transfer summarization note68887-9LOINCOphthalmology Transfer summarization note68583-4LOINCOrthopedic surgery Transfer summarization note68715-2LOINCPain medicine Transfer summarization note68726-9LOINCPediatric cardiology Transfer summarization note68737-6LOINCPediatric endocrinology Transfer summarization note68745-9LOINCPediatric gastroenterology Transfer summarization note68756-6LOINCPediatric hematology-oncology Transfer summarization note...Unstructured Document (V2)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.10.2 (open)]SEQ Table \* ARABIC52: Unstructured Document (V2) ContextsContained By:Contains:An unstructured document is a document which is used when the patient record is captured in an unstructured format that is encapsulated within an image file or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) document. There is a need to raise the level of interoperability for these documents to provide full access to the longitudinal patient record across a continuum of care. Until this gap is addressed, image and multi-media files will continue to be a portion of the patient record that remains difficult to access and share with all participants in a patient’s care. The Unstructured Document type addresses this gap by providing consistent guidance on the use of CDA for such documents.An Unstructured Document (UD) document type can (1) include unstructured content, such as a graphic, directly in a text element with a mediaType attribute, or (2) reference a single document file, such as a word-processing document, using a text/reference element.Notes: In the template introduction, add IG Sections 4.1, 4.2, 4.3, and the explanations of the individual constraints. Value set - Supported File FormatsSEQ Table \* ARABIC53: Unstructured Document (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.22.1.10.2']templateId1..1SHALL7710@root1..1SHALL100542.16.840.1.113883.10.20.22.1.10.2component1..1SHALL31085nonXMLBody1..1SHALL31086text1..1SHALL31087@mediaType0..1MAY310882.16.840.1.113883.11.20.7.1 (SupportedFileFormats)recordTarget1..1SHALL31089patientRole1..1SHALL31090id1..1SHALL31091author1..1SHALL31092assignedAuthor1..1SHALL31093addr1..1SHALL31094telecom1..1SHALL31095custodian1..1SHALL31096assignedCustodian1..1SHALL31097representedCustodianOrganization1..1SHALL31098id1..1SHALL31099name1..1SHALL31100telecom1..1SHALL31101addr1..1SHALL31102Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:7710) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.10.2" (CONF:10054).SHALL contain exactly one [1..1] recordTarget (CONF:31089).This recordTarget SHALL contain exactly one [1..1] patientRole (CONF:31090).This patientRole SHALL contain exactly one [1..1] id (CONF:31091).SHALL contain exactly one [1..1] author (CONF:31092).This author SHALL contain exactly one [1..1] assignedAuthor (CONF:31093).This assignedAuthor SHALL contain exactly one [1..1] addr (CONF:31094).This assignedAuthor SHALL contain exactly one [1..1] telecom (CONF:31095).SHALL contain exactly one [1..1] custodian (CONF:31096).This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:31097).This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:31098).This representedCustodianOrganization SHALL contain exactly one [1..1] id (CONF:31099).This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:31100).This representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:31101).This representedCustodianOrganization SHALL contain exactly one [1..1] addr (CONF:31102).SHALL contain exactly one [1..1] component (CONF:31085).This component SHALL contain exactly one [1..1] nonXMLBody (CONF:31086).This nonXMLBody SHALL contain exactly one [1..1] text (CONF:31087).This text MAY contain zero or one [0..1] @mediaType, which SHALL be selected from ValueSet SupportedFileFormats 2.16.840.1.113883.11.20.7.1 (CONF:31088).The text element SHALL either contain a reference element with a value attribute, or have a representation attribute with the value of B64, a mediaType attribute, and contain the media content (CONF:31103).SEQ Table \* ARABIC54: SupportedFileFormatsValue Set: SupportedFileFormats 2.16.840.1.113883.11.20.7.1A value set of the file formats supported by the Unstructured Document IG.CodeCode SystemPrint NameUS Realm Header - Patient Generated Document (NEW)[ClinicalDocument: templateId 2.16.840.1.113883.10.20.29.1 (open)]SEQ Table \* ARABIC55: US Realm Header - Patient Generated Document (NEW) ContextsContained By:Contains:The US Realm Patient Generated Document header template must conform to the Universal Realm Patient Generated Document header template. This template is designed to be used in conjunction with the US C-CDA General Header. It includes additional conformances which further constrain the US C-CDA General Header. SEQ Table \* ARABIC56: US Realm Header - Patient Generated Document (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueClinicalDocument[templateId/@root = '2.16.840.1.113883.10.20.29.1']templateId1..1SHALL28458@root1..1SHALL284592.16.840.1.113883.10.20.29.1recordTarget1..1SHALL28460patientRole1..1SHALL28461id1..*SHALL28462@root1..1SHALL28463@extension0..1SHOULD28464patient1..1SHALL28465guardian0..*MAY28469id0..*SHOULD28470@root1..1SHALL28471@extension0..1SHOULD28472code0..1SHOULD284732.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)languageCommunication0..*SHOULD28474preferenceInd0..1MAY28475providerOrganization0..1MAY28476author1..*SHALL28477assignedAuthor1..1SHALL28478id1..*SHALL28479@root0..1SHOULD28480code1..1SHALL28481@code1..1SHALL286762.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)dataEnterer0..1MAY28678assignedEntity1..1SHALL28679code0..1MAY286802.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)informant0..*MAY28681relatedEntity1..1SHALL28682code0..1MAY28683@code0..1SHOULD286842.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)custodian1..1SHALL28685assignedCustodian1..1SHALL28686representedCustodianOrganization1..1SHALL28687id1..*SHALL28688@root1..1SHALL28689informationRecipient0..*MAY28690intendedRecipient1..1SHALL28691id0..*SHOULD28692@root0..1SHOULD28693legalAuthenticator0..1MAY28694assignedEntity1..1SHALL28695id1..*SHALL28696code0..1MAY28697@code0..1MAY286982.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)authenticator0..*MAY28699assignedEntity1..1SHALL28700id1..*SHALL28701code0..1SHOULD287022.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)participant0..*MAY28703@typeCode1..1SHALL28704associatedEntity1..1SHALL28705code0..1SHOULD287062.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)inFulfillmentOf0..*MAY28707order1..1SHALL28708id1..*SHALL28709documentationOf0..*MAY28710serviceEvent1..1SHALL28711code0..1SHOULD28712performer0..*SHOULD28713functionCode0..1MAY28714assignedEntity1..1SHALL28715id1..*SHALL28716code0..1MAY287182.16.840.1.113883.11.20.12.1 (Personal And Legal Relationship Role Type)Conforms to US Realm Header (V2) template (2.16.840.1.113883.10.20.22.1.1.2).SHALL contain exactly one [1..1] templateId (CONF:28458) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.29.1" (CONF:28459).The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patients language of preference and the predominant language used by the organization receiving the CDA.The patient MAY include 0..] guardian(s). When that role is present, it SHOULD include a code element. The guardian/code element encodes the relationship between the person in the role of guardian and the patient.Does the patient/guardian role refer to legal guardian???HL7 Vocabulary simply describes guardian as a relationship to a ward.??This need not be a formal legal relationship. If legal guardian exists for the patient, should it be included or only if they are “present” for the generation of the PGD? When a guardian relationship exists for the patient, it may be represented, regardless of who is present at the time the document is generated. Examples for the use of the patient/guardian role:A child’s parent MAY be represented in the guardian role.??In this case, the guardian/code element would encode the personal relationship of “mother” for the child’s mom or “father” for the child’s dad.An elderly person’s child MAY be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of “daughter” or “son”, or if a legal relationship existed, the relationship of “legal guardian” could be encoded.SHALL contain exactly one [1..1] recordTarget (CONF:28460).This recordTarget SHALL contain exactly one [1..1] patientRole (CONF:28461).This patientRole SHALL contain at least one [1..*] id (CONF:28462).The combination of the @root and @extension attributes record the person’s identity in a secure, trusted, and unique way. Such ids SHALL contain exactly one [1..1] @root (CONF:28463).Such ids SHOULD contain zero or one [0..1] @extension (CONF:28464).This patientRole SHALL contain exactly one [1..1] patient (CONF:28465).This patient MAY contain zero or more [0..*] guardian (CONF:28469).The guardian, if present, SHOULD contain zero or more [0..*] id (CONF:28470).The combination of the @root and @extension attributes record the person’s identity in a secure, trusted, and unique way.??The id, if present, SHALL contain exactly one [1..1] @root (CONF:28471).The id, if present, SHOULD contain zero or one [0..1] @extension (CONF:28472).The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:28473).This patient SHOULD contain zero or more [0..*] languageCommunication (CONF:28474).The languageCommunication, if present, MAY contain zero or one [0..1] preferenceInd (CONF:28475).Note: Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language.If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1.If present, this organization represents the provider organization where the person is claiming to be a patient.This patientRole MAY contain zero or one [0..1] providerOrganization (CONF:28476).Note: If present, this organization represents the provider organization where the person is claiming to be a patient.The author element represents the creator of the clinical document.??The author may be a device, or a person. The person is the patient or the patient’s advocate.SHALL contain at least one [1..*] author (CONF:28477).Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:28478).This assignedAuthor SHALL contain at least one [1..*] id (CONF:28479).The combination of the @root and @extension attributes record the person’s identity in a secure, trusted, and unique way. Such ids SHOULD contain zero or one [0..1] @root (CONF:28480).When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.This assignedAuthor SHALL contain exactly one [1..1] code (CONF:28481).This code SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 (CONF:28676).The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the DataEnterer is missing, this role is assumed to be played by the Author.MAY contain zero or one [0..1] dataEnterer (CONF:28678).The dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:28679).This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:28680).The informant element describes the source of the information in a medical document.Assigned health care providers may be a source of information when a document is created. (e.g., a nurse's aide who provides information about a recent significant health care event that occurred within an acute care facility.) In these cases, the assignedEntity element is used.When the informant is a personal relation, that informant is represented in the relatedEntity element, even if the personal relation is medical professional.??The code element of the relatedEntity describes the relationship between the informant and the patient. The relationship between the informant and the patient??needs to be described to help the receiver of the clinical document understand the information in the document. MAY contain zero or more [0..*] informant (CONF:28681).The informant element describes the source of the information in a medical document.Assigned health care providers may be a source of information when a document is created. (e.g., a nurse's aide who provides information about a recent significant health care event that occurred within an acute care facility.) In these cases, the assignedEntity element is used.When the informant is a personal relation, that informant is represented in the relatedEntity element, even if the personal relation is medical professional.??The code element of the relatedEntity describes the relationship between the informant and the patient. The relationship between the informant and the patient??needs to be described to help the receiver of the clinical document understand the information in the document. The informant, if present, SHALL contain exactly one [1..1] relatedEntity (CONF:28682).Note: Each informant can be either an assignedEntity (a clinician serving the patient) OR a relatedEntity (a person with a personal or legal relationship with the patient).NOTE: RelatedEntity seems to be missing an id element. This relatedEntity MAY contain zero or one [0..1] code (CONF:28683).The code, if present, SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 (CONF:28684).The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.SHALL contain exactly one [1..1] custodian (CONF:28685).This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:28686).The representedCustodianOrganization may be the person when the document is not maintained by an organization. This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:28687).The combined @root and @extension attributes record the custodian organization’s identity in a secure, trusted, and unique way.This representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:28688).Such ids SHALL contain exactly one [1..1] @root (CONF:28689).The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart.MAY contain zero or more [0..*] informationRecipient (CONF:28690).The informationRecipient, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:28691).The combined @root and @extension??attributes to record the information recipient’s identity in a secure, trusted, and unique way.This intendedRecipient SHOULD contain zero or more [0..*] id (CONF:28692).For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider.The ids MAY reference the id of a person or organization entity specified elsewhere in the document.The id, if present, SHOULD contain zero or one [0..1] @root (CONF:28693).In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated.The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority.Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system.Note that the legal authenticator, if present, must be a person.MAY contain zero or one [0..1] legalAuthenticator (CONF:28694).The legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:28695).The combined @root and @extension??attributes to record the information recipient’s identity in a secure, trusted, and unique way.This assignedEntity SHALL contain at least one [1..*] id (CONF:28696).This assignedEntity MAY contain zero or one [0..1] code (CONF:28697).The code, if present, MAY contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 (CONF:28698).MAY contain zero or more [0..*] authenticator (CONF:28699).The authenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:28700).The combined @root and @extension??attributes to record the authenticator’s identity in a secure, trusted, and unique way. This assignedEntity SHALL contain at least one [1..*] id (CONF:28701).This assignedEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:28702).The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)MAY contain zero or more [0..*] participant (CONF:28703).Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30The participant, if present, SHALL contain exactly one [1..1] @typeCode (CONF:28704).The participant, if present, SHALL contain exactly one [1..1] associatedEntity (CONF:28705).This associatedEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:28706).MAY contain zero or more [0..*] inFulfillmentOf (CONF:28707).The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:28708).A scheduled appointment or service event in a practice management system may be represented using this id element.This order SHALL contain at least one [1..*] id (CONF:28709).MAY contain zero or more [0..*] documentationOf (CONF:28710).The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:28711).The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document.This serviceEvent SHOULD contain zero or one [0..1] code (CONF:28712).serviceEvent/performer represents the healthcare providers, allied health professionals or other individuals involved in the current or pertinent historical care of the patient during the time span covered by the documentThis serviceEvent SHOULD contain zero or more [0..*] performer (CONF:28713).The functionCode SHALL be selected from value set ParticipationType 2.16.840.1.113883.1.11.10901 When indicating the performer was the primary care physician the functionCode shall be =”PCP”The performer, if present, MAY contain zero or one [0..1] functionCode (CONF:28714).The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:28715).The combined @root and @extension??attributes record the performer’s identity in a secure, trusted, and unique way.This assignedEntity SHALL contain at least one [1..*] id (CONF:28716).If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value setThis assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:28718).SEQ Table \* ARABIC57: Personal And Legal Relationship Role TypeValue Set: Personal And Legal Relationship Role Type 2.16.840.1.113883.11.20.12.1A personal or legal relationship records the role of a person in relation to another person, or a person to himself or herself. This value set is to be used when recording relationships based on personal or family ties or through legal assignment of responsibility. Direct URL PendingValueset Source: SystemPrint NameHUSBRoleCodehusbandWIFERoleCodewifeFRNDRoleCodefriendSISINLAWRoleCodesister-in-lawSELFRoleCodeselfPUNCLERoleCodepaternal uncle...Section-Level TemplatesThis chapter contains the section-level templates referenced by one or more of the document types of this consolidated guide. These templates describe the purpose of each section and the section-level constraints. Section-level templates are always included in a document. One and only one of each section type is allowed in a given document instance. Please see the document context tables to determine the sections that are contained in in a given document type. Please see the conformance verb in the conformance statements to determine if it is required (SHALL), strongly recommended (SHOULD) or optional (MAY).Each section-level template contains the following:???Template metadata (e.g., templateId, etc.)???Description and explanatory narrative???LOINC section code ???Section title???Requirements for a text element ???Entry-level template names and Ids for referenced templates (required and optional)Narrative TextThe text element within the section stores the narrative to be rendered, as described in the CDA R2 specification, and is referred to as the CDA narrative block.The content model of the CDA narrative block schema is hand crafted to meet requirements of human readability and rendering. The schema is registered as a MIME type (text/x-hl7-text+xml), which is the fixed media type for the text element.As noted in the CDA R2 specification, the document originator is responsible for ensuring that the narrative block contains the complete, human readable, attested content of the section. Structured entries support computer processing and computation and are not a replacement for the attestable, human-readable content of the CDA narrative block. The special case of structured entries with an entry relationship of "DRIV" (is derived from) indicates to the receiving application that the source of the narrative block is the structured entries, and that the contents of the two are clinically equivalent.??As for all CDA documents—even when a report consisting entirely of structured entries is transformed into CDA—the encoding application must ensure that the authenticated content (narrative plus multimedia) is a faithful and complete rendering of the clinical content of the structured source data. As a general guideline, a generated narrative block should include the same human readable content that would be available to users viewing that content in the originating system. Although content formatting in the narrative block need not be identical to that in the originating system, the narrative block should use elements from the CDA narrative block schema to provide sufficient formatting to support human readability when rendered according to the rules defined in Section Narrative Block (§ 4.3.5 ) of the CDA R2 specification.By definition, a receiving application cannot assume that all clinical content in a section (i.e., in the narrative block and multimedia) is contained in the structured entries unless the entries in the section have an entry relationship of "DRIV".Additional specification information for the CDA narrative block can be found in the CDA R2 specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and 6.Advance Directives Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.21.2 (open)]SEQ Table \* ARABIC58: Advance Directives Section (entries optional) (V2) ContextsContained By:Contains:Consultation Note (V2) (optional)Referral Note (NEW) (optional)Continuity of Care Document (CCD) (V2) (optional)Advance Directive OrganizerThis section contains data defining the patient’s advance directives and any reference to supporting documentation, including living wills, healthcare proxies, and CPR and resuscitation status. If the referenced documents are available, they can be included in the CCD exchange package. The most recent directives are required, if known, and should be listed in as much detail as possible. This section differentiates between 'advance directives' and 'advance directive documents'. The former is the directions to be followed whereas the latter refers to a legal document containing those directions. SEQ Table \* ARABIC59: Advance Directives Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.21.2']templateId1..1SHALL7928@root1..1SHALL103762.16.840.1.113883.10.20.22.2.21.2code1..1SHALL15340@code1..1SHALL153422.16.840.1.113883.6.1 (LOINC) = 42348-3@codeSystem1..1SHALL308122.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7930text1..1SHALL7931entry0..*MAY7957organizer1..1SHALL15443SHALL contain exactly one [1..1] templateId (CONF:7928) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.21.2" (CONF:10376).SHALL contain exactly one [1..1] code (CONF:15340).This code SHALL contain exactly one [1..1] @code="42348-3" Advance Directives (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15342).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30812).SHALL contain exactly one [1..1] title (CONF:7930).SHALL contain exactly one [1..1] text (CONF:7931).MAY contain zero or more [0..*] entry (CONF:7957) such that itSHALL contain exactly one [1..1] Advance Directive Organizer (templateId:2.16.840.1.113883.10.20.22.4.108) (CONF:15443).Figure SEQ Table \* ARABIC7: Sample<section>  <templateId root="2.16.840.1.113883.10.20.22.2.21.2" /> <code code="42348-3" codeSystem="2.16.840.1.113883.6.1" />  <title>ADVANCE DIRECTIVES</title> <text> Narrative Text </text> <entry typeCode="DRIV"> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.108" />  <id root="af6ebdf2-d996-11e2-a5b8-f23c91aec05e" /> </organizer> </entry> <entry typeCode="DRIV"> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.108" />  <id root="af6ebdf2-d996-11e2-a5b8-f23c91aec05e" /> </organizer> </entry></section>Advance Directives Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.21.1.2 (open)]SEQ Table \* ARABIC60: Advance Directives Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (required)Advance Directive OrganizerThis section contains data defining the patient’s advance directives and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. This section contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status. If referenced documents are available, they can be included in the CCD exchange package. Structured Advance Directives including but not limited to, Intubation and Ventilation, Medications, Antibiotics treatment are represented using Advance Directive Observation template(s). Advance Directive Organizers are used to group the observations for each type of Advance Directive by type (e.g., one Organizer for Medications, and one for Resuscitation).NOTE: The descriptions in this section differentiate between “advance directives” and “advance directive documents”. The former are the directions whereas the latter are legal documents containing those directions. Thus, an advance directive might be “no cardiopulmonary resuscitation”, and this directive might be stated in a legal advance directive document.SEQ Table \* ARABIC61: Advance Directives Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.21.1.2']templateId1..1SHALL30227@root1..1SHALL302282.16.840.1.113883.10.20.22.2.21.1.2entry1..*SHALL30235organizer1..1SHALL30236Conforms to Advance Directives Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.21.2).SHALL contain exactly one [1..1] templateId (CONF:30227) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.21.1.2" (CONF:30228).SHALL contain at least one [1..*] entry (CONF:30235) such that itSHALL contain exactly one [1..1] Advance Directive Organizer (templateId:2.16.840.1.113883.10.20.22.4.108) (CONF:30236).Figure SEQ Table \* ARABIC8: Sample<section>  <templateId root="2.16.840.1.113883.10.20.22.2.21.1.2" /> <code code="42348-3" codeSystem="2.16.840.1.113883.6.1" />  <title>ADVANCE DIRECTIVES</title> <text> Narrative Text </text> <entry typeCode="DRIV"> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.108" />  <id root="af6ebdf2-d996-11e2-a5b8-f23c91aec05e" /> </organizer> </entry> <entry typeCode="DRIV"> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.108" />  <id root="af6ebdf2-d996-11e2-a5b8-f23c91aec05e" /> </organizer> </entry></section>Allergies Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.6.2 (open)]SEQ Table \* ARABIC62: Allergies Section (entries optional) (V2) ContextsContained By:Contains:Discharge Summary (V2) (required)History and Physical (V2) (required)Procedure Note (V2) (optional)Progress Note (V2) (optional)Allergy Problem Act (V2)This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives). At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.SEQ Table \* ARABIC63: Allergies Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.6.2']templateId1..1SHALL7800@root1..1SHALL103782.16.840.1.113883.10.20.22.2.6.2code1..1SHALL15345@code1..1SHALL153462.16.840.1.113883.6.1 (LOINC) = 48765-2title1..1SHALL7802text1..1SHALL7803entry0..*SHOULD7804act1..1SHALL15444SHALL contain exactly one [1..1] templateId (CONF:7800) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.6.2" (CONF:10378).SHALL contain exactly one [1..1] code (CONF:15345).This code SHALL contain exactly one [1..1] @code="48765-2" Allergies, adverse reactions, alerts (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15346).SHALL contain exactly one [1..1] title (CONF:7802).SHALL contain exactly one [1..1] text (CONF:7803).SHOULD contain zero or more [0..*] entry (CONF:7804) such that itSHALL contain exactly one [1..1] Allergy Problem Act (V2) (templateId:2.16.840.1.113883.10.20.22.4.30.2) (CONF:15444).Allergies Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.6.1.2 (open)]SEQ Table \* ARABIC64: Allergies Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (required)Consultation Note (V2) (required)Referral Note (NEW) (required)Continuity of Care Document (CCD) (V2) (required)Allergy Problem Act (V2)This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives). At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.SEQ Table \* ARABIC65: Allergies Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.6.1.2']templateId1..1SHALL7527@root1..1SHALL103792.16.840.1.113883.10.20.22.2.6.1.2code1..1SHALL15349@code1..1SHALL153502.16.840.1.113883.6.1 (LOINC) = 48765-2title1..1SHALL7534text1..1SHALL7530entry1..*SHALL7531act1..1SHALL15446Conforms to Allergies Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.6.2).SHALL contain exactly one [1..1] templateId (CONF:7527) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.6.1.2" (CONF:10379).SHALL contain exactly one [1..1] code (CONF:15349).This code SHALL contain exactly one [1..1] @code="48765-2" Allergies, adverse reactions, alerts (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15350).SHALL contain exactly one [1..1] title (CONF:7534).SHALL contain exactly one [1..1] text (CONF:7530).SHALL contain at least one [1..*] entry (CONF:7531) such that itSHALL contain exactly one [1..1] Allergy Problem Act (V2) (templateId:2.16.840.1.113883.10.20.22.4.30.2) (CONF:15446).Anesthesia Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.25.2 (open)]SEQ Table \* ARABIC66: Anesthesia Section (V2) ContextsContained By:Contains:Operative Note (V2) (required)Procedure Note (V2) (optional)Medication Activity (V2)Procedure Activity Procedure (V2)The Anesthesia section briefly records the type of anesthesia (e.g., general or local) and may state the actual agent used.??This may or may not be a subsection of the Procedure Description section.??The full details of anesthesia are usually found in a separate Anesthesia Note.SEQ Table \* ARABIC67: Anesthesia Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.25.2']templateId1..1SHALL8066@root1..1SHALL103802.16.840.1.113883.10.20.22.2.25.2code1..1SHALL15351@code1..1SHALL1535259774-0@codeSystem1..1SHALL308302.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8068text1..1SHALL8069entry0..*MAY8092procedure1..1SHALL15447entry0..*MAY8094substanceAdministration1..1SHALL31127SHALL contain exactly one [1..1] templateId (CONF:8066) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.25.2" (CONF:10380).SHALL contain exactly one [1..1] code (CONF:15351).This code SHALL contain exactly one [1..1] @code="59774-0" Anesthesia (CONF:15352).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30830).SHALL contain exactly one [1..1] title (CONF:8068).SHALL contain exactly one [1..1] text (CONF:8069).MAY contain zero or more [0..*] entry (CONF:8092) such that itSHALL contain exactly one [1..1] Procedure Activity Procedure (V2) (templateId:2.16.840.1.113883.10.20.22.4.14.2) (CONF:15447).MAY contain zero or more [0..*] entry (CONF:8094) such that itSHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:31127).Assessment and Plan Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.9.2 (open)]SEQ Table \* ARABIC68: Assessment and Plan Section (V2) ContextsContained By:Contains:Consultation Note (V2) (optional)Referral Note (NEW) (optional)History and Physical (V2) (optional)Procedure Note (V2) (optional)Progress Note (V2) (optional)Act Plan (V2)This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan sections may be combined or separated to meet local policy requirements.See also the Assessment Section: templateId 2.16.840.1.113883.10.20.22.2.8 and Plan of Treatment Section (V2): templateId 2.16.840.1.113883.10.20.22.2.10.2SEQ Table \* ARABIC69: Assessment and Plan Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.9.2']templateId1..1SHALL7705@root1..1SHALL103812.16.840.1.113883.10.20.22.2.9.2code1..1SHALL15353@code1..1SHALL1535451847-2text1..1SHALL7707entry0..*MAY7708act1..1SHALL15448SHALL contain exactly one [1..1] templateId (CONF:7705) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.9.2" (CONF:10381).SHALL contain exactly one [1..1] code (CONF:15353).This code SHALL contain exactly one [1..1] @code="51847-2" Assessment and Plan (CONF:15354).SHALL contain exactly one [1..1] text (CONF:7707).MAY contain zero or more [0..*] entry (CONF:7708) such that itSHALL contain exactly one [1..1] Act Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.39.2) (CONF:15448).Assessment Section[section: templateId 2.16.840.1.113883.10.20.22.2.8 (open)]SEQ Table \* ARABIC70: Assessment Section ContextsContained By:Contains:Consultation Note (V2) (optional)Referral Note (NEW) (optional)History and Physical (V2) (optional)Procedure Note (V2) (optional)Progress Note (V2) (optional)The Assessment section (also referred to as “impression” or “diagnoses” outside of the context of CDA) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment may be a list of specific disease entities or a narrative block.SEQ Table \* ARABIC71: Assessment Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.8']templateId1..1SHALL7711@root1..1SHALL103822.16.840.1.113883.10.20.22.2.8text1..1SHALL7713code1..1SHALL14757@code1..1SHALL147582.16.840.1.113883.6.1 (LOINC) = 51848-0title1..1SHALL16774SHALL contain exactly one [1..1] templateId (CONF:7711) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.8" (CONF:10382).SHALL contain exactly one [1..1] code (CONF:14757).This code SHALL contain exactly one [1..1] @code="51848-0" Assessments (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:14758).SHALL contain exactly one [1..1] title (CONF:16774).SHALL contain exactly one [1..1] text (CONF:7713).Chief Complaint and Reason for Visit Section[section: templateId 2.16.840.1.113883.10.20.22.2.13 (open)]SEQ Table \* ARABIC72: Chief Complaint and Reason for Visit Section ContextsContained By:Contains:Consultation Note (V2) (optional)Referral Note (NEW) (required)Discharge Summary (V2) (optional)History and Physical (V2) (optional)Procedure Note (V2) (optional)This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit).??Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.SEQ Table \* ARABIC73: Chief Complaint and Reason for Visit Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.13']templateId1..1SHALL7840@root1..1SHALL103832.16.840.1.113883.10.20.22.2.13title1..1SHALL7842text1..1SHALL7843code1..1SHALL15449@code1..1SHALL154502.16.840.1.113883.6.1 (LOINC) = 46239-0SHALL contain exactly one [1..1] templateId (CONF:7840) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.13" (CONF:10383).SHALL contain exactly one [1..1] code (CONF:15449).This code SHALL contain exactly one [1..1] @code="46239-0" Chief Complaint and Reason for Visit (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15450).SHALL contain exactly one [1..1] title (CONF:7842).SHALL contain exactly one [1..1] text (CONF:7843).Chief Complaint Section[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 (open)]SEQ Table \* ARABIC74: Chief Complaint Section ContextsContained By:Contains:Consultation Note (V2) (optional)Referral Note (NEW) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (optional)Procedure Note (V2) (optional)Progress Note (V2) (optional)This section records the patient's chief complaint (the patient’s own description).SEQ Table \* ARABIC75: Chief Complaint Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1']templateId1..1SHALL7832@root1..1SHALLUID104531.3.6.1.4.1.19376.1.5.3.1.1.13.2.1title1..1SHALL7834text1..1SHALL7835code1..1SHALL15451@code1..1SHALL154522.16.840.1.113883.6.1 (LOINC) = 10154-3SHALL contain exactly one [1..1] templateId (CONF:7832) such that itSHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1" (CONF:10453).SHALL contain exactly one [1..1] code (CONF:15451).This code SHALL contain exactly one [1..1] @code="10154-3" Chief Complaint (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15452).SHALL contain exactly one [1..1] title (CONF:7834).SHALL contain exactly one [1..1] text (CONF:7835).Complications (OpNote) (obsolete)[section: templateId 2.16.840.1.113883.10.20.22.2.32.obsolete (open)]SEQ Table \* ARABIC76: Complications (OpNote) (obsolete) ContextsContained By:Contains:This template is obsolete and will be deleted completely in the future.This is replaced by the Complications Section.SEQ Table \* ARABIC77: Complications (OpNote) (obsolete) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.32.obsolete']Complications Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.37.2 (open)]SEQ Table \* ARABIC78: Complications Section (V2) ContextsContained By:Contains:Operative Note (V2) (required)Procedure Note (V2) (required)Problem Observation (V2)This section contains problems that occurred during or around the time of a procedure. The complications may be known risks or unanticipated problems.SEQ Table \* ARABIC79: Complications Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.37.2']templateId1..1SHALL8174@root1..1SHALL103842.16.840.1.113883.10.20.22.2.37.2code1..1SHALL15453@code1..1SHALL1545455109-3@codeSystem1..1SHALL308602.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8176text1..1SHALL8177entry0..*MAY8795observation1..1SHALL15455SHALL contain exactly one [1..1] templateId (CONF:8174) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.37.2" (CONF:10384).SHALL contain exactly one [1..1] code (CONF:15453).This code SHALL contain exactly one [1..1] @code="55109-3" Complications (CONF:15454).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30860).SHALL contain exactly one [1..1] title (CONF:8176).SHALL contain exactly one [1..1] text (CONF:8177).MAY contain zero or more [0..*] entry (CONF:8795) such that itSHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15455).Note: Note: When no coded entries or negation of entries are present, narrative section/text will be provided containing details of the complication(s) or that there were no complications.DICOM Object Catalog Section - DCM 121181[section: templateId 2.16.840.1.113883.10.20.6.1.1 (open)]SEQ Table \* ARABIC80: DICOM Object Catalog Section - DCM 121181 ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)Study ActDICOM Object Catalog lists all referenced objects and their parent Series and Studies, plus other DICOM attributes required for retrieving the objects.DICOM Object Catalog sections are not intended for viewing and contain empty section text.SEQ Table \* ARABIC81: DICOM Object Catalog Section - DCM 121181 Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.6.1.1']templateId1..1SHALL8525@root1..1SHALLUID104542.16.840.1.113883.10.20.6.1.1entry1..*SHALL8530act1..1SHALL15458code1..1SHALL15456@code1..1SHALL154571.2.840.10008.2.16.4 (DCM) = 121181SHALL contain exactly one [1..1] templateId (CONF:8525) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.1.1" (CONF:10454).SHALL contain exactly one [1..1] code (CONF:15456).This code SHALL contain exactly one [1..1] @code="121181" Dicom Object Catalog (CodeSystem: DCM 1.2.840.10008.2.16.4 STATIC) (CONF:15457).SHALL contain at least one [1..*] entry (CONF:8530).Such entries SHALL contain exactly one [1..1] Study Act (templateId:2.16.840.1.113883.10.20.6.2.6) (CONF:15458).A DICOM Object Catalog SHALL be present if the document contains references to DICOM Images. If present, it SHALL be the first section in the document (CONF:8527).Figure SEQ Table \* ARABIC9: Sample<section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.1.1" /> <code code="121181" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="DICOM Object Catalog" /> <entry>  <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.6" /> <id root="1.2.840.113619.2.62.994044785528.114289542805" /> <code code="113014" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Study" />  <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <id root="1.2.840.113619.2.62.994044785528.20060823223142485051" /> <code code="113015" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Series">...</code>   <entryRelationship typeCode="COMP"> <observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8" />...</observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8" />...</observation> </entryRelationship> </act> </entryRelationship> </act> </entry></section>Discharge Diet Section (deprecated)[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.33.2 (open)]SEQ Table \* ARABIC82: Discharge Diet Section (deprecated) ContextsContained By:Contains:This section is deprecated and may be deleted in the future. Use the Nutrition Section instead.This section records a narrative description of the expectations for diet and nutrition, including nutrition prescription, proposals, goals, and order requests for monitoring, tracking, or improving the nutritional status of the patient, used in a discharge from a facility such as an emergency department, hospital, or nursing home.SEQ Table \* ARABIC83: Discharge Diet Section (deprecated) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '1.3.6.1.4.1.19376.1.5.3.1.3.33.2']templateId1..1SHALL7975@root1..1SHALLUID104551.3.6.1.4.1.19376.1.5.3.1.3.33.2code1..1SHALL15459@code1..1SHALL1546042344-2@codeSystem1..1SHALL31140title1..1SHALL7977text1..1SHALL7978SHALL contain exactly one [1..1] templateId (CONF:7975) such that itSHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.33.2" (CONF:10455).SHALL contain exactly one [1..1] code (CONF:15459).This code SHALL contain exactly one [1..1] @code="42344-2" Discharge Diet (CONF:15460).This code SHALL contain exactly one [1..1] @codeSystem (CONF:31140).SHALL contain exactly one [1..1] title (CONF:7977).SHALL contain exactly one [1..1] text (CONF:7978).Encounters Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.22.2 (open)]SEQ Table \* ARABIC84: Encounters Section (entries optional) (V2) ContextsContained By:Contains:Continuity of Care Document (CCD) (V2) (optional)Encounter Activity (V2)This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An Encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment. This section may contain all encounters for the time period being summarized, but should include notable encounters.SEQ Table \* ARABIC85: Encounters Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.22.2']templateId1..1SHALL7940@root1..1SHALL103862.16.840.1.113883.10.20.22.2.22.2code1..1SHALL15461@code1..1SHALL1546246240-8@codeSystem1..1SHALL311362.16.840.1.113883.6.1 (LOINC)title1..1SHALL7942text1..1SHALL7943entry0..*SHOULD7951encounter1..1SHALL15465SHALL contain exactly one [1..1] templateId (CONF:7940) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.22.2" (CONF:10386).SHALL contain exactly one [1..1] code (CONF:15461).This code SHALL contain exactly one [1..1] @code="46240-8" Encounters (CONF:15462).This code SHALL contain exactly one [1..1] @codeSystem (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:31136).SHALL contain exactly one [1..1] title (CONF:7942).SHALL contain exactly one [1..1] text (CONF:7943).SHOULD contain zero or more [0..*] entry (CONF:7951) such that itSHALL contain exactly one [1..1] Encounter Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.49.2) (CONF:15465).Encounters Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.22.1.2 (open)]SEQ Table \* ARABIC86: Encounters Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Encounter Activity (V2)This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An Encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment. This section may contain all encounters for the time period being summarized, but should include notable encounters.SEQ Table \* ARABIC87: Encounters Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.22.1.2']templateId1..1SHALL8705@root1..1SHALL103872.16.840.1.113883.10.20.22.2.22.1.2code1..1SHALL15466@code1..1SHALL1546746240-8@codeSystem1..1SHALL311372.16.840.1.113883.6.1 (LOINC)title1..1SHALL8707text1..1SHALL8708entry1..*SHALL8709encounter1..1SHALL15468Conforms to Encounters Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.22.2).SHALL contain exactly one [1..1] templateId (CONF:8705) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.22.1.2" (CONF:10387).SHALL contain exactly one [1..1] code (CONF:15466).This code SHALL contain exactly one [1..1] @code="46240-8" Encounters (CONF:15467).This code SHALL contain exactly one [1..1] @codeSystem (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:31137).SHALL contain exactly one [1..1] title (CONF:8707).SHALL contain exactly one [1..1] text (CONF:8708).SHALL contain at least one [1..*] entry (CONF:8709) such that itSHALL contain exactly one [1..1] Encounter Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.49.2) (CONF:15468).Family History Section[section: templateId 2.16.840.1.113883.10.20.22.2.15 (open)]SEQ Table \* ARABIC88: Family History Section ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Continuity of Care Document (CCD) (V2) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (required)Procedure Note (V2) (optional)Family History OrganizerThis section contains data defining the patient’s genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient’s healthcare risk profile.SEQ Table \* ARABIC89: Family History Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.15']templateId1..1SHALL7932@root1..1SHALL103882.16.840.1.113883.10.20.22.2.15title1..1SHALL7934text1..1SHALL7935entry0..*MAY7955organizer1..1SHALL15471code1..1SHALL15469@code1..1SHALL154702.16.840.1.113883.6.1 (LOINC) = 10157-6SHALL contain exactly one [1..1] templateId (CONF:7932) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.15" (CONF:10388).SHALL contain exactly one [1..1] code (CONF:15469).This code SHALL contain exactly one [1..1] @code="10157-6" Family History (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15470).SHALL contain exactly one [1..1] title (CONF:7934).SHALL contain exactly one [1..1] text (CONF:7935).MAY contain zero or more [0..*] entry (CONF:7955) such that itSHALL contain exactly one [1..1] Family History Organizer (templateId:2.16.840.1.113883.10.20.22.4.45) (CONF:15471).Fetus Subject Context[relatedSubject: templateId 2.16.840.1.113883.10.20.6.2.3 (open)]SEQ Table \* ARABIC90: Fetus Subject Context ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)For reports on mothers and their fetus(es), information on a mother is mapped to recordTarget, PatientRole, and Patient. Information on the fetus is mapped to subject, relatedSubject, and SubjectPerson at the CDA section level. Both context information on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.SEQ Table \* ARABIC91: Fetus Subject Context Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValuerelatedSubject[templateId/@root = '2.16.840.1.113883.10.20.6.2.3']templateId1..1SHALL9189@root1..1SHALL105352.16.840.1.113883.10.20.6.2.3code1..1SHALL9190@code1..1SHALL264551.2.840.10008.2.16.4 (DCM) = 121026subject1..1SHALL9191name1..1SHALL15347SHALL contain exactly one [1..1] templateId (CONF:9189) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.3" (CONF:10535).SHALL contain exactly one [1..1] code (CONF:9190).This code SHALL contain exactly one [1..1] @code="121026" (CodeSystem: DCM 1.2.840.10008.2.16.4) (CONF:26455).SHALL contain exactly one [1..1] subject (CONF:9191).The name element is used to store the DICOM fetus ID, typically a pseudonym such as fetus_1.This subject SHALL contain exactly one [1..1] name (CONF:15347).Figure SEQ Table \* ARABIC10: Sample<relatedSubject> <templateId root="2.16.840.1.113883.10.20.6.2.3" /> <code code="121026" codeSystem="1.2.840.10008.2.16.4" displayName="Fetus" /> <subject> <name>fetus_1</name> </subject></relatedSubject>Findings Section (DIR)[section: templateId 2.16.840.1.113883.10.20.6.1.2 (open)]SEQ Table \* ARABIC92: Findings Section (DIR) ContextsContained By:Contains:Diagnostic Imaging Report (V2) (required)The Findings section contains the main narrative body of the report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines??for the codes in the various observations and procedures recorded in this section.SEQ Table \* ARABIC93: Findings Section (DIR) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.6.1.2']templateId1..1SHALL8531@root1..1SHALLUID104562.16.840.1.113883.10.20.6.1.2SHALL contain exactly one [1..1] templateId (CONF:8531) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.1.2" (CONF:10456).This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections.??However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:8532).Functional Status Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.14.2 (open)]SEQ Table \* ARABIC94: Functional Status Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (required)Continuity of Care Document (CCD) (V2) (optional)Discharge Summary (V2) (optional)Assessment Scale ObservationCaregiver CharacteristicsFunctional Status Observation (V2)Functional Status Organizer (V2)Non-Medicinal Supply Activity (V2)Self-Care Activities (ADL and IADL) (NEW)Sensory and Speech Status (NEW)The Functional Status section contains observations and assessments of a patient's physical abilities.??A patient’s functional status may include information regarding the patient’s general function such as ambulation, ability to perform Activities of Daily Living (ADLs), (e.g. bathing, dressing, feeding, grooming) Instrumental Activities of Daily Living (IADLs) (e.g. shopping, using a telephone, balancing a check book).??Problems that impact function (e.g. dyspnea, dysphagia) can be contained in the section.SEQ Table \* ARABIC95: Functional Status Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.14.2']templateId1..1SHALL7920@root1..1SHALL103892.16.840.1.113883.10.20.22.2.14.2code1..1SHALL14578@code1..1SHALL1457947420-5@codeSystem1..1SHALL308662.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7922text1..1SHALL7923entry0..*MAY14414organizer1..1SHALL14415entry0..*MAY14418observation1..1SHALL14419entry0..*MAY14426observation1..1SHALL14427entry0..*MAY14580observation1..1SHALL14581entry0..*MAY14582supply1..1SHALL30783entry0..*MAY16777observation1..1SHALL31009entry0..*MAY16779observation1..1SHALL31011SHALL contain exactly one [1..1] templateId (CONF:7920) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.14.2" (CONF:10389).SHALL contain exactly one [1..1] code (CONF:14578).This code SHALL contain exactly one [1..1] @code="47420-5" Functional Status (CONF:14579).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30866).SHALL contain exactly one [1..1] title (CONF:7922).SHALL contain exactly one [1..1] text (CONF:7923).MAY contain zero or more [0..*] entry (CONF:14414) such that itSHALL contain exactly one [1..1] Functional Status Organizer (V2) (templateId:2.16.840.1.113883.10.20.22.4.66.2) (CONF:14415).MAY contain zero or more [0..*] entry (CONF:14418) such that itSHALL contain exactly one [1..1] Functional Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.67.2) (CONF:14419).MAY contain zero or more [0..*] entry (CONF:14426) such that itSHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14427).MAY contain zero or more [0..*] entry (CONF:14580) such that itSHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14581).MAY contain zero or more [0..*] entry (CONF:14582) such that itSHALL contain exactly one [1..1] Non-Medicinal Supply Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.50.2) (CONF:30783).MAY contain zero or more [0..*] entry (CONF:16777) such that itSHALL contain exactly one [1..1] Self-Care Activities (ADL and IADL) (NEW) (templateId:2.16.840.1.113883.10.20.22.4.128) (CONF:31009).MAY contain zero or more [0..*] entry (CONF:16779) such that itSHALL contain exactly one [1..1] Sensory and Speech Status (NEW) (templateId:2.16.840.1.113883.10.20.22.4.127) (CONF:31011).Figure SEQ Table \* ARABIC11: Sample<section> <templateId root="2.16.840.1.113883.10.20.22.2.14.2" />  <code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status" /> <title>FUNCTIONAL STATUS</title> <text> ... </text> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.128" /> ... </observation> </entry> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.127" /> ... </observation> </entry> <entry> <organizer classCode="CLUSTER" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.66.2" /> .... </organizer> </entry> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.67.2" /> ... </observation> </entry> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.72" /> ... </observation> </entry></section>General Status Section[section: templateId 2.16.840.1.113883.10.20.2.5 (open)]SEQ Table \* ARABIC96: General Status Section ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)History and Physical (V2) (required)The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.SEQ Table \* ARABIC97: General Status Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.2.5']templateId1..1SHALL7985@root1..1SHALLUID104572.16.840.1.113883.10.20.2.5title1..1SHALL7987text1..1SHALL7988code1..1SHALL15472@code1..1SHALL154732.16.840.1.113883.6.1 (LOINC) = 10210-3SHALL contain exactly one [1..1] templateId (CONF:7985) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.2.5" (CONF:10457).SHALL contain exactly one [1..1] code (CONF:15472).This code SHALL contain exactly one [1..1] @code="10210-3" General Status (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15473).SHALL contain exactly one [1..1] title (CONF:7987).SHALL contain exactly one [1..1] text (CONF:7988).Goals Section (NEW)[section: templateId 2.16.840.1.113883.10.20.22.2.60 (open)]SEQ Table \* ARABIC98: Goals Section (NEW) ContextsContained By:Contains:Care Plan (NEW) (required)Goal Observation (NEW)This template represents patient Goals.??A goal is a defined outcome or condition to be achieved in the process of patient care. Goals include patient-defined goals (e.g., alleviation of health concerns, positive outcomes from interventions,?longevity, function, symptom management, comfort) and clinician-specific goals to achieve desired and agreed upon outcomes.SEQ Table \* ARABIC99: Goals Section (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.60']templateId1..1SHALL29584@root1..1SHALL295852.16.840.1.113883.10.20.22.2.60code1..1SHALL29586@code1..1SHALL2958761146-7@codeSystem1..1SHALL295882.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1entry1..*SHALL30719observation1..1SHALL30720title1..1SHALL30721text1..1SHALL30722SHALL contain exactly one [1..1] templateId (CONF:29584) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.60" (CONF:29585).SHALL contain exactly one [1..1] code (CONF:29586).This code SHALL contain exactly one [1..1] @code="61146-7" Goals (CONF:29587).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:29588).SHALL contain exactly one [1..1] title (CONF:30721).SHALL contain exactly one [1..1] text (CONF:30722).SHALL contain at least one [1..*] entry (CONF:30719) such that itSHALL contain exactly one [1..1] Goal Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.121) (CONF:30720).Health Concerns Section (NEW)[section: templateId 2.16.840.1.113883.10.20.22.2.58 (open)]SEQ Table \* ARABIC100: Health Concerns Section (NEW) ContextsContained By:Contains:Care Plan (NEW) (required)Health Concern Act (NEW)Health Status Observation (V2)The Health Concerns section contains data that describes an interest or worry about a health state or process that has the potential to require attention, intervention or management.SEQ Table \* ARABIC101: Health Concerns Section (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.58']templateId1..1SHALL28804@root1..1SHALL288052.16.840.1.113883.10.20.22.2.58code1..1SHALL28806@code1..1SHALL2880746030-3@codeSystem1..1SHALL288082.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL28809text1..1SHALL28810entry0..1SHOULD30483observation1..1SHALL30484entry1..*SHALLEntry30768act1..1SHALL30769SHALL contain exactly one [1..1] templateId (CONF:28804) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.58" (CONF:28805).SHALL contain exactly one [1..1] code (CONF:28806).This code SHALL contain exactly one [1..1] @code="46030-3" Health Conditions Section (CONF:28807).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:28808).SHALL contain exactly one [1..1] title (CONF:28809).SHALL contain exactly one [1..1] text (CONF:28810).SHOULD contain zero or one [0..1] entry (CONF:30483) such that itSHALL contain exactly one [1..1] Health Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.5.2) (CONF:30484).SHALL contain at least one [1..*] entry (CONF:30768) such that itSHALL contain exactly one [1..1] Health Concern Act (NEW) (templateId:2.16.840.1.113883.10.20.22.4.132) (CONF:30769).Health Status Evaluations/Outcomes Section (NEW)[section: templateId 2.16.840.1.113883.10.20.22.2.61 (open)]SEQ Table \* ARABIC102: Health Status Evaluations/Outcomes Section (NEW) ContextsContained By:Contains:Care Plan (NEW) (required)Outcome Observation (NEW)This template represents status, at a point in time, of health status evaluations or outcomes related to established care plan goals and/or interventions.SEQ Table \* ARABIC103: Health Status Evaluations/Outcomes Section (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.61']templateId1..1SHALL29578@root1..1SHALL295792.16.840.1.113883.10.20.22.2.61code1..1SHALL29580@code1..1SHALL2958111383-7@codeSystem1..1SHALL295822.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL29589text1..1SHALL29590entry1..*SHALL31227observation1..1SHALL31228SHALL contain exactly one [1..1] templateId (CONF:29578) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.61" (CONF:29579).SHALL contain exactly one [1..1] code (CONF:29580).This code SHALL contain exactly one [1..1] @code="11383-7" Patient Problem Outcome (CONF:29581).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:29582).SHALL contain exactly one [1..1] title (CONF:29589).SHALL contain exactly one [1..1] text (CONF:29590).SHALL contain at least one [1..*] entry (CONF:31227).Such entries SHALL contain exactly one [1..1] Outcome Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.144) (CONF:31228).History of Past Illness Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.20.2 (open)]SEQ Table \* ARABIC104: History of Past Illness Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (required)Procedure Note (V2) (optional)Problem Observation (V2)This section contains a record of the patient’s past complaints, problems, and diagnoses. It contains data from the patient’s past up to the patient’s current complaint or reason for seeking medical care.SEQ Table \* ARABIC105: History of Past Illness Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.20.2']templateId1..1SHALL7828@root1..1SHALL103902.16.840.1.113883.10.20.22.2.20.2code1..1SHALL15474@code1..1SHALL1547511348-0@codeSystem1..1SHALL308312.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7830text1..1SHALL7831entry0..*MAY8791observation1..1SHALL15476SHALL contain exactly one [1..1] templateId (CONF:7828) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.20.2" (CONF:10390).SHALL contain exactly one [1..1] code (CONF:15474).This code SHALL contain exactly one [1..1] @code="11348-0" History of Past Illness (CONF:15475).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30831).SHALL contain exactly one [1..1] title (CONF:7830).SHALL contain exactly one [1..1] text (CONF:7831).MAY contain zero or more [0..*] entry (CONF:8791) such that itSHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15476).History of Present Illness Section[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.4 (open)]SEQ Table \* ARABIC106: History of Present Illness Section ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (required)Referral Note (NEW) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (optional)Procedure Note (V2) (optional)The History of Present Illness section describes the history related to the reason for the encounter.??It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.SEQ Table \* ARABIC107: History of Present Illness Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '1.3.6.1.4.1.19376.1.5.3.1.3.4']templateId1..1SHALL7848@root1..1SHALLUID104581.3.6.1.4.1.19376.1.5.3.1.3.4title1..1SHALL7850text1..1SHALL7851code1..1SHALL15477@code1..1SHALL154782.16.840.1.113883.6.1 (LOINC) = 10164-2SHALL contain exactly one [1..1] templateId (CONF:7848) such that itSHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.4" (CONF:10458).SHALL contain exactly one [1..1] code (CONF:15477).This code SHALL contain exactly one [1..1] @code="10164-2" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15478).SHALL contain exactly one [1..1] title (CONF:7850).SHALL contain exactly one [1..1] text (CONF:7851).Hospital Admission Diagnosis Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.43.2 (open)]SEQ Table \* ARABIC108: Hospital Admission Diagnosis Section (V2) ContextsContained By:Contains:Discharge Summary (V2) (optional)Hospital Admission Diagnosis (V2)This section contains a narrative description of the problems or diagnoses identified by the clinician at the time of the patient’s admission. This section may contain coded entries representing the admitting diagnoses.SEQ Table \* ARABIC109: Hospital Admission Diagnosis Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.43.2']templateId1..1SHALL9930@root1..1SHALL103912.16.840.1.113883.10.20.22.2.43.2code1..1SHALL15479@code1..1SHALL1548046241-6@codeSystem1..1SHALL308652.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL9932text1..1SHALL9933entry0..1SHOULD9934act1..1SHALL15481SHALL contain exactly one [1..1] templateId (CONF:9930) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.43.2" (CONF:10391).SHALL contain exactly one [1..1] code (CONF:15479).This code SHALL contain exactly one [1..1] @code="46241-6" Hospital Admission Diagnosis (CONF:15480).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30865).SHALL contain exactly one [1..1] title (CONF:9932).SHALL contain exactly one [1..1] text (CONF:9933).SHOULD contain zero or one [0..1] entry (CONF:9934).The entry, if present, SHALL contain exactly one [1..1] Hospital Admission Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.34.2) (CONF:15481).Hospital Admission Medications Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.44.2 (open)]SEQ Table \* ARABIC110: Hospital Admission Medications Section (entries optional) (V2) ContextsContained By:Contains:Discharge Summary (V2) (optional)Admission Medication (V2)The section contains the medications administered prior to admission to the facility. The currently active medications must also be listed.SEQ Table \* ARABIC111: Hospital Admission Medications Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.44.2']templateId1..1SHALL10098@root1..1SHALL103922.16.840.1.113883.10.20.22.2.44.2code1..1SHALL15482@code1..1SHALL154832.16.840.1.113883.6.1 (LOINC) = 42346-7title1..1SHALL10100text1..1SHALL10101entry0..*SHOULD10102act1..1SHALL15484SHALL contain exactly one [1..1] templateId (CONF:10098) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.44.2" (CONF:10392).SHALL contain exactly one [1..1] code (CONF:15482).This code SHALL contain exactly one [1..1] @code="42346-7" Medications on Admission (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15483).SHALL contain exactly one [1..1] title (CONF:10100).SHALL contain exactly one [1..1] text (CONF:10101).SHOULD contain zero or more [0..*] entry (CONF:10102) such that itSHALL contain exactly one [1..1] Admission Medication (V2) (templateId:2.16.840.1.113883.10.20.22.4.36.2) (CONF:15484).Hospital Consultations Section[section: templateId 2.16.840.1.113883.10.20.22.2.42 (open)]SEQ Table \* ARABIC112: Hospital Consultations Section ContextsContained By:Contains:Discharge Summary (V2) (optional)The Hospital Consultations section records consultations that occurred during the admission.SEQ Table \* ARABIC113: Hospital Consultations Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.42']templateId1..1SHALL9915@root1..1SHALL103932.16.840.1.113883.10.20.22.2.42title1..1SHALL9917text1..1SHALL9918code1..1SHALL15485@code1..1SHALL154862.16.840.1.113883.6.1 (LOINC) = 18841-7SHALL contain exactly one [1..1] templateId (CONF:9915) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.42" (CONF:10393).SHALL contain exactly one [1..1] code (CONF:15485).This code SHALL contain exactly one [1..1] @code="18841-7" Hospital Consultations Section (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15486).SHALL contain exactly one [1..1] title (CONF:9917).SHALL contain exactly one [1..1] text (CONF:9918).Hospital Course Section[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.5 (open)]SEQ Table \* ARABIC114: Hospital Course Section ContextsContained By:Contains:Discharge Summary (V2) (required)The Hospital Course section describes the sequence of events from admission to discharge in a hospital facility.SEQ Table \* ARABIC115: Hospital Course Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '1.3.6.1.4.1.19376.1.5.3.1.3.5']templateId1..1SHALL7852@root1..1SHALLUID104591.3.6.1.4.1.19376.1.5.3.1.3.5title1..1SHALL7854text1..1SHALL7855code1..1SHALL15487@code1..1SHALL154882.16.840.1.113883.6.1 (LOINC) = 8648-8SHALL contain exactly one [1..1] templateId (CONF:7852) such that itSHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.5" (CONF:10459).SHALL contain exactly one [1..1] code (CONF:15487).This code SHALL contain exactly one [1..1] @code="8648-8" Hospital Course (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15488).SHALL contain exactly one [1..1] title (CONF:7854).SHALL contain exactly one [1..1] text (CONF:7855).Hospital Discharge Diagnosis Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.24.2 (open)]SEQ Table \* ARABIC116: Hospital Discharge Diagnosis Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Discharge Summary (V2) (required)Hospital Discharge Diagnosis (V2)This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization. This section includes an optional entry to record patient conditions.SEQ Table \* ARABIC117: Hospital Discharge Diagnosis Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.24.2']templateId1..1SHALL7979@root1..1SHALL103942.16.840.1.113883.10.20.22.2.24.2code1..1SHALL15355@code1..1SHALL1535611535-2@codeSystem1..1SHALL308612.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7981text1..1SHALL7982entry0..1SHOULD7983act1..1SHALL15489SHALL contain exactly one [1..1] templateId (CONF:7979) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.24.2" (CONF:10394).SHALL contain exactly one [1..1] code (CONF:15355).This code SHALL contain exactly one [1..1] @code="11535-2" Hospital Discharge Diagnosis (CONF:15356).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30861).SHALL contain exactly one [1..1] title (CONF:7981).SHALL contain exactly one [1..1] text (CONF:7982).SHOULD contain zero or one [0..1] entry (CONF:7983).The entry, if present, SHALL contain exactly one [1..1] Hospital Discharge Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.33.2) (CONF:15489).Hospital Discharge Instructions Section[section: templateId 2.16.840.1.113883.10.20.22.2.41 (open)]SEQ Table \* ARABIC118: Hospital Discharge Instructions Section ContextsContained By:Contains:Discharge Summary (V2) (optional)The Hospital Discharge Instructions section records instructions at discharge.SEQ Table \* ARABIC119: Hospital Discharge Instructions Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.41']templateId1..1SHALL9919@root1..1SHALL103952.16.840.1.113883.10.20.22.2.41title1..1SHALL9921text1..1SHALL9922code1..1SHALL15357@code1..1SHALL153582.16.840.1.113883.6.1 (LOINC) = 8653-8SHALL contain exactly one [1..1] templateId (CONF:9919) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.41" (CONF:10395).SHALL contain exactly one [1..1] code (CONF:15357).This code SHALL contain exactly one [1..1] @code="8653-8" Hospital Discharge Instructions (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15358).SHALL contain exactly one [1..1] title (CONF:9921).SHALL contain exactly one [1..1] text (CONF:9922).Hospital Discharge Medications Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.11.2 (open)]SEQ Table \* ARABIC120: Hospital Discharge Medications Section (entries optional) (V2) ContextsContained By:Contains:Discharge Summary (V2) (required)Discharge Medication (V2)This section contains the medications the patient is intended to take or stop after discharge. Current, active medications must be listed. The section may also include a patient’s prescription history and indicate the source of the medication list.SEQ Table \* ARABIC121: Hospital Discharge Medications Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.11.2']templateId1..1SHALL7816@root1..1SHALL103962.16.840.1.113883.10.20.22.2.11.2code1..1SHALL15359@code1..1SHALL153602.16.840.1.113883.6.1 (LOINC) = 10183-2title1..1SHALL7818text1..1SHALL7819entry0..*SHOULD7820act1..1SHALL15490SHALL contain exactly one [1..1] templateId (CONF:7816) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.11.2" (CONF:10396).SHALL contain exactly one [1..1] code (CONF:15359).This code SHALL contain exactly one [1..1] @code="10183-2" Hospital Discharge Medications (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15360).SHALL contain exactly one [1..1] title (CONF:7818).SHALL contain exactly one [1..1] text (CONF:7819).SHOULD contain zero or more [0..*] entry (CONF:7820) such that itSHALL contain exactly one [1..1] Discharge Medication (V2) (templateId:2.16.840.1.113883.10.20.22.4.35.2) (CONF:15490).Hospital Discharge Medications Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.11.1.2 (open)]SEQ Table \* ARABIC122: Hospital Discharge Medications Section (entries required) (V2) ContextsContained By:Contains:Discharge Medication (V2)The Hospital Discharge Medications section defines the medications that the patient is intended to take (or stop) after discharge. At a minimum, the currently active medications should be listed with an entire medication history as an option. The section may also include a patient’s prescription history and indicate the source of the medication list, for example, from a pharmacy system versus from the patient.Notes: DO NOT INCLUDE IN CONSOLIDATION GUIDE. NO REQUIREMENT for REQUIRED ENTRIESSEQ Table \* ARABIC123: Hospital Discharge Medications Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.11.1.2']templateId1..1SHALL7822@root1..1SHALL103972.16.840.1.113883.10.20.22.2.11.1.2code1..1SHALL15361@code1..1SHALL153622.16.840.1.113883.6.1 (LOINC) = 10183-2title1..1SHALL7824text1..1SHALL7825entry1..*SHALL7826act1..1SHALL15491Conforms to Hospital Discharge Medications Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.11.2).SHALL contain exactly one [1..1] templateId (CONF:7822) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.11.1.2" (CONF:10397).SHALL contain exactly one [1..1] code (CONF:15361).This code SHALL contain exactly one [1..1] @code="10183-2" Hospital Discharge Medications (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15362).SHALL contain exactly one [1..1] title (CONF:7824).SHALL contain exactly one [1..1] text (CONF:7825).SHALL contain at least one [1..*] entry (CONF:7826) such that itSHALL contain exactly one [1..1] Discharge Medication (V2) (templateId:2.16.840.1.113883.10.20.22.4.35.2) (CONF:15491).Hospital Discharge Physical Section[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.26 (open)]SEQ Table \* ARABIC124: Hospital Discharge Physical Section ContextsContained By:Contains:Discharge Summary (V2) (optional)The Hospital Discharge Physical section records a narrative description of the patient’s physical findings.SEQ Table \* ARABIC125: Hospital Discharge Physical Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '1.3.6.1.4.1.19376.1.5.3.1.3.26']templateId1..1SHALL7971@root1..1SHALLUID104601.3.6.1.4.1.19376.1.5.3.1.3.26title1..1SHALL7973text1..1SHALL7974code1..1SHALL15363@code1..1SHALL153642.16.840.1.113883.6.1 (LOINC) = 10184-0SHALL contain exactly one [1..1] templateId (CONF:7971) such that itSHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.26" (CONF:10460).SHALL contain exactly one [1..1] code (CONF:15363).This code SHALL contain exactly one [1..1] @code="10184-0" Hospital Discharge Physical (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15364).SHALL contain exactly one [1..1] title (CONF:7973).SHALL contain exactly one [1..1] text (CONF:7974).Hospital Discharge Studies Summary Section[section: templateId 2.16.840.1.113883.10.20.22.2.16 (open)]SEQ Table \* ARABIC126: Hospital Discharge Studies Summary Section ContextsContained By:Contains:Discharge Summary (V2) (optional)This section records the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends, and could record all results for the period of time being documented.Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram.Procedure results are typically generated by a clinician wanting to provide more granular information about component observations made during the performance of a procedure, such as when a gastroenterologist reports the size of a polyp observed during a colonoscopy.Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in specimen collection.SEQ Table \* ARABIC127: Hospital Discharge Studies Summary Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.16']templateId1..1SHALL7910@root1..1SHALL103982.16.840.1.113883.10.20.22.2.16title1..1SHALL7912text1..1SHALL7913code1..1SHALL15365@code1..1SHALL153662.16.840.1.113883.6.1 (LOINC) = 11493-4SHALL contain exactly one [1..1] templateId (CONF:7910) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.16" (CONF:10398).SHALL contain exactly one [1..1] code (CONF:15365).This code SHALL contain exactly one [1..1] @code="11493-4" Hospital Discharge Studies Summary (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15366).SHALL contain exactly one [1..1] title (CONF:7912).SHALL contain exactly one [1..1] text (CONF:7913).Immunizations Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.2.2 (open)]SEQ Table \* ARABIC128: Immunizations Section (entries optional) (V2) ContextsContained By:Contains:Consultation Note (V2) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (optional)Immunization Activity (V2)The Immunizations section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.SEQ Table \* ARABIC129: Immunizations Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.2.2']templateId1..1SHALL7965@root1..1SHALL103992.16.840.1.113883.10.20.22.2.2.2code1..1SHALL15367@code1..1SHALL153682.16.840.1.113883.6.1 (LOINC) = 11369-6title1..1SHALL7967text1..1SHALL7968entry0..*SHOULD7969substanceAdministration1..1SHALL15494SHALL contain exactly one [1..1] templateId (CONF:7965) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.2.2" (CONF:10399).SHALL contain exactly one [1..1] code (CONF:15367).This code SHALL contain exactly one [1..1] @code="11369-6" Immunizations (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15368).SHALL contain exactly one [1..1] title (CONF:7967).SHALL contain exactly one [1..1] text (CONF:7968).SHOULD contain zero or more [0..*] entry (CONF:7969) such that itSHALL contain exactly one [1..1] Immunization Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.52.2) (CONF:15494).Immunizations Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.2.1.2 (open)]SEQ Table \* ARABIC130: Immunizations Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Referral Note (NEW) (optional)Continuity of Care Document (CCD) (V2) (optional)Immunization Activity (V2)The Immunizations section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.SEQ Table \* ARABIC131: Immunizations Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.2.1.2']templateId1..1SHALL9015@root1..1SHALL104002.16.840.1.113883.10.20.22.2.2.1.2code1..1SHALL15369@code1..1SHALL153702.16.840.1.113883.6.1 (LOINC) = 11369-6title1..1SHALL9017text1..1SHALL9018entry1..*SHALL9019substanceAdministration1..1SHALL15495Conforms to Immunizations Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.2.2).SHALL contain exactly one [1..1] templateId (CONF:9015) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.2.1.2" (CONF:10400).SHALL contain exactly one [1..1] code (CONF:15369).This code SHALL contain exactly one [1..1] @code="11369-6" Immunizations (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15370).SHALL contain exactly one [1..1] title (CONF:9017).SHALL contain exactly one [1..1] text (CONF:9018).SHALL contain at least one [1..*] entry (CONF:9019) such that itSHALL contain exactly one [1..1] Immunization Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.52.2) (CONF:15495).Implants Section[section: templateId 2.16.840.1.113883.10.20.22.2.33 (open)]SEQ Table \* ARABIC132: Implants Section ContextsContained By:Contains:Replaced by template: 2.16.840.1.113883.10.20.22.2.40Notes: Replaced by template: 2.16.840.1.113883.10.20.22.2.40SEQ Table \* ARABIC133: Implants Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.33']templateId1..1SHALL8042@root1..1SHALL104012.16.840.1.113883.10.20.22.2.33title1..1SHALL8044text1..1SHALL8045code1..1SHALL15371@code1..1SHALL153722.16.840.1.113883.6.1 (LOINC) = 55122-6SHALL contain exactly one [1..1] templateId (CONF:8042) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.33" (CONF:10401).SHALL contain exactly one [1..1] code (CONF:15371).This code SHALL contain exactly one [1..1] @code="55122-6" Implants (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15372).SHALL contain exactly one [1..1] title (CONF:8044).SHALL contain exactly one [1..1] text (CONF:8045).Instructions Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.45.2 (open)]SEQ Table \* ARABIC134: Instructions Section (V2) ContextsContained By:Contains:History and Physical (V2) (optional)Progress Note (V2) (optional)Instruction (V2)The Instructions section records instructions given to a patient. List patient decision aids here.SEQ Table \* ARABIC135: Instructions Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.45.2']templateId1..1SHALL10112@root1..1SHALL313842.16.840.1.113883.10.20.22.2.45.2code1..1SHALL15375@code1..1SHALL153762.16.840.1.113883.6.1 (LOINC) = 69730-0title1..1SHALL10114text1..1SHALL10115entry0..*SHOULD10116act1..1SHALL31398SHALL contain exactly one [1..1] templateId (CONF:10112) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.45.2" (CONF:31384).SHALL contain exactly one [1..1] code (CONF:15375).This code SHALL contain exactly one [1..1] @code="69730-0" Instructions (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15376).SHALL contain exactly one [1..1] title (CONF:10114).SHALL contain exactly one [1..1] text (CONF:10115).SHOULD contain zero or more [0..*] entry (CONF:10116).The entry, if present, SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31398).Interventions Section (V2)[section: templateId 2.16.840.1.113883.10.20.21.2.3.2 (open)]SEQ Table \* ARABIC136: Interventions Section (V2) ContextsContained By:Contains:Care Plan (NEW) (required)Progress Note (V2) (optional)Intervention Act (NEW)This template represents Interventions.??Interventions are actions taken to maximize the prospects of achieving the patient’s or provider’s goals of care, including the removal of barriers to success. Interventions can be planned, ordered, historical, etc.Interventions include actions that may be ongoing (e.g. maintenance medications that the patient is taking, or monitoring the patient’s health status or the status of an intervention). Instructions are a subset of interventions and may include self-care instructions. Instructions are information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice.SEQ Table \* ARABIC137: Interventions Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.21.2.3.2']templateId1..1SHALL8680@root1..1SHALLUID104612.16.840.1.113883.10.20.21.2.3.2code1..1SHALL15377@code1..1SHALL1537862387-6@codeSystem1..1SHALL308642.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8682text1..1SHALL8683entry0..*SHOULD30996act1..1SHALL30997SHALL contain exactly one [1..1] templateId (CONF:8680) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.21.2.3.2" (CONF:10461).SHALL contain exactly one [1..1] code (CONF:15377).This code SHALL contain exactly one [1..1] @code="62387-6" Interventions Provided (CONF:15378).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30864).SHALL contain exactly one [1..1] title (CONF:8682).SHALL contain exactly one [1..1] text (CONF:8683).SHOULD contain zero or more [0..*] entry (CONF:30996).The entry, if present, SHALL contain exactly one [1..1] Intervention Act (NEW) (templateId:2.16.840.1.113883.10.20.22.4.131) (CONF:30997).Medical (General) History Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.39.2 (open)]SEQ Table \* ARABIC138: Medical (General) History Section (V2) ContextsContained By:Contains:Procedure Note (V2) (optional)Medical Equipment Organizer (NEW)The Medical History section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medical device history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.SEQ Table \* ARABIC139: Medical (General) History Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.39.2']templateId1..1SHALL8160@root1..1SHALL104032.16.840.1.113883.10.20.22.2.39.2code1..1SHALL15379@code1..1SHALL153802.16.840.1.113883.6.1 (LOINC) = 11329-0title1..1SHALL8162text1..1SHALL8163entry0..*MAY31196organizer1..1SHALL31197SHALL contain exactly one [1..1] templateId (CONF:8160) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.39.2" (CONF:10403).SHALL contain exactly one [1..1] code (CONF:15379).This code SHALL contain exactly one [1..1] @code="11329-0" Medical (General) History (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15380).SHALL contain exactly one [1..1] title (CONF:8162).SHALL contain exactly one [1..1] text (CONF:8163).MAY contain zero or more [0..*] entry (CONF:31196) such that itSHALL contain exactly one [1..1] Medical Equipment Organizer (NEW) (templateId:2.16.840.1.113883.10.20.22.4.135) (CONF:31197).Figure SEQ Table \* ARABIC12: Sample<section> <templateId root="2.16.840.1.113883.10.20.22.2.39.2" /> <code code="11329-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICAL (GENERAL) HISTORY" /> <title>MEDICAL (GENERAL) HISTORY</title> <text> <list listType="ordered"> <item>Patient has had recent issue with acne that does not seem to be related to any particular cause.</item> <item>Previous concerns of oral cancer was actually irritated gums as a result of mild food allergy.</item> <item>Patient had recent weight gain due to sedentary lifestyle and new job.</item> <item> Patient has a history of Stoma Bag Closure usage between 01 Jan 2011 to 06 June 2011 </item> </list> </text>  <entry> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.135" /> ... </organizer> </entry></section>Medical Equipment Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.23.2 (open)]SEQ Table \* ARABIC140: Medical Equipment Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Continuity of Care Document (CCD) (V2) (optional)Medical Device Applied (NEW)Medical Equipment Organizer (NEW)This section defines supportive health and external medical devices and equipment. This section lists any pertinent durable medical equipment (DME) used to help maintain the patient’s health status. All equipment relevant to the diagnosis, care, or treatment of a patient should be included. The device applied to a patient is represented using a Medical Device Applied template with a moodCode of “EVN”. The moodCode of “INT” is used for ordered medical devices. These Medical Devices may be grouped together within a Medical Equipment Organizer.SEQ Table \* ARABIC141: Medical Equipment Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.23.2']templateId1..1SHALL7944@root1..1SHALL104042.16.840.1.113883.10.20.22.2.23.2code1..1SHALL15381@code1..1SHALL1538246264-8@codeSystem1..1SHALL308282.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7946text1..1SHALL7947entry0..*SHOULD7948organizer1..1SHALL30351entry0..*SHOULD31125procedure1..1SHALL31126SHALL contain exactly one [1..1] templateId (CONF:7944) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.23.2" (CONF:10404).SHALL contain exactly one [1..1] code (CONF:15381).This code SHALL contain exactly one [1..1] @code="46264-8" Medical Equipment (CONF:15382).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30828).SHALL contain exactly one [1..1] title (CONF:7946).SHALL contain exactly one [1..1] text (CONF:7947).SHOULD contain zero or more [0..*] entry (CONF:7948) such that itSHALL contain exactly one [1..1] Medical Equipment Organizer (NEW) (templateId:2.16.840.1.113883.10.20.22.4.135) (CONF:30351).SHOULD contain zero or more [0..*] entry (CONF:31125) such that itSHALL contain exactly one [1..1] Medical Device Applied (NEW) (templateId:2.16.840.1.113883.10.20.22.4.115) (CONF:31126).Figure SEQ Table \* ARABIC13: Sample<section>  <templateId root="2.16.840.1.113883.10.20.22.2.23.2" /> <code code="46264-8" codeSystem="2.16.840.1.113883.6.1" />  <title>MEDICAL EQUIPMENT</title> <text>... </text> <entry typeCode="DRIV"> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.135" />  ... </organizer> </entry> <entry typeCode="DRIV">  <procedure classCode="PROC" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.115" /> ... </procedure> </entry></section>Medications Administered Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.38.2 (open)]SEQ Table \* ARABIC142: Medications Administered Section (V2) ContextsContained By:Contains:Procedure Note (V2) (optional)Medication Activity (V2)The Medications Administered section contains medications and fluids administered during a procedure, the procedure's encounter or other activity excluding anesthetic medications. This section is not intended for ongoing medications and medication history.SEQ Table \* ARABIC143: Medications Administered Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.38.2']templateId1..1SHALL8152@root1..1SHALL104052.16.840.1.113883.10.20.22.2.38.2code1..1SHALL15383@code1..1SHALL1538429549-3@codeSystem1..1SHALL308292.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8154text1..1SHALL8155entry0..*MAY8156substanceAdministration1..1SHALL15499SHALL contain exactly one [1..1] templateId (CONF:8152) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.38.2" (CONF:10405).SHALL contain exactly one [1..1] code (CONF:15383).This code SHALL contain exactly one [1..1] @code="29549-3" Medications Administered (CONF:15384).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30829).SHALL contain exactly one [1..1] title (CONF:8154).SHALL contain exactly one [1..1] text (CONF:8155).MAY contain zero or more [0..*] entry (CONF:8156).The entry, if present, SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:15499).Figure SEQ Table \* ARABIC14: Sample<section> <templateId root="2.16.840.1.113883.10.20.22.2.38.2" /> <code code="29549-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICATIONS ADMINISTERED" /> <title>MEDICATIONS ADMINISTERED</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Medication</th> <th>Directions</th> <th>Start Date</th> <th>Status</th> <th>Indications</th> <th>Fill Instructions</th> </tr> </thead> <tbody> <tr> <td> <content ID="MedAdministered_1">Proventil 0.09 MG/ACTUAT inhalant solution</content> </td> <td>0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing</td> <td>20070103</td> <td>Active</td> <td>Pneumonia (233604007 SNOMED CT)</td> <td>Generic Substitition Allowed</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.16.2" />  ... </substanceAdministration> </entry></section>Medications Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.1.2 (open)]SEQ Table \* ARABIC144: Medications Section (entries optional) (V2) ContextsContained By:Contains:History and Physical (V2) (required)Procedure Note (V2) (optional)Progress Note (V2) (optional)Medication Activity (V2)The Medications section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are to be listed, with an entire medication history as an option. The section also could describe a patient's prescription and dispense history and information about intended drug monitoring.SEQ Table \* ARABIC145: Medications Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.1.2']templateId1..1SHALL7791@root1..1SHALL104322.16.840.1.113883.10.20.22.2.1.2code1..1SHALL15385@code1..1SHALL1538610160-0@codeSystem1..1SHALL308242.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7793text1..1SHALL7794entry0..*SHOULD7795@nullFlavor0..1MAY15984substanceAdministration1..1SHALL10076SHALL contain exactly one [1..1] templateId (CONF:7791) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.1.2" (CONF:10432).SHALL contain exactly one [1..1] code (CONF:15385).This code SHALL contain exactly one [1..1] @code="10160-0" History of medication use (CONF:15386).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30824).SHALL contain exactly one [1..1] title (CONF:7793).SHALL contain exactly one [1..1] text (CONF:7794).SHOULD contain zero or more [0..*] entry (CONF:7795) such that itMAY contain zero or one [0..1] @nullFlavor (CONF:15984).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:10076).Figure SEQ Table \* ARABIC15: Sample<section>  <templateId root="2.16.840.1.113883.10.20.22.2.1.2" /> <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE" /> <title>MEDICATIONS</title> <text>  ... </text></section>Medications Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.1.1.2 (open)]SEQ Table \* ARABIC146: Medications Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (required)Consultation Note (V2) (optional)Referral Note (NEW) (required)Continuity of Care Document (CCD) (V2) (required)Medication Activity (V2)The Medications section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are to be listed, with an entire medication history as an option. The section also could describe a patient's prescription and dispense history and information about intended drug monitoring. This section requires that there be either an entry indicating the subject is not known to be on any medications, or that there be entries summarizing the subject's medications.SEQ Table \* ARABIC147: Medications Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.1.1.2']templateId1..1SHALL7568@root1..1SHALL104332.16.840.1.113883.10.20.22.2.1.2code1..1SHALL15387@code1..1SHALL1538810160-0@codeSystem1..1SHALL308252.16.840.1.113883.6.1title1..1SHALL7570text1..1SHALL7571entry1..*SHALL7572substanceAdministration1..1SHALL10077Conforms to Medications Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.1.2).SHALL contain exactly one [1..1] templateId (CONF:7568) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.1.2" (CONF:10433).SHALL contain exactly one [1..1] code (CONF:15387).This code SHALL contain exactly one [1..1] @code="10160-0" History of medication use (CONF:15388).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:30825).SHALL contain exactly one [1..1] title (CONF:7570).SHALL contain exactly one [1..1] text (CONF:7571).SHALL contain at least one [1..*] entry (CONF:7572) such that itSHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:10077).Figure SEQ Table \* ARABIC16: Sample<section>  <templateId root="2.16.840.1.113883.10.20.22.2.1.1.2" />  <templateId root="2.16.840.1.113883.10.20.22.2.1.2" /> <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE" /> <title>MEDICATIONS</title> <text> Narrative Text </text> <entry> <substanceAdministration classCode="SBADM" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.16.2" /> .... </substanceAdministration> </entry></section>Mental Status Section (NEW)[section: templateId 2.16.840.1.113883.10.20.22.2.56 (open)]SEQ Table \* ARABIC148: Mental Status Section (NEW) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Assessment Scale ObservationCaregiver CharacteristicsCognitive Abilities Observation (NEW)Cognitive Status Observation (V2)Cognitive Status Organizer (V2)Mental Status Observation (NEW)Non-Medicinal Supply Activity (V2)The Mental Status section contains observation and evaluations related to patient's psychological and mental competency and deficits including cognitive functioning (e.g. mood, anxiety, perceptual disturbances) cognitive ability (e.g. concentration, intellect, visual-spatial perception).SEQ Table \* ARABIC149: Mental Status Section (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.56']templateId1..1SHALL28293@root1..1SHALL282942.16.840.1.113883.10.20.22.2.14code1..1SHALL28295@code1..1SHALL282962.16.840.1.113883.6.1 (LOINC) = 10190-7@codeSystem1..1SHALL308262.16.840.1.113883.6.1title1..1SHALL28297text1..1SHALL28298entry0..*MAY28301organizer1..1SHALL28302entry0..*MAY28305observation1..1SHALL28306entry0..*MAY28311observation1..1SHALL28312entry0..*MAY28313observation1..1SHALL28314entry0..*MAY28315supply1..1SHALL30782entry0..*MAY28323observation1..1SHALL28324entry0..*MAY28325observation1..1SHALL28326SHALL contain exactly one [1..1] templateId (CONF:28293) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.14" (CONF:28294).SHALL contain exactly one [1..1] code (CONF:28295).This code SHALL contain exactly one [1..1] @code="10190-7" Mental Status (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:28296).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:30826).SHALL contain exactly one [1..1] title (CONF:28297).SHALL contain exactly one [1..1] text (CONF:28298).MAY contain zero or more [0..*] entry (CONF:28301) such that itSHALL contain exactly one [1..1] Cognitive Status Organizer (V2) (templateId:2.16.840.1.113883.10.20.22.4.75.2) (CONF:28302).MAY contain zero or more [0..*] entry (CONF:28305) such that itSHALL contain exactly one [1..1] Cognitive Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.74.2) (CONF:28306).MAY contain zero or more [0..*] entry (CONF:28311) such that itSHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:28312).MAY contain zero or more [0..*] entry (CONF:28313) such that itSHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:28314).MAY contain zero or more [0..*] entry (CONF:28315) such that itSHALL contain exactly one [1..1] Non-Medicinal Supply Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.50.2) (CONF:30782).MAY contain zero or more [0..*] entry (CONF:28323) such that itSHALL contain exactly one [1..1] Cognitive Abilities Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.126) (CONF:28324).MAY contain zero or more [0..*] entry (CONF:28325) such that itSHALL contain exactly one [1..1] Mental Status Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.125) (CONF:28326).Figure SEQ Table \* ARABIC17: Mental Status Section <section> <templateId root="2.16.840.1.113883.10.20.22.2.14"/>  <code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MENTAL STATUS"/> <title>MENTAL STATUS</title> <text> ... </text> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.125"/> ... </entry> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.126"/> ... </entry> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.74.2"/> ... </entry> <entry> <organizer classCode="CLUSTER" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.75.2"/> <id root="a7bc1062-8649-42a0-833d-ekd65bd013c9"/> ... </organizer> </entry> </section>Nutrition Section (NEW)[section: templateId 2.16.840.1.113883.10.20.22.2.57 (open)]SEQ Table \* ARABIC150: Nutrition Section (NEW) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Discharge Summary (V2) (optional)Nutrition Recommendations (NEW)Nutritional Status Observation (NEW)The Nutrition Section represents diet and nutrition information including special diet requirements and restrictions (e.g. soft mechanical diet, liquids only, enteral feeding). It also represents the overall nutritional status of the patient, nutrition assessment findings, and diet recommendations.SEQ Table \* ARABIC151: Nutrition Section (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.57']templateId1..1SHALL30477@root1..1SHALLUID304782.16.840.1.113883.10.20.22.2.57title1..1SHALL31042text1..1SHALL31043code1..1SHALL30318@code1..1SHALL3031961144-2@codeSystem1..1SHALL303202.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1entry0..*SHOULD30321observation1..1SHALL30322entry0..*MAY30343observation1..1SHALL30344SHALL contain exactly one [1..1] templateId (CONF:30477) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.57" (CONF:30478).SHALL contain exactly one [1..1] code (CONF:30318).This code SHALL contain exactly one [1..1] @code="61144-2" Diet and nutrition (CONF:30319).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30320).SHALL contain exactly one [1..1] title (CONF:31042).SHALL contain exactly one [1..1] text (CONF:31043).SHOULD contain zero or more [0..*] entry (CONF:30321) such that itSHALL contain exactly one [1..1] Nutritional Status Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.124) (CONF:30322).MAY contain zero or more [0..*] entry (CONF:30343) such that itSHALL contain exactly one [1..1] Nutrition Recommendations (NEW) (templateId:2.16.840.1.113883.10.20.22.4.130) (CONF:30344).Figure SEQ Table \* ARABIC18: Sample <section>  <templateId root="2.16.840.1.113883.10.20.2.5.2"/> <code code="61144-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diet and Nutrition"/> <title>NUTRITION SECTION</title> <text> <paragraph>Nutritional Status: well nourished</paragraph> <paragraph>Nutrition Assessment: Dietary Requirements; low sodium diet, Dietary Intake, high carbohydrate diet; BMI 25-29 overweight </paragraph> <paragraph>Nutritional Recommendations: BMI 22; Nutrition Education "Lean Meats"</paragraph> </text> <entry>  <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.124"/> ... <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.138"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/> ... </observation> </entryRelationship> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.138"/> ... </observation> </entryRelationship> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.138"/> .... </observation> </entryRelationship> </observation> </entry> <entry> <procedure moodCode="RQO" classCode="PROC">  <templateId root="2.16.840.1.113883.10.20.22.4.136"/>  <templateId root="2.16.840.1.113883.10.20.22.4.130"/> ... </entry> </section>Objective Section[section: templateId 2.16.840.1.113883.10.20.21.2.1 (open)]SEQ Table \* ARABIC152: Objective Section ContextsContained By:Contains:Progress Note (V2) (optional)The Objective section contains data about the patient gathered through tests, measures, or observations that produce a quantified or categorized result. It includes important and relevant positive and negative test results, physical findings, review of systems, and other measurements and observations.SEQ Table \* ARABIC153: Objective Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.21.2.1']templateId1..1SHALL7869@root1..1SHALLUID104622.16.840.1.113883.10.20.21.2.1title1..1SHALL7871text1..1SHALL7872code1..1SHALL15389@code1..1SHALL153902.16.840.1.113883.6.1 (LOINC) = 61149-1SHALL contain exactly one [1..1] templateId (CONF:7869) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.21.2.1" (CONF:10462).SHALL contain exactly one [1..1] code (CONF:15389).This code SHALL contain exactly one [1..1] @code="61149-1" Objective (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15390).SHALL contain exactly one [1..1] title (CONF:7871).SHALL contain exactly one [1..1] text (CONF:7872).Observer Context[assignedAuthor: templateId 2.16.840.1.113883.10.20.6.2.4 (open)]SEQ Table \* ARABIC154: Observer Context ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)The Observer Context is used to override the author specified in the CDA Header. It is valid as a direct child element of a section.SEQ Table \* ARABIC155: Observer Context Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueassignedAuthor[templateId/@root = '2.16.840.1.113883.10.20.6.2.4']templateId1..1SHALL9194@root1..1SHALL105362.16.840.1.113883.10.20.6.2.4id1..*SHALL9196SHALL contain exactly one [1..1] templateId (CONF:9194) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.4" (CONF:10536).The id element contains the author's id or the DICOM device observer UIDSHALL contain at least one [1..*] id (CONF:9196).Either assignedPerson or assignedAuthoringDevice SHALL be present (CONF:9198).Figure SEQ Table \* ARABIC19: Sample<assignedAuthor> <templateId root="2.16.840.1.113883.10.20.6.2.4" /> <id extension="121008" root="2.16.840.1.113883.19.5" /> <assignedPerson> <name> <given>Richard</given> <family>Blitz</family> <suffix>MD</suffix> </name> </assignedPerson></assignedAuthor>Operative Note Fluids Section[section: templateId 2.16.840.1.113883.10.20.7.12 (open)]SEQ Table \* ARABIC156: Operative Note Fluids Section ContextsContained By:Contains:Operative Note (V2) (optional)The Operative Note Fluids section may be used to record fluids administered during the surgical procedure.SEQ Table \* ARABIC157: Operative Note Fluids Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.7.12']templateId1..1SHALL8030@root1..1SHALLUID104632.16.840.1.113883.10.20.7.12title1..1SHALL8032text1..1SHALL8033code1..1SHALL15391@code1..1SHALL153922.16.840.1.113883.6.1 (LOINC) = 10216-0SHALL contain exactly one [1..1] templateId (CONF:8030) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.7.12" (CONF:10463).SHALL contain exactly one [1..1] code (CONF:15391).This code SHALL contain exactly one [1..1] @code="10216-0" Operative Note Fluids (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15392).SHALL contain exactly one [1..1] title (CONF:8032).SHALL contain exactly one [1..1] text (CONF:8033).If the Operative Note Fluids section is present, there SHALL be a statement providing details of the fluids administered or SHALL explicitly state there were no fluids administered (CONF:8052).Operative Note Surgical Procedure Section[section: templateId 2.16.840.1.113883.10.20.7.14 (open)]SEQ Table \* ARABIC158: Operative Note Surgical Procedure Section ContextsContained By:Contains:Operative Note (V2) (optional)The Operative Note Surgical Procedure section can be used to restate the procedures performed if appropriate for an enterprise workflow.??The procedure(s) performed associated with the Operative Note are formally modeled in the header using serviceEvent.SEQ Table \* ARABIC159: Operative Note Surgical Procedure Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.7.14']templateId1..1SHALL8034@root1..1SHALLUID104642.16.840.1.113883.10.20.7.14title1..1SHALL8036text1..1SHALL8037code1..1SHALL15393@code1..1SHALL153942.16.840.1.113883.6.1 (LOINC) = 10223-6SHALL contain exactly one [1..1] templateId (CONF:8034) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.7.14" (CONF:10464).SHALL contain exactly one [1..1] code (CONF:15393).This code SHALL contain exactly one [1..1] @code="10223-6" Operative Note Surgical Procedure (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15394).SHALL contain exactly one [1..1] title (CONF:8036).SHALL contain exactly one [1..1] text (CONF:8037).If the surgical procedure section is present there SHALL be text indicating the procedure performed (CONF:8054).Payers Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.18.2 (open)]SEQ Table \* ARABIC160: Payers Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Continuity of Care Document (CCD) (V2) (optional)Coverage Activity (V2)The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care.Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient’s pertinent current payment sources should be listed.The sources of payment are represented as a Coverage Activity, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by preference. The Coverage Activity has a sequence number that represents the preference order. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded.SEQ Table \* ARABIC161: Payers Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.18.2']templateId1..1SHALL7924@root1..1SHALL104342.16.840.1.113883.10.20.22.2.18.2code1..1SHALL15395@code1..1SHALL153962.16.840.1.113883.6.1 (LOINC) = 48768-6title1..1SHALL7926text1..1SHALL7927entry0..*SHOULD7959act1..1SHALL15501SHALL contain exactly one [1..1] templateId (CONF:7924) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.18.2" (CONF:10434).SHALL contain exactly one [1..1] code (CONF:15395).This code SHALL contain exactly one [1..1] @code="48768-6" Payers (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15396).SHALL contain exactly one [1..1] title (CONF:7926).SHALL contain exactly one [1..1] text (CONF:7927).SHOULD contain zero or more [0..*] entry (CONF:7959) such that itSHALL contain exactly one [1..1] Coverage Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.60.2) (CONF:15501).Physical Exam Section (V2)[section: templateId 2.16.840.1.113883.10.20.2.10.2 (open)]SEQ Table \* ARABIC162: Physical Exam Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (required)Referral Note (NEW) (optional)History and Physical (V2) (required)Procedure Note (V2) (optional)Progress Note (V2) (optional)Highest Pressure Ulcer StageNumber of Pressure Ulcers ObservationWound Observation (NEW)The Physical Exam section includes direct observations made by the clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient’s body. This section includes only observations made by the examining clinician using inspection, palpation, auscultation, and percussion; it does not include laboratory or imaging findings. The exam may be limited to pertinent body systems based on the patient’s chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically. The Physical Exam section may contain multiple nested subsections: Vital Signs, General Status, and those listed in the Additional Physical Examination Subsections appendix.SEQ Table \* ARABIC163: Physical Exam Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.2.10.2']templateId1..1SHALL7806@root1..1SHALLUID104652.16.840.1.113883.10.20.2.10.2code1..1SHALL15397@code1..1SHALL1539829545-1@codeSystem0..1MAY309312.16.840.1.113883.6.1title1..1SHALL7808text1..1SHALL7809entry0..*MAY17094observation1..1SHALL30930entry0..*MAY17096observation1..1SHALL17097entry0..*MAY17098observation1..1SHALL17099SHALL contain exactly one [1..1] templateId (CONF:7806) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.2.10.2" (CONF:10465).SHALL contain exactly one [1..1] code (CONF:15397).This code SHALL contain exactly one [1..1] @code="29545-1" Physical Findings (CONF:15398).This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:30931).SHALL contain exactly one [1..1] title (CONF:7808).SHALL contain exactly one [1..1] text (CONF:7809).MAY contain zero or more [0..*] entry (CONF:17094) such that itSHALL contain exactly one [1..1] Wound Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.114) (CONF:30930).MAY contain zero or more [0..*] entry (CONF:17096) such that itSHALL contain exactly one [1..1] Number of Pressure Ulcers Observation (templateId:2.16.840.1.113883.10.20.22.4.76) (CONF:17097).MAY contain zero or more [0..*] entry (CONF:17098) such that itSHALL contain exactly one [1..1] Highest Pressure Ulcer Stage (templateId:2.16.840.1.113883.10.20.22.4.77) (CONF:17099).Physical Findings of Skin Section[section: templateId 2.16.840.1.113883.10.20.22.2.62 (open)]SEQ Table \* ARABIC164: Physical Findings of Skin Section ContextsContained By:Contains:Wound Observation (NEW)The Skin Physical Exam section includes direct observations made by the clinician. This section includes only observations made by the examining clinician using inspection and palpation; it does not include laboratory or imaging findings. The examination may be reported as a collection of random clinical statements or it may be reported categorically. SEQ Table \* ARABIC165: Physical Findings of Skin Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.62']templateId1..1SHALL29899@root1..1SHALLUID299002.16.840.1.113883.10.20.22.2.62code1..1SHALL29901@code1..1SHALL299022.16.840.1.113883.6.1 (LOINC) = 10206-1title1..1SHALL29903text1..1SHALL29904entry0..*MAY29905observation1..1SHALL29906SHALL contain exactly one [1..1] templateId (CONF:29899) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.62" (CONF:29900).SHALL contain exactly one [1..1] code (CONF:29901).This code SHALL contain exactly one [1..1] @code="10206-1" Physical findings of Skin Narrative (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:29902).SHALL contain exactly one [1..1] title (CONF:29903).SHALL contain exactly one [1..1] text (CONF:29904).MAY contain zero or more [0..*] entry (CONF:29905) such that itSHALL contain exactly one [1..1] Wound Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.114) (CONF:29906).Plan of Treatment Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.10.2 (open)]SEQ Table \* ARABIC166: Plan of Treatment Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Continuity of Care Document (CCD) (V2) (optional)Discharge Summary (V2) (required)History and Physical (V2) (optional)Operative Note (V2) (optional)Procedure Note (V2) (optional)Progress Note (V2) (optional)Act Plan (V2)Encounter Plan (V2)Handoff Communication (NEW)Instruction (V2)Observation Plan (V2)Procedure Plan (V2)Substance Administration Plan (V2)Supply Plan (V2)The Plan of Treatment section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only, which are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient, clinical reminders, patient’s values, beliefs, preferences, care expectations and overarching goals of care. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. Values may include the importance of quality of life over longevity. These values are taken into account when prioritizing all problems and their treatments. Beliefs may include comfort with dying or the refusal of blood transfusions because of the patient’s religious convictions.??Preferences may include liquid medicines over tablets, or treatment via secure email instead of in person. Care expectations could range from only being treated by female clinicians, to expecting all calls to be returned within 24 hours. Overarching goals described in this section are not tied to a specific condition, problem, health concern, or intervention. Examples of overarching goals could be to minimize pain or dependence on others, or to walk a daughter down the aisle for her marriage.??The plan may also indicate that patient education will be provided. SEQ Table \* ARABIC167: Plan of Treatment Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.10.2']templateId1..1SHALL7723@root1..1SHALL104352.16.840.1.113883.10.20.22.2.10.2code1..1SHALL14749@code1..1SHALL147502.16.840.1.113883.6.1 (LOINC) = 18776-5@codeSystem1..1SHALL308132.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL16986text1..1SHALL7725entry0..*MAY7726observation1..1SHALL14751entry0..*MAY8805encounter1..1SHALL30472entry0..*MAY8807act1..1SHALL30473entry0..*MAY8809procedure1..1SHALL30474entry0..*MAY8811substanceAdministration1..1SHALL30475entry0..*MAY8813supply1..1SHALL30476entry0..*MAY14695act1..1SHALL31397entry0..*MAY29621act1..1SHALL30868SHALL contain exactly one [1..1] templateId (CONF:7723) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.10.2" (CONF:10435).SHALL contain exactly one [1..1] code (CONF:14749).This code SHALL contain exactly one [1..1] @code="18776-5" Plan of Treatment (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:14750).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30813).SHALL contain exactly one [1..1] title (CONF:16986).SHALL contain exactly one [1..1] text (CONF:7725).MAY contain zero or more [0..*] entry (CONF:7726) such that itSHALL contain exactly one [1..1] Observation Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.44.2) (CONF:14751).MAY contain zero or more [0..*] entry (CONF:8805) such that itSHALL contain exactly one [1..1] Encounter Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.40.2) (CONF:30472).MAY contain zero or more [0..*] entry (CONF:8807) such that itSHALL contain exactly one [1..1] Act Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.39.2) (CONF:30473).MAY contain zero or more [0..*] entry (CONF:8809) such that itSHALL contain exactly one [1..1] Procedure Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.41.2) (CONF:30474).MAY contain zero or more [0..*] entry (CONF:8811) such that itSHALL contain exactly one [1..1] Substance Administration Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.42.2) (CONF:30475).MAY contain zero or more [0..*] entry (CONF:8813) such that itSHALL contain exactly one [1..1] Supply Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.43.2) (CONF:30476).MAY contain zero or more [0..*] entry (CONF:14695) such that itSHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31397).MAY contain zero or more [0..*] entry (CONF:29621) such that itSHALL contain exactly one [1..1] Handoff Communication (NEW) (templateId:2.16.840.1.113883.10.20.22.4.141) (CONF:30868).Planned Procedure Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.30.2 (open)]SEQ Table \* ARABIC168: Planned Procedure Section (V2) ContextsContained By:Contains:Operative Note (V2) (optional)Procedure Note (V2) (optional)Procedure Plan (V2)This section contains the procedure(s) that a clinician planned based on the preoperative assessment. SEQ Table \* ARABIC169: Planned Procedure Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.30.2']templateId1..1SHALL8082@root1..1SHALL104362.16.840.1.113883.10.20.22.2.30.2code1..1SHALL15399@code1..1SHALL154002.16.840.1.113883.6.1 (LOINC) = 59772-4title1..1SHALL8084text1..1SHALL8085entry0..*MAY8744procedure1..1SHALL15502SHALL contain exactly one [1..1] templateId (CONF:8082) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.30.2" (CONF:10436).SHALL contain exactly one [1..1] code (CONF:15399).This code SHALL contain exactly one [1..1] @code="59772-4" Planned Procedure (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15400).SHALL contain exactly one [1..1] title (CONF:8084).SHALL contain exactly one [1..1] text (CONF:8085).MAY contain zero or more [0..*] entry (CONF:8744) such that itSHALL contain exactly one [1..1] Procedure Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.41.2) (CONF:15502).Postoperative Diagnosis Section[section: templateId 2.16.840.1.113883.10.20.22.2.35 (open)]SEQ Table \* ARABIC170: Postoperative Diagnosis Section ContextsContained By:Contains:Operative Note (V2) (required)The Postoperative Diagnosis section records the diagnosis or diagnoses discovered or confirmed during the surgery.??Often it is the same as the preoperative diagnosis.SEQ Table \* ARABIC171: Postoperative Diagnosis Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.35']templateId1..1SHALL8101@root1..1SHALL104372.16.840.1.113883.10.20.22.2.35title1..1SHALL8103text1..1SHALL8104code1..1SHALL15401@code1..1SHALL154022.16.840.1.113883.6.1 (LOINC) = 10218-6SHALL contain exactly one [1..1] templateId (CONF:8101) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.35" (CONF:10437).SHALL contain exactly one [1..1] code (CONF:15401).This code SHALL contain exactly one [1..1] @code="10218-6" Postoperative Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15402).SHALL contain exactly one [1..1] title (CONF:8103).SHALL contain exactly one [1..1] text (CONF:8104).Postprocedure Diagnosis Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.36.2 (open)]SEQ Table \* ARABIC172: Postprocedure Diagnosis Section (V2) ContextsContained By:Contains:Procedure Note (V2) (required)Postprocedure Diagnosis (V2)The Postprocedure Diagnosis section records the diagnosis or diagnoses discovered or confirmed during the procedure. Often it is the same as the pre-procedure diagnosis or indication.SEQ Table \* ARABIC173: Postprocedure Diagnosis Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.36.2']templateId1..1SHALL8167@root1..1SHALL104382.16.840.1.113883.10.20.22.2.36.2code1..1SHALL15403@code1..1SHALL1540459769-0@codeSystem1..1SHALL308622.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8170text1..1SHALL8171entry0..1SHOULD8762act1..1SHALL15503SHALL contain exactly one [1..1] templateId (CONF:8167) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.36.2" (CONF:10438).SHALL contain exactly one [1..1] code (CONF:15403).This code SHALL contain exactly one [1..1] @code="59769-0" Postprocedure Diagnosis (CONF:15404).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30862).SHALL contain exactly one [1..1] title (CONF:8170).SHALL contain exactly one [1..1] text (CONF:8171).SHOULD contain zero or one [0..1] entry (CONF:8762) such that itSHALL contain exactly one [1..1] Postprocedure Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.51.2) (CONF:15503).Preoperative Diagnosis Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.34.2 (open)]SEQ Table \* ARABIC174: Preoperative Diagnosis Section (V2) ContextsContained By:Contains:Operative Note (V2) (required)Preoperative Diagnosis (V2)The Preoperative Diagnosis section records the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.SEQ Table \* ARABIC175: Preoperative Diagnosis Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.34.2']templateId1..1SHALL8097@root1..1SHALL104392.16.840.1.113883.10.20.22.2.34.2code1..1SHALL15405@code1..1SHALL1540610219-4@codeSystem1..1SHALL308632.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8099text1..1SHALL8100entry0..1SHOULD10096act1..1SHALL15504SHALL contain exactly one [1..1] templateId (CONF:8097) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.34.2" (CONF:10439).SHALL contain exactly one [1..1] code (CONF:15405).This code SHALL contain exactly one [1..1] @code="10219-4" Preoperative Diagnosis (CONF:15406).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30863).SHALL contain exactly one [1..1] title (CONF:8099).SHALL contain exactly one [1..1] text (CONF:8100).SHOULD contain zero or one [0..1] entry (CONF:10096) such that itSHALL contain exactly one [1..1] Preoperative Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.65.2) (CONF:15504).Problem Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.5.2 (open)]SEQ Table \* ARABIC176: Problem Section (entries optional) (V2) ContextsContained By:Contains:Discharge Summary (V2) (optional)History and Physical (V2) (optional)Progress Note (V2) (optional)Health Status Observation (V2)Problem Concern Act (Condition) (V2)This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. Overall health status may be represented in this section.SEQ Table \* ARABIC177: Problem Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.5.2']templateId1..1SHALL7877@root1..1SHALL104402.16.840.1.113883.10.20.22.2.5.1.2code1..1SHALL15407@code1..1SHALL1540811450-4@codeSystem1..1SHALL31141title1..1SHALL7879text1..1SHALL7880entry0..*SHOULD7881act1..1SHALL15505entry0..1MAY30481observation1..1SHALL30482SHALL contain exactly one [1..1] templateId (CONF:7877) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.5.1.2" (CONF:10440).SHALL contain exactly one [1..1] code (CONF:15407).This code SHALL contain exactly one [1..1] @code="11450-4" Problem List (CONF:15408).This code SHALL contain exactly one [1..1] @codeSystem (CONF:31141).SHALL contain exactly one [1..1] title (CONF:7879).SHALL contain exactly one [1..1] text (CONF:7880).SHOULD contain zero or more [0..*] entry (CONF:7881) such that itSHALL contain exactly one [1..1] Problem Concern Act (Condition) (V2) (templateId:2.16.840.1.113883.10.20.22.4.3.2) (CONF:15505).MAY contain zero or one [0..1] entry (CONF:30481) such that itSHALL contain exactly one [1..1] Health Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.5.2) (CONF:30482).Problem Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.5.1.2 (open)]SEQ Table \* ARABIC178: Problem Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (required)Consultation Note (V2) (required)Referral Note (NEW) (required)Continuity of Care Document (CCD) (V2) (required)Health Status Observation (V2)Problem Concern Act (Condition) (V2)This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed.??Overall health status may be represented in this section.SEQ Table \* ARABIC179: Problem Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.5.1.2']templateId1..1SHALL9179@root1..1SHALL104412.16.840.1.113883.10.20.22.2.5.1.2code1..1SHALL15409@code1..1SHALL1541011450-4@codeSystem1..1SHALL31142title1..1SHALL9181text1..1SHALL9182entry1..*SHALL9183act1..1SHALL15506entry0..1MAY30479observation1..1SHALL30480Conforms to Problem Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.5.2).SHALL contain exactly one [1..1] templateId (CONF:9179) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.5.1.2" (CONF:10441).SHALL contain exactly one [1..1] code (CONF:15409).This code SHALL contain exactly one [1..1] @code="11450-4" Problem List (CONF:15410).This code SHALL contain exactly one [1..1] @codeSystem (CONF:31142).SHALL contain exactly one [1..1] title (CONF:9181).SHALL contain exactly one [1..1] text (CONF:9182).SHALL contain at least one [1..*] entry (CONF:9183).Such entries SHALL contain exactly one [1..1] Problem Concern Act (Condition) (V2) (templateId:2.16.840.1.113883.10.20.22.4.3.2) (CONF:15506).MAY contain zero or one [0..1] entry (CONF:30479) such that itSHALL contain exactly one [1..1] Health Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.5.2) (CONF:30480).Procedure Description Section[section: templateId 2.16.840.1.113883.10.20.22.2.27 (open)]SEQ Table \* ARABIC180: Procedure Description Section ContextsContained By:Contains:Operative Note (V2) (required)Procedure Note (V2) (required)The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data. Local practice often identifies the level and type of detail required based on the procedure or specialty.SEQ Table \* ARABIC181: Procedure Description Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.27']templateId1..1SHALL8062@root1..1SHALL104422.16.840.1.113883.10.20.22.2.27title1..1SHALL8064text1..1SHALL8065code1..1SHALL15411@code1..1SHALL154122.16.840.1.113883.6.1 (LOINC) = 29554-3SHALL contain exactly one [1..1] templateId (CONF:8062) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.27" (CONF:10442).SHALL contain exactly one [1..1] code (CONF:15411).This code SHALL contain exactly one [1..1] @code="29554-3" Procedure Description (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15412).SHALL contain exactly one [1..1] title (CONF:8064).SHALL contain exactly one [1..1] text (CONF:8065).Procedure Disposition Section[section: templateId 2.16.840.1.113883.10.20.18.2.12 (open)]SEQ Table \* ARABIC182: Procedure Disposition Section ContextsContained By:Contains:Operative Note (V2) (optional)Procedure Note (V2) (optional)The Procedure Disposition section records the status and condition of the patient at the completion of the procedure or surgery. It often also states where the patent was transferred to for the next level of care.SEQ Table \* ARABIC183: Procedure Disposition Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.18.2.12']templateId1..1SHALL8070@root1..1SHALLUID104662.16.840.1.113883.10.20.18.2.12title1..1SHALL8072text1..1SHALL8073code1..1SHALL15413@code1..1SHALL154142.16.840.1.113883.6.1 (LOINC) = 59775-7SHALL contain exactly one [1..1] templateId (CONF:8070) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.18.2.12" (CONF:10466).SHALL contain exactly one [1..1] code (CONF:15413).This code SHALL contain exactly one [1..1] @code="59775-7" Procedure Disposition (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15414).SHALL contain exactly one [1..1] title (CONF:8072).SHALL contain exactly one [1..1] text (CONF:8073).Procedure Estimated Blood Loss Section[section: templateId 2.16.840.1.113883.10.20.18.2.9 (open)]SEQ Table \* ARABIC184: Procedure Estimated Blood Loss Section ContextsContained By:Contains:Operative Note (V2) (required)Procedure Note (V2) (optional)The Estimated Blood Loss section may be a subsection of another section such as the Procedure Description section. The Estimated Blood Loss section records the approximate amount of blood that the patient lost during the procedure or surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it may be descriptive, e.g., “minimal” or “none”.SEQ Table \* ARABIC185: Procedure Estimated Blood Loss Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.18.2.9']templateId1..1SHALL8074@root1..1SHALLUID104672.16.840.1.113883.10.20.18.2.9title1..1SHALL8076text1..1SHALL8077code1..1SHALL15415@code1..1SHALL154162.16.840.1.113883.6.1 (LOINC) = 59770-8SHALL contain exactly one [1..1] templateId (CONF:8074) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.18.2.9" (CONF:10467).SHALL contain exactly one [1..1] code (CONF:15415).This code SHALL contain exactly one [1..1] @code="59770-8" Procedure Estimated Blood Loss (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15416).SHALL contain exactly one [1..1] title (CONF:8076).SHALL contain exactly one [1..1] text (CONF:8077).The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:8741).Procedure Findings Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.28.2 (open)]SEQ Table \* ARABIC186: Procedure Findings Section (V2) ContextsContained By:Contains:Operative Note (V2) (required)Procedure Note (V2) (optional)Problem Observation (V2)The Procedure Findings section records clinically significant observations confirmed or discovered during the procedure or surgery.SEQ Table \* ARABIC187: Procedure Findings Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.28.2']templateId1..1SHALL8078@root1..1SHALL104432.16.840.1.113883.10.20.22.2.28.2code1..1SHALL15417@code1..1SHALL1541859776-5@codeSystem1..1SHALL308592.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8080text1..1SHALL8081entry0..*MAY8090observation1..1SHALL15507SHALL contain exactly one [1..1] templateId (CONF:8078) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.28.2" (CONF:10443).SHALL contain exactly one [1..1] code (CONF:15417).This code SHALL contain exactly one [1..1] @code="59776-5" Procedure Findings (CONF:15418).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30859).SHALL contain exactly one [1..1] title (CONF:8080).SHALL contain exactly one [1..1] text (CONF:8081).MAY contain zero or more [0..*] entry (CONF:8090) such that itSHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15507).Procedure Implants Section[section: templateId 2.16.840.1.113883.10.20.22.2.40 (open)]SEQ Table \* ARABIC188: Procedure Implants Section ContextsContained By:Contains:Operative Note (V2) (optional)Procedure Note (V2) (optional)The Procedure Implants section records any materials placed during the procedure including stents, tubes, and drains.Notes: This section replaces: 2.16.840.1.113883.10.20.22.2.40SEQ Table \* ARABIC189: Procedure Implants Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.40']templateId1..1SHALL8178@root1..1SHALL104442.16.840.1.113883.10.20.22.2.40title1..1SHALL8180text1..1SHALL8181code1..1SHALL15373@code1..1SHALL153742.16.840.1.113883.6.1 (LOINC) = 59771-6SHALL contain exactly one [1..1] templateId (CONF:8178) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.40" (CONF:10444).SHALL contain exactly one [1..1] code (CONF:15373).This code SHALL contain exactly one [1..1] @code="59771-6" Procedure Implants (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15374).SHALL contain exactly one [1..1] title (CONF:8180).SHALL contain exactly one [1..1] text (CONF:8181).The Implants section SHALL include a statement providing details of the implants placed, or assert no implants were placed (CONF:8769).Procedure Indications Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.29.2 (open)]SEQ Table \* ARABIC190: Procedure Indications Section (V2) ContextsContained By:Contains:Operative Note (V2) (optional)Procedure Note (V2) (required)Indication (V2)This section contains the reason(s) for the procedure or surgery. This section may include the preprocedure diagnoses as well as symptoms contributing to the reason for the procedure.SEQ Table \* ARABIC191: Procedure Indications Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.29.2']templateId1..1SHALL8058@root1..1SHALL104452.16.840.1.113883.10.20.22.2.29.2code1..1SHALL15419@code1..1SHALL1542059768-2@codeSystem1..1SHALL308272.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8060text1..1SHALL8061entry0..*MAY8743observation1..1SHALL15508SHALL contain exactly one [1..1] templateId (CONF:8058) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.29.2" (CONF:10445).SHALL contain exactly one [1..1] code (CONF:15419).This code SHALL contain exactly one [1..1] @code="59768-2" Procedure Indications (CONF:15420).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30827).SHALL contain exactly one [1..1] title (CONF:8060).SHALL contain exactly one [1..1] text (CONF:8061).MAY contain zero or more [0..*] entry (CONF:8743) such that itSHALL contain exactly one [1..1] Indication (V2) (templateId:2.16.840.1.113883.10.20.22.4.19.2) (CONF:15508).Procedure Specimens Taken Section[section: templateId 2.16.840.1.113883.10.20.22.2.31 (open)]SEQ Table \* ARABIC192: Procedure Specimens Taken Section ContextsContained By:Contains:Operative Note (V2) (required)Procedure Note (V2) (optional)The Procedure Specimens Taken section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.SEQ Table \* ARABIC193: Procedure Specimens Taken Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.31']templateId1..1SHALL8086@root1..1SHALL104462.16.840.1.113883.10.20.22.2.31title1..1SHALL8088text1..1SHALL8089code1..1SHALL15421@code1..1SHALL154222.16.840.1.113883.6.1 (LOINC) = 59773-2SHALL contain exactly one [1..1] templateId (CONF:8086) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.31" (CONF:10446).SHALL contain exactly one [1..1] code (CONF:15421).This code SHALL contain exactly one [1..1] @code="59773-2" Procedure Specimens Taken (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15422).SHALL contain exactly one [1..1] title (CONF:8088).SHALL contain exactly one [1..1] text (CONF:8089).The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:8742).Procedures Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.7.2 (open)]SEQ Table \* ARABIC194: Procedures Section (entries optional) (V2) ContextsContained By:Contains:Consultation Note (V2) (optional)Referral Note (NEW) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (optional)Procedure Note (V2) (optional)Procedure Activity Act (V2)Procedure Activity Observation (V2)Procedure Activity Procedure (V2)This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section is intended to include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change).The length of an encounter is documented in the documentationOf/encompassingEncounter/effectiveTime and length of service in documentationOf/ServiceEvent/effectiveTime.SEQ Table \* ARABIC195: Procedures Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.7.2']templateId1..1SHALL6270@root1..1SHALL62712.16.840.1.113883.10.20.22.2.7.2code1..1SHALL15423@code1..1SHALL1542447519-4@codeSystem1..1SHALL311392.16.840.1.113883.6.1 (LOINC)title1..1SHALL17184text1..1SHALL6273entry0..*MAY6274procedure1..1SHALL15509entry0..1MAY6278observation1..1SHALL15510entry0..1MAY8533act1..1SHALL15511SHALL contain exactly one [1..1] templateId (CONF:6270) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.7.2" (CONF:6271).SHALL contain exactly one [1..1] code (CONF:15423).This code SHALL contain exactly one [1..1] @code="47519-4" History of Procedures (CONF:15424).This code SHALL contain exactly one [1..1] @codeSystem (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:31139).SHALL contain exactly one [1..1] title (CONF:17184).SHALL contain exactly one [1..1] text (CONF:6273).MAY contain zero or more [0..*] entry (CONF:6274) such that itSHALL contain exactly one [1..1] Procedure Activity Procedure (V2) (templateId:2.16.840.1.113883.10.20.22.4.14.2) (CONF:15509).MAY contain zero or one [0..1] entry (CONF:6278) such that itSHALL contain exactly one [1..1] Procedure Activity Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.13.2) (CONF:15510).MAY contain zero or one [0..1] entry (CONF:8533) such that itSHALL contain exactly one [1..1] Procedure Activity Act (V2) (templateId:2.16.840.1.113883.10.20.22.4.12.2) (CONF:15511).Procedures Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.7.1.2 (open)]SEQ Table \* ARABIC196: Procedures Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Continuity of Care Document (CCD) (V2) (required)Procedure Activity Act (V2)Procedure Activity Observation (V2)Procedure Activity Procedure (V2)This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section may contain all procedures for the period of time being summarized, but should include notable procedures. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change).SEQ Table \* ARABIC197: Procedures Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.7.1.2']templateId1..1SHALL7891@root1..1SHALL104472.16.840.1.113883.10.20.22.2.7.1.2code1..1SHALL15425@code1..1SHALL1542647519-4@codeSystem1..1SHALL311382.16.840.1.113883.6.1 (LOINC)title1..1SHALL7893text1..1SHALL7894entry0..*MAY7895procedure1..1SHALL15512entry0..*MAY8017observation1..1SHALL15513entry0..*MAY8019act1..1SHALL15514Conforms to Procedures Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.7.2).SHALL contain exactly one [1..1] templateId (CONF:7891) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.7.1.2" (CONF:10447).SHALL contain exactly one [1..1] code (CONF:15425).This code SHALL contain exactly one [1..1] @code="47519-4" History of Procedures (CONF:15426).This code SHALL contain exactly one [1..1] @codeSystem (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:31138).SHALL contain exactly one [1..1] title (CONF:7893).SHALL contain exactly one [1..1] text (CONF:7894).MAY contain zero or more [0..*] entry (CONF:7895) such that itSHALL contain exactly one [1..1] Procedure Activity Procedure (V2) (templateId:2.16.840.1.113883.10.20.22.4.14.2) (CONF:15512).MAY contain zero or more [0..*] entry (CONF:8017) such that itSHALL contain exactly one [1..1] Procedure Activity Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.13.2) (CONF:15513).MAY contain zero or more [0..*] entry (CONF:8019) such that itSHALL contain exactly one [1..1] Procedure Activity Act (V2) (templateId:2.16.840.1.113883.10.20.22.4.12.2) (CONF:15514).There SHALL be at least one entry conformant to Procedure Activity Act (V2) (templateId 2.16.840.1.113883.10.20.22.4.12.2) or Procedure Activity Observation (V2) (templateId: 2.16.840.1.113883.10.20.22.4.13.2) or Procedure Activity Procedure (V2) (templateId: 2.16.840.1.113883.10.20.22.4.14.2) (CONF:8021).Reason for Referral Section (V2)[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.1.2 (open)]SEQ Table \* ARABIC198: Reason for Referral Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (required)Consultation Note (V2) (optional)Referral Note (NEW) (required)Patient Referral Activity Observation (NEW)This section contains the reason(s) for a patient’s referral by a provider to a consulting provider. An optional Chief Complaint section may capture the patient’s description of the reason for the consultation.SEQ Table \* ARABIC199: Reason for Referral Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '1.3.6.1.4.1.19376.1.5.3.1.3.1.2']templateId1..1SHALL7844@root1..1SHALLUID104681.3.6.1.4.1.19376.1.5.3.1.3.1.2code1..1SHALL15427@code1..1SHALL1542842349-1@codeSystem1..1SHALL308672.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7846text1..1SHALL7847entry0..*MAY30808observation1..1SHALL30897SHALL contain exactly one [1..1] templateId (CONF:7844) such that itSHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.1.2" (CONF:10468).SHALL contain exactly one [1..1] code (CONF:15427).This code SHALL contain exactly one [1..1] @code="42349-1" Reason for Referral (CONF:15428).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:30867).SHALL contain exactly one [1..1] title (CONF:7846).SHALL contain exactly one [1..1] text (CONF:7847).MAY contain zero or more [0..*] entry (CONF:30808) such that itSHALL contain exactly one [1..1] Patient Referral Activity Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.140) (CONF:30897).Figure SEQ Table \* ARABIC20: Sample<component> <section> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1.2" /> <code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for Referral " /> <title>REASON FOR REFERRAL</title> <text>Request for Patient referral for consultation.</text> <entry> <observation classCode="OBS" moodCode="INT">  <templateId root="2.16.840.1.113883.10.20.22.4.140" /> ... </observation> </entry> </section></component>Reason for Visit Section[section: templateId 2.16.840.1.113883.10.20.22.2.12 (open)]SEQ Table \* ARABIC200: Reason for Visit Section ContextsContained By:Contains:Consultation Note (V2) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (optional)Procedure Note (V2) (optional)This section records the patient’s reason for the patient's visit (as documented by the provider).??Local policy determines whether Reason for Visit and Chief Complaint are in separate or combined sections.SEQ Table \* ARABIC201: Reason for Visit Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.12']templateId1..1SHALL7836@root1..1SHALL104482.16.840.1.113883.10.20.22.2.12title1..1SHALL7838text1..1SHALL7839code1..1SHALL15429@code1..1SHALL154302.16.840.1.113883.6.1 (LOINC) = 29299-5SHALL contain exactly one [1..1] templateId (CONF:7836) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.12" (CONF:10448).SHALL contain exactly one [1..1] code (CONF:15429).This code SHALL contain exactly one [1..1] @code="29299-5" Reason for Visit (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15430).SHALL contain exactly one [1..1] title (CONF:7838).SHALL contain exactly one [1..1] text (CONF:7839).Results Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.3.2 (open)]SEQ Table \* ARABIC202: Results Section (entries optional) (V2) ContextsContained By:Contains:History and Physical (V2) (required)Progress Note (V2) (optional)Result Organizer (V2)The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented.Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.Procedure results are typically generated by a clinician to provide more granular information about component observations made during??a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.SEQ Table \* ARABIC203: Results Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.3.2']templateId1..1SHALL7116@root1..1SHALL91362.16.840.1.113883.10.20.22.2.3.2code1..1SHALL15431@code1..1SHALL1543230954-2@codeSystem1..1SHALL310412.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8891text1..1SHALL7118entry0..*SHOULD7119organizer1..1SHALL15515SHALL contain exactly one [1..1] templateId (CONF:7116) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.3.2" (CONF:9136).SHALL contain exactly one [1..1] code (CONF:15431).This code SHALL contain exactly one [1..1] @code="30954-2" Relevant diagnostic tests and/or laboratory data (CONF:15432).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:31041).SHALL contain exactly one [1..1] title (CONF:8891).SHALL contain exactly one [1..1] text (CONF:7118).SHOULD contain zero or more [0..*] entry (CONF:7119) such that itSHALL contain exactly one [1..1] Result Organizer (V2) (templateId:2.16.840.1.113883.10.20.22.4.1.2) (CONF:15515).Results Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.3.1.2 (open)]SEQ Table \* ARABIC204: Results Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (required)Consultation Note (V2) (optional)Referral Note (NEW) (required)Continuity of Care Document (CCD) (V2) (required)Result Observation (V2)Result Organizer (V2)The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented.Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.Procedure results are typically generated by a clinician to provide more granular information about component observations made during??a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.SEQ Table \* ARABIC205: Results Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.3.1.2']templateId1..1SHALL7108@root1..1SHALL91372.16.840.1.113883.10.20.22.2.3.1.2code1..1SHALL15433@code1..1SHALL1543430954-2@codeSystem1..1SHALL310402.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL8892text1..1SHALL7111entry1..*SHALL7112organizer1..1SHALL15516component1..*SHALL31482observation1..1SHALL31483Conforms to Results Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.3.2).SHALL contain exactly one [1..1] templateId (CONF:7108) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.3.1.2" (CONF:9137).SHALL contain exactly one [1..1] code (CONF:15433).This code SHALL contain exactly one [1..1] @code="30954-2" Relevant diagnostic tests and/or laboratory data (CONF:15434).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:31040).SHALL contain exactly one [1..1] title (CONF:8892).SHALL contain exactly one [1..1] text (CONF:7111).SHALL contain at least one [1..*] entry (CONF:7112) such that itSHALL contain exactly one [1..1] Result Organizer (V2) (templateId:2.16.840.1.113883.10.20.22.4.1.2) (CONF:15516).All coded results must be contained in an Organizer with the corresponding result type or order. This organizer SHALL contain at least one [1..*] component (CONF:31482).Such components SHALL contain exactly one [1..1] Result Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.2.2) (CONF:31483).Review of Systems Section[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.18 (open)]SEQ Table \* ARABIC206: Review of Systems Section ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Discharge Summary (V2) (optional)History and Physical (V2) (required)Procedure Note (V2) (optional)Progress Note (V2) (optional)The Review of Systems section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.SEQ Table \* ARABIC207: Review of Systems Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '1.3.6.1.4.1.19376.1.5.3.1.3.18']templateId1..1SHALL7812@root1..1SHALLUID104691.3.6.1.4.1.19376.1.5.3.1.3.18title1..1SHALL7814text1..1SHALL7815code1..1SHALL15435@code1..1SHALL154362.16.840.1.113883.6.1 (LOINC) = 10187-3SHALL contain exactly one [1..1] templateId (CONF:7812) such that itSHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.18" (CONF:10469).SHALL contain exactly one [1..1] code (CONF:15435).This code SHALL contain exactly one [1..1] @code="10187-3" Review of Systems (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15436).SHALL contain exactly one [1..1] title (CONF:7814).SHALL contain exactly one [1..1] text (CONF:7815).Social History Section (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.17.2 (open)]SEQ Table \* ARABIC208: Social History Section (V2) ContextsContained By:Contains:Transfer Summary (NEW) (optional)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Continuity of Care Document (CCD) (V2) (required)Discharge Summary (V2) (optional)History and Physical (V2) (required)Procedure Note (V2) (optional)Caregiver CharacteristicsCharacteristics of Home Environment (NEW)Cultural and Religious Observation (NEW)Current Smoking Status (V2)Pregnancy ObservationSocial History Observation (V2)Tobacco Use (V2)This section contains social history data that influences a patient’s physical, psychological or emotional health (e.g. smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header.SEQ Table \* ARABIC209: Social History Section (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.17.2']templateId1..1SHALL7936@root1..1SHALL104492.16.840.1.113883.10.20.22.2.17.2code1..1SHALL14819@code1..1SHALL1482029762-2@codeSystem1..1SHALL308142.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL7938text1..1SHALL7939entry0..*MAY7953observation1..1SHALL14821entry0..*MAY9132observation1..1SHALL14822entry0..1SHOULD14823observation1..1SHALL14824entry0..*MAY16816observation1..1SHALL16817entry0..*MAY28361observation1..1SHALL28362entry0..*MAY28366observation1..1SHALL28367entry0..*MAY28825observation1..1SHALL28826SHALL contain exactly one [1..1] templateId (CONF:7936) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.17.2" (CONF:10449).SHALL contain exactly one [1..1] code (CONF:14819).This code SHALL contain exactly one [1..1] @code="29762-2" Social History (CONF:14820).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30814).SHALL contain exactly one [1..1] title (CONF:7938).SHALL contain exactly one [1..1] text (CONF:7939).MAY contain zero or more [0..*] entry (CONF:7953) such that itSHALL contain exactly one [1..1] Social History Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.38.2) (CONF:14821).MAY contain zero or more [0..*] entry (CONF:9132) such that itSHALL contain exactly one [1..1] Pregnancy Observation (templateId:2.16.840.1.113883.10.20.15.3.8) (CONF:14822).SHOULD contain zero or one [0..1] entry (CONF:14823) such that itSHALL contain exactly one [1..1] Current Smoking Status (V2) (templateId:2.16.840.1.113883.10.20.22.4.78.2) (CONF:14824).MAY contain zero or more [0..*] entry (CONF:16816) such that itSHALL contain exactly one [1..1] Tobacco Use (V2) (templateId:2.16.840.1.113883.10.20.22.4.85.2) (CONF:16817).MAY contain zero or more [0..*] entry (CONF:28361) such that itSHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:28362).MAY contain zero or more [0..*] entry (CONF:28366) such that itSHALL contain exactly one [1..1] Cultural and Religious Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.111) (CONF:28367).MAY contain zero or more [0..*] entry (CONF:28825) such that itSHALL contain exactly one [1..1] Characteristics of Home Environment (NEW) (templateId:2.16.840.1.113883.10.20.22.4.109) (CONF:28826).Figure SEQ Table \* ARABIC21: Sample<component> <section> <templateId root="2.16.840.1.113883.10.20.22.2.17.2"/> <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"/> <title>SOCIAL HISTORY</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Social History Element</th> <th>Description</th> <th>Effective Dates</th> </tr> </thead> <tbody> <tr> <td>Alcohol Use</td> <td>2 Drinks per Week</td> <td>March 12, 2013</td> </tr> <tr><td>Smoking Status</td><td>Former smoker</td><td>May 1, 2005 - Feb 27, 2009</td> </tr> <tr> <td>Characteristics of Care Environment</td> <td>Homeless</td> <td>March 12, 2013</td> </tr> <tr> <td>Cultural and Religious Observations</td> <td>Does not accept blood tranfusions, or donates, or stores blood for transfusion.</td> <td>March 12, 2013</td> </tr> </tbody> </table> </text> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.38"/> ... </observation> </entry> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.78"/> ... </observation> </entry><entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.72"/> ... </observation></entry><entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.111"/> ... </observation></entry><entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.109"/> ... </observation></entry>Subjective Section[section: templateId 2.16.840.1.113883.10.20.21.2.2 (open)]SEQ Table \* ARABIC210: Subjective Section ContextsContained By:Contains:Progress Note (V2) (optional)The Subjective section describes in a narrative format the patient’s current condition and/or interval changes as reported by the patient or by the patient’s guardian or another informant.SEQ Table \* ARABIC211: Subjective Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.21.2.2']templateId1..1SHALL7873@root1..1SHALLUID104702.16.840.1.113883.10.20.21.2.2title1..1SHALL7875text1..1SHALL7876code1..1SHALL15437@code1..1SHALL154382.16.840.1.113883.6.1 (LOINC) = 61150-9SHALL contain exactly one [1..1] templateId (CONF:7873) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.21.2.2" (CONF:10470).SHALL contain exactly one [1..1] code (CONF:15437).This code SHALL contain exactly one [1..1] @code="61150-9" Subjective (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15438).SHALL contain exactly one [1..1] title (CONF:7875).SHALL contain exactly one [1..1] text (CONF:7876).Surgery Description Section[section: templateId 2.16.840.1.113883.10.20.22.2.26 (open)]SEQ Table \* ARABIC212: Surgery Description Section ContextsContained By:Contains:replaced by 2.16.840.1.113883.10.20.22.2.27SEQ Table \* ARABIC213: Surgery Description Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.26']templateId1..1SHALL8022@root1..1SHALL104502.16.840.1.113883.10.20.22.2.26title1..1SHALL8024text1..1SHALL8025code1..1SHALL15439@code1..1SHALL154402.16.840.1.113883.6.1 (LOINC) = 29554-3SHALL contain exactly one [1..1] templateId (CONF:8022) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.26" (CONF:10450).SHALL contain exactly one [1..1] code (CONF:15439).This code SHALL contain exactly one [1..1] @code="29554-3" Surgery Description (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15440).SHALL contain exactly one [1..1] title (CONF:8024).SHALL contain exactly one [1..1] text (CONF:8025).Surgical Drains Section[section: templateId 2.16.840.1.113883.10.20.7.13 (open)]SEQ Table \* ARABIC214: Surgical Drains Section ContextsContained By:Contains:Operative Note (V2) (optional)The Surgical Drains section may be used to record drains placed during the surgical procedure. Optionally, surgical drain placement may be represented with a text element in the Procedure Description Section.SEQ Table \* ARABIC215: Surgical Drains Section Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.7.13']templateId1..1SHALL8038@root1..1SHALLUID104732.16.840.1.113883.10.20.7.13title1..1SHALL8040text1..1SHALL8041code1..1SHALL15441@code1..1SHALL154422.16.840.1.113883.6.1 (LOINC) = 11537-8SHALL contain exactly one [1..1] templateId (CONF:8038) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.7.13" (CONF:10473).SHALL contain exactly one [1..1] code (CONF:15441).This code SHALL contain exactly one [1..1] @code="11537-8" Surgical Drains (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15442).SHALL contain exactly one [1..1] title (CONF:8040).SHALL contain exactly one [1..1] text (CONF:8041).If the Surgical Drains section is present, there SHALL be a statement providing details of the drains placed or SHALL explicitly state there were no drains placed (CONF:8056).Vital Signs Section (entries optional) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.4.2 (open)]SEQ Table \* ARABIC216: Vital Signs Section (entries optional) (V2) ContextsContained By:Contains:Discharge Summary (V2) (optional)History and Physical (V2) (required)Progress Note (V2) (optional)Vital Signs Organizer (V2)The Vital Signs section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends.Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.SEQ Table \* ARABIC217: Vital Signs Section (entries optional) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.4.2']templateId1..1SHALL7268@root1..1SHALL104512.16.840.1.113883.10.20.22.2.4.2code1..1SHALL15242@code1..1SHALL152432.16.840.1.113883.6.1 (LOINC) = 8716-3@codeSystem1..1SHALL309022.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL9966text1..1SHALL7270entry0..*SHOULD7271organizer1..1SHALL15517SHALL contain exactly one [1..1] templateId (CONF:7268) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.4.2" (CONF:10451).SHALL contain exactly one [1..1] code (CONF:15242).This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15243).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30902).SHALL contain exactly one [1..1] title (CONF:9966).SHALL contain exactly one [1..1] text (CONF:7270).SHOULD contain zero or more [0..*] entry (CONF:7271) such that itSHALL contain exactly one [1..1] Vital Signs Organizer (V2) (templateId:2.16.840.1.113883.10.20.22.4.26.2) (CONF:15517).Vital Signs Section (entries required) (V2)[section: templateId 2.16.840.1.113883.10.20.22.2.4.1.2 (open)]SEQ Table \* ARABIC218: Vital Signs Section (entries required) (V2) ContextsContained By:Contains:Transfer Summary (NEW) (required)Consultation Note (V2) (optional)Referral Note (NEW) (optional)Continuity of Care Document (CCD) (V2) (required)Vital Signs Organizer (V2)The Vital Signs section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends.Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.SEQ Table \* ARABIC219: Vital Signs Section (entries required) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesection[templateId/@root = '2.16.840.1.113883.10.20.22.2.4.1.2']templateId1..1SHALL7273@root1..1SHALL104522.16.840.1.113883.10.20.22.2.4.1.2code1..1SHALL15962@code1..1SHALL159638716-3@codeSystem1..1SHALL309032.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1title1..1SHALL9967text1..1SHALL7275entry1..*SHALL7276organizer1..1SHALL15964Conforms to Vital Signs Section (entries optional) (V2) template (2.16.840.1.113883.10.20.22.2.4.2).SHALL contain exactly one [1..1] templateId (CONF:7273) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.4.1.2" (CONF:10452).SHALL contain exactly one [1..1] code (CONF:15962).This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CONF:15963).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:30903).SHALL contain exactly one [1..1] title (CONF:9967).SHALL contain exactly one [1..1] text (CONF:7275).SHALL contain at least one [1..*] entry (CONF:7276) such that itSHALL contain exactly one [1..1] Vital Signs Organizer (V2) (templateId:2.16.840.1.113883.10.20.22.4.26.2) (CONF:15964).Entry-Level TemplatesThis chapter describes the clinical statement entry templates used within the sections of the consolidated documents. Entry templates contain constraints that are required for conformance. Entry-level templates are always in sections.Each entry-level template description contains the following information:???Key template metadata (e.g., templateId, etc.)???Description and explanatory narrative.???Required CDA acts, participants and vocabularies.???Optional CDA acts, participants and vocabularies.Several entry-level templates require an effectiveTime:The effectiveTime of an observation is the time interval over which the observation is known to be true. The low and high values should be as precise as possible, but no more precise than known. While CDA has multiple mechanisms to record this time interval (e.g., by low and high values, low and width, high and width, or center point and width), we constrain most to use only the low/high form. The low??value is the earliest point for which the condition is known to have existed. The high value, when present, indicates the time at which the observation was no longer known to be true. The full description of effectiveTime and time intervals is contained in the CDA R2 normative edition.Provenance in entry templates:In this version of Consolidated CDA, we have added a “SHOULD” Author constraint on several entry-level templates. Authorship and Author timestamps must be explicitly asserted in these cases, unless the values propagated from the document header hold true.ID in entry templates:Entry-level templates may also describe an id element, which is an identifier for that entry. This id may be referenced within the document, or by the system receiving the document. The id assigned must be globally unique. Act Plan (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.39.2 (open)]SEQ Table \* ARABIC220: Act Plan (V2) ContextsContained By:Contains:Plan of Treatment Section (V2) (optional)Goal Observation (NEW) (optional)Assessment and Plan Section (V2) (optional)Intervention Act (NEW) (optional)Patient Priority Preference (NEW)Provider Priority Preference (NEW)This is the generic template for the Plan Activity. The activities in this template represent procedures are not classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures. The priority of the activity to the patient and provider is communicated through Patient Priority Preference and Provider Priority Preference. The effective time indicates the time when activity is intended to take place.SEQ Table \* ARABIC221: Act Plan (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.39.2']@classCode1..1SHALL85382.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL85392.16.840.1.113883.11.20.9.23 (Plan of Care moodCode (Act/Encounter/Procedure))templateId1..1SHALL30430@root1..1SHALL304312.16.840.1.113883.10.20.22.4.39.2id1..*SHALL8546statusCode1..1SHALL30432effectiveTime1..1SHALL30433performer0..*MAY30435participant0..*MAY30436entryRelationship0..*MAY31067@typeCode1..1SHALL310682.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31069entryRelationship0..*MAY31070@typeCode1..1SHALL310712.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31072SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8538).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Plan of Care moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:8539).SHALL contain exactly one [1..1] templateId (CONF:30430) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.39.2" (CONF:30431).SHALL contain at least one [1..*] id (CONF:8546).SHALL contain exactly one [1..1] statusCode (CONF:30432).SHALL contain exactly one [1..1] effectiveTime (CONF:30433).Performers represent clinicians who are responsible for assessing and treating the patient.MAY contain zero or more [0..*] performer (CONF:30435).Participants represent those in supporting roles such as caregiver, who participate in the patient's care.MAY contain zero or more [0..*] participant (CONF:30436).This entryRelationship represents the priority that a patient places on the activity.MAY contain zero or more [0..*] entryRelationship (CONF:31067) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31068).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31069).This entryRelationship represents the priority that a provider places on the activity.MAY contain zero or more [0..*] entryRelationship (CONF:31070) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31071).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31072).SEQ Table \* ARABIC222: Plan of Care moodCode (Act/Encounter/Procedure)Value Set: Plan of Care moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23CodeCode SystemPrint NameINTActMoodIntentARQActMoodAppointment RequestPRMSActMoodPromisePRPActMoodProposalRQOActMoodRequestFigure SEQ Table \* ARABIC22: Sample<entry> <act moodCode="INT" classCode="ACT"> <templateId root="2.16.840.1.113883.10.20.22.4.39.2"/>  <id root="9a6d1bac-17d3-4195-89a4-1121bc809a5c"/> <code xsi:type="CD" code="225358003" displayName="wound care (regime/therapy)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <statusCode code="new"/> <effectiveTime value="20130615"/> <participant typeCode="IND"> <participantRole classCode="IND"> <code code="MTH" codeSystem="2.16.840.1.113883.5.111" displayName="Mother"/> </participantRole> </participant> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.142"/> ... </observation> </entryRelationship> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.143"/> ... </observation> </entryRelationship> </act></entry>Act Reference (NEW)[act: templateId 2.16.840.1.113883.10.20.22.4.122 (closed)]SEQ Table \* ARABIC223: Act Reference (NEW) ContextsContained By:Contains:This template represents the act of referencing another entry in a CDA document instance. Its purpose is to obviate the need to repeat the complete xml representation of the referred to entry when relating one entry to another. For example, in a Care Plan it is necessary to repeatedly relate Health Concerns, Goals, Interventions and Outcomes. The id is required and must be the same id as the entry/id it is referencing. Act/Code is nulled to “NP” (Not Present).SEQ Table \* ARABIC224: Act Reference (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.122']@classCode1..1SHALL314852.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL314862.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL31487@root1..1SHALL31488temp-OID-ActReferenceid1..1SHALL31489code1..1SHALL31490@nullFlavor1..1SHALL314912.16.840.1.113883.5.1008 (HL7NullFlavor) = NPstatusCode1..1SHALL31498@code0..1MAY314992.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31485).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:31486).SHALL contain exactly one [1..1] templateId (CONF:31487) such that itSHALL contain exactly one [1..1] @root="temp-OID-ActReference" (CONF:31488).The ID has to be the same as some other entry/id in the same document.SHALL contain exactly one [1..1] id (CONF:31489).SHALL contain exactly one [1..1] code (CONF:31490).This code SHALL contain exactly one [1..1] @nullFlavor="NP" Not Present (CodeSystem: HL7NullFlavor 2.16.840.1.113883.5.1008) (CONF:31491).SHALL contain exactly one [1..1] statusCode (CONF:31498).This statusCode MAY contain zero or one [0..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:31499).Figure SEQ Table \* ARABIC23: Act Reference ...<act classCode="ACT" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.132" /> <id root="4eab0e52-dd7d-4285-99eb-72d32ddb195c" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern" /> ... <entryRelationship typeCode="REFR"> ... <code code="282291009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" displayName="Diagnosis" /> ... <value xsi:type="CD" code="233604007" codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED" displayName="Pneumonia" />  <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.122" /> <id root="3700b3b0-fbed-11e2-b778-0800200c9a66" />  <code nullFlavor="NP" /> <statusCode code="completed"/> </act> </entryRelationship> </observation></entryRelationship></act>... ...<entry> <observation classCode="OBS" moodCode="GOL"> <id root="3700b3b0-fbed-11e2-b778-0800200c9a66"/> <code code="252465000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" displayName="Pulse oximetry" /> <statusCode code="active" /> <value xsi:type="IVL_PQ"> <low value="92" unit="%"/> </value>  </observation></entry> ...Figure SEQ Table \* ARABIC24: CCD Containment ExampleShow how an encounter can include a discharge diagnosis which references an item on the problem list using the Act Reference template<observation> <id root="1234567"/> <code code="123" codeSystem="1.2.3" displayName="asthma"/></observation><encounter> <entryRelationship typeCode="COMP"> <act> <code code="145" codeSystem="4.5.6" displayName="discharge diagnosis"/> <templateId root="2.16.840.1.113883.10.20.22.4.33.2"/>  <entryRelationship typeCode="SUBJ"> <act classCode="ACT" moodCode="XXX"> <templateId root="temp-OID-ActReference" /> <id root="1234567"/> <code nullFlavor="NP" /> </act> </entryRelationship> </act> </entryRelationship></encounter>Admission Medication (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.36.2 (open)]SEQ Table \* ARABIC225: Admission Medication (V2) ContextsContained By:Contains:Hospital Admission Medications Section (entries optional) (V2) (optional)Medication Activity (V2)The Admission Medications entry codes medications that the patient took prior to admission.SEQ Table \* ARABIC226: Admission Medication (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.36.2']@classCode1..1SHALL76982.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL76992.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16758@root1..1SHALL167592.16.840.1.113883.10.20.22.4.36.2code1..1SHALL15518@code1..1SHALL155192.16.840.1.113883.6.1 (LOINC) = 42346-7entryRelationship1..*SHALL7701@typeCode1..1SHALL77022.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJsubstanceAdministration1..1SHALL15520SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7698).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7699).SHALL contain exactly one [1..1] templateId (CONF:16758) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.36.2" (CONF:16759).SHALL contain exactly one [1..1] code (CONF:15518).This code SHALL contain exactly one [1..1] @code="42346-7" Medications on Admission (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15519).SHALL contain at least one [1..*] entryRelationship (CONF:7701) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7702).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:15520).Figure SEQ Table \* ARABIC25: Sample<act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.36.2" /> <code code="42346-7" /> <entryRelationship typeCode="SUBJ"> <substanceAdministration classCode="SBADM" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.16.2" /> ... </substanceAdministration> </entryRelationship></act>Advance Directive Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.48.2 (open)]SEQ Table \* ARABIC227: Advance Directive Observation (V2) ContextsContained By:Contains:Advance Directive Organizer (required)Intervention Act (NEW) (optional)This clinical statement represents Advance Directives Observations findings (e.g., “resuscitation status is Full Code”) rather than orders, and should not be considered legal documents. The related legal documents are referenced using the reference/externalReference element.The Advance Directive Observation describes the patient’s directives, including but not limited to???Medications???Transfer of Care to Hospital???Treatment???Procedures???Intubation and Ventilation???Diagnostic Tests???Tests. The patient’s directives are coded in the observation/value element using codes from SNOMED CT.SEQ Table \* ARABIC228: Advance Directive Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.48.2']@classCode1..1SHALL86482.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL86492.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL8655@root1..1SHALL104852.16.840.1.113883.10.20.22.4.48.2id1..*SHALL8654code1..1SHALL86512.16.840.1.113883.1.11.20.2.2 (AdvanceDirectiveTypeCode (V2))statusCode1..1SHALL8652@code1..1SHALL190822.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL8656low1..1SHALL28719high1..1SHALL15521participant1..*SHOULD8662@typeCode1..1SHALL86632.16.840.1.113883.5.90 (HL7ParticipationType) = VRFtemplateId1..1SHALL8664@root1..1SHALL104862.16.840.1.113883.10.20.1.58time0..1SHOULD8665participantRole1..1SHALL8825code0..1SHOULD284462.16.840.1.113883.5.111 (RoleCode)addr0..*MAY28451playingEntity0..1MAY28428code0..1SHOULD284292.16.840.1.113883.11.20.9.51 (Healthcare Agent Qualifier Value Set)name0..*MAY28454participant0..*SHOULD8667@typeCode1..1SHALL86682.16.840.1.113883.5.90 (HL7ParticipationType) = CSTparticipantRole1..1SHALL8669@classCode1..1SHALL86702.16.840.1.113883.5.110 (RoleClass) = AGNTcode0..1SHOULD284402.16.840.1.113883.5.111 (RoleCode)addr0..1SHOULD8671telecom0..*SHOULD8672playingEntity1..1SHALL8824code0..1SHOULD284442.16.840.1.113883.11.20.9.51 (Healthcare Agent Qualifier Value Set)name1..1SHALL8673reference1..*SHOULD8692@typeCode1..1SHALL86942.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRexternalDocument1..1SHALL8693id1..*SHALL8695text0..1MAY8696@mediaType0..1MAY8703text/plainreference0..1MAY8697versionNumber0..1MAY28430value0..1SHOULD30804SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8648).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8649).SHALL contain exactly one [1..1] templateId (CONF:8655) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.48.2" (CONF:10485).SHALL contain at least one [1..*] id (CONF:8654).SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet AdvanceDirectiveTypeCode (V2) 2.16.840.1.113883.1.11.20.2.2 STATIC 2006-10-17 (CONF:8651).SHALL contain exactly one [1..1] statusCode (CONF:8652).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19082).SHALL contain exactly one [1..1] effectiveTime (CONF:8656).This effectiveTime SHALL contain exactly one [1..1] low (CONF:28719).This effectiveTime SHALL contain exactly one [1..1] high (CONF:15521).SHOULD contain zero or one [0..1] value (CONF:30804).SHOULD contain at least one [1..*] participant (CONF:8662) such that itSHALL contain exactly one [1..1] @typeCode="VRF" Verifier (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8663).SHALL contain exactly one [1..1] templateId (CONF:8664).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.58" (CONF:10486).SHOULD contain zero or one [0..1] time (CONF:8665).The data type of Observation/participant/time in a verification SHALL be TS (time stamp) (CONF:8666).SHALL contain exactly one [1..1] participantRole (CONF:8825).This participantRole SHOULD contain zero or one [0..1] code (CodeSystem: RoleCode 2.16.840.1.113883.5.111 DYNAMIC) (CONF:28446).This participantRole MAY contain zero or more [0..*] addr (CONF:28451).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:28452).This participantRole MAY contain zero or one [0..1] playingEntity (CONF:28428).The playingEntity, if present, SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Agent Qualifier Value Set 2.16.840.1.113883.11.20.9.51 STATIC (CONF:28429).The playingEntity, if present, MAY contain zero or more [0..*] name (CONF:28454).The playingEntity/name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:28455).SHOULD contain zero or more [0..*] participant (CONF:8667) such that itSHALL contain exactly one [1..1] @typeCode="CST" Custodian (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8668).SHALL contain exactly one [1..1] participantRole (CONF:8669).This participantRole SHALL contain exactly one [1..1] @classCode="AGNT" Agent (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:8670).This participantRole SHOULD contain zero or one [0..1] code (CodeSystem: RoleCode 2.16.840.1.113883.5.111 DYNAMIC) (CONF:28440).Note: SHALL contain Healthcare Agent role, Example: 'Health Care Agent' or 'Substitute decision maker'.This participantRole SHOULD contain zero or one [0..1] addr (CONF:8671).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:28453).This participantRole SHOULD contain zero or more [0..*] telecom (CONF:8672).This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:8824).This playingEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Agent Qualifier Value Set 2.16.840.1.113883.11.20.9.51 (CONF:28444).This playingEntity SHALL contain exactly one [1..1] name (CONF:8673).The name of the agent who can provide a copy of the Advance Directive SHALL be recorded in the??name element inside the??playingEntity??element (CONF:8674).The playingEntity/name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:28456).SHOULD contain at least one [1..*] reference (CONF:8692) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8694).SHALL contain exactly one [1..1] externalDocument (CONF:8693).This externalDocument SHALL contain at least one [1..*] id (CONF:8695).This externalDocument MAY contain zero or one [0..1] text (CONF:8696).The text, if present, MAY contain zero or one [0..1] @mediaType="text/plain" (CONF:8703).The text, if present, MAY contain zero or one [0..1] reference (CONF:8697).The URL of a referenced advance directive document MAY be present, and SHALL be represented in Observation/reference/ExternalDocument/text/reference (CONF:8698).If a URL is referenced, then it SHOULD have a corresponding linkHTML element in narrative block (CONF:8699).This externalDocument MAY contain zero or one [0..1] versionNumber (CONF:28430).SEQ Table \* ARABIC229: AdvanceDirectiveTypeCode (V2)Value Set: AdvanceDirectiveTypeCode (V2) 2.16.840.1.113883.1.11.20.2.2CodeCode SystemPrint Name52765003SNOMED CTIntubation61420007SNOMED CTTube Feedings78823007SNOMED CTLife Support14152002SNOMED CTIntravenous infusion281789004SNOMED CTAntibiotics439569004SNOMED CTResuscitation40617009SNOMED CTArtificial respiration18629005SNOMED CT Administration of medication5447007SNOMED CTTransfusion429202003SNOMED CTTransfer of care to hospital108241001SNOMED CTDialysis procedure103693007SNOMED CTDiagnostic procedure304253006SNOMED CTNot for resuscitationSEQ Table \* ARABIC230: Healthcare Agent Qualifier Value SetValue Set: Healthcare Agent Qualifier Value Set 2.16.840.1.113883.11.20.9.51CodeCode SystemPrint Name63161005SNOMED CTPrincipal2603003SNOMED CTSecondaryFigure SEQ Table \* ARABIC26: Sample<observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.48.2"/> <id root="9b54c3c9-1673-49c7-aef9-b037ed72ed27"/> <code code="439569004" codeSystem="2.16.840.1.113883.6.96" displayName="Resuscitation"> <originalText>Cardiopulmonary resuscitation: for a patient in cardiac or respiratory arrest</originalText> </code> <statusCode code="completed"/> <effectiveTime> <low value="20110213"/> <high nullFlavor="NA"/> </effectiveTime> <value xsi:type="CD" code="304253006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED -CT" displayName="Not for resuscitation"> <originalText>Do not resucitate</originalText> </value> <participant typeCode="VRF"> <templateId root="2.16.840.1.113883.10.20.1.58"/> <time value="201302013"/> <participantRole> <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/> <code code="MD" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Medical Doctor"/> <addr> <streetAddressLine>1006 Health Drive</streetAddressLine> <city>Ann Arbor</city> <state>MI</state> <postalCode>97867</postalCode> <country>US</country> </addr> <telecom value="tel:(995)555-1006" use="WP"/> <playingEntity> <code code="63161005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Principal"/> <name> <prefix>Dr.</prefix> <family>James</family> <given>Case</given> </name> </playingEntity> </participantRole> </participant> <participant typeCode="VRF"> <templateId root="2.16.840.1.113883.10.20.1.58"/> <time value="201302013"/> <participantRole> <id root="58f9c91e-d9df-11e2-b1b8-f23c91aec05e"/> <code code="MOH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Medical Officer of Health"/> <addr> <streetAddressLine>1006 Health Drive</streetAddressLine> <city>Ann Arbor</city> <state>MI</state> <postalCode>97867</postalCode> <country>US</country> </addr> <telecom value="tel:(995)555-3016" use="WP"/> <playingEntity> <code code="2603003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="RoleCode" displayName="Secondary"/> <name> <prefix>Dr.</prefix> <family>Jane</family> <given>Jenner</given> </name> </playingEntity> </participantRole> </participant> <participant typeCode="CST"> <participantRole classCode="AGNT"> <code code="MTH" codeSystem="2.16.840.1.113883.5.111" displayName="Mother"/> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97867</postalCode> <country>US</country> </addr> <telecom value="tel:(999)555-1212" use="WP"/> <playingEntity> <code code="63161005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Principal"/> <name> <prefix>Mrs.</prefix> <given>Martha</given> <family>Jones</family> </name> </playingEntity> </participantRole> </participant> <reference typeCode="REFR"> <seperatableInd value="false"/> <externalDocument> <id root="b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3"/> <text mediaType="application/pdf"> <reference value="AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf" /> </text> <versionNumber value="1"/> </externalDocument> </reference></observation>Advance Directive Organizer[organizer: templateId 2.16.840.1.113883.10.20.22.4.108 (open)]SEQ Table \* ARABIC231: Advance Directive Organizer ContextsContained By:Contains:Advance Directives Section (entries optional) (V2) (optional)Advance Directives Section (entries required) (V2) (required)Advance Directive Observation (V2)This clinical statement groups a set of advance directive observations.SEQ Table \* ARABIC232: Advance Directive Organizer Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.108']component1..*SHALL28420observation1..1SHALL28421@classCode1..1SHALL284102.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALL284112.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL28412@root1..1SHALL284132.16.840.1.113883.10.20.22.4.108id1..*SHALL28414code1..1SHALL28415@code1..1SHALL31230310301000@codeSystem1..1SHALL312312.16.840.1.113883.6.96 (SNOMED CT)statusCode1..1SHALL28418@code1..1SHALL313462.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="CLUSTER", which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6) STATIC (CONF:28410).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:28411).SHALL contain exactly one [1..1] templateId (CONF:28412) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.108" (CONF:28413).SHALL contain at least one [1..*] id (CONF:28414).SHALL contain exactly one [1..1] code (CONF:28415).This code SHALL contain exactly one [1..1] @code="310301000" advance healthcare directive status (CONF:31230).This code SHALL contain exactly one [1..1] @codeSystem (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31231).SHALL contain exactly one [1..1] statusCode (CONF:28418).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:31346).SHALL contain at least one [1..*] component (CONF:28420) such that itSHALL contain exactly one [1..1] Advance Directive Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.48.2) (CONF:28421).Figure SEQ Table \* ARABIC27: Sample<organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.108"/>  <id root="af6ebdf2-d996-11e2-a5b8-f23c91aec05e"/> <code code="310301000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED -CT" displayName="advance healthcare directive status"/> <statusCode code="completed"/> <effectiveTime value="20130202"/> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.48.2"/> ... </component> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.48.2"/> <id root="9b54c3c9-1673-49c7-aef9-b037ed72ed27"/> ... </component> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.48.2"/> ... </component></organizer>Age Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.31 (open)]SEQ Table \* ARABIC233: Age Observation ContextsContained By:Contains:Family History Observation (optional)Problem Observation (V2) (optional)This Age Observation represents the subject's age at onset of an event or observation. The age of a relative in a Family History Observation at the time of that observation could also be inferred by comparing RelatedSubject/subject/birthTime with Observation/effectiveTime. However, a common scenario is that a patient will know the age of a relative when the relative had a certain condition or when the relative died, but will not know the actual year (e.g., "grandpa died of a heart attack at the age of 50"). Often times, neither precise dates nor ages are known (e.g. "cousin died of congenital heart disease as an infant").SEQ Table \* ARABIC234: Age Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.31']@classCode1..1SHALL76132.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL76142.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALL7615@code1..1SHALL167762.16.840.1.113883.6.96 (SNOMED CT) = 445518008value1..1SHALLPQ7617@unit1..1SHALLCS76182.16.840.1.113883.11.20.9.21 (AgePQ_UCUM)templateId1..1SHALL7899@root1..1SHALL104872.16.840.1.113883.10.20.22.4.31statusCode1..1SHALL15965@code1..1SHALL159662.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7613).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7614).SHALL contain exactly one [1..1] templateId (CONF:7899) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.31" (CONF:10487).SHALL contain exactly one [1..1] code (CONF:7615).This code SHALL contain exactly one [1..1] @code="445518008" Age At Onset (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:16776).SHALL contain exactly one [1..1] statusCode (CONF:15965).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:15966).SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7617).This value SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet AgePQ_UCUM 2.16.840.1.113883.11.20.9.21 DYNAMIC (CONF:7618).SEQ Table \* ARABIC235: AgePQ_UCUMValue Set: AgePQ_UCUM 2.16.840.1.113883.11.20.9.21A valueSet of UCUM codes for representing age value unitsCodeCode SystemPrint NameminUCUMMinutehUCUMHourdUCUMDaywkUCUMWeekmoUCUMMonthaUCUMYearFigure SEQ Table \* ARABIC28: Sample<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.31" />  <code code="445518008" codeSystem="2.16.840.1.113883.6.96" displayName="Age At Onset" /> <statusCode code="completed" /> <value xsi:type="PQ" value="57" unit="a" /></observation>Allergy Problem Act (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.30.2 (open)]SEQ Table \* ARABIC236: Allergy Problem Act (V2) ContextsContained By:Contains:Allergies Section (entries optional) (V2) (optional)Allergies Section (entries required) (V2) (required)Allergy - Intolerance Observation (V2)Author Participant (NEW)This template reflects an ongoing concern on behalf of the provider that placed the allergy on a patient’s allergy list. So long as the underlying condition is of concern to the provider (i.e. so long as the allergy, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”. Only when the underlying allergy is no longer of concern is the statusCode set to “completed”. The effectiveTime reflects the time that the underlying allergy was felt to be a concern.The statusCode of the Allergy Problem Act is the definitive indication of the status of the concern, whereas the effectiveTime of the nested Allergy - Intolerance Observation is the definitive indication of whether or not the underlying allergy is resolved. The effectiveTime/low of the Allergy Problem Act asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. The effectiveTime/high asserts when the concern was completed (e.g. when the clinician deemed there is no longer any need to track the underlying condition).SEQ Table \* ARABIC237: Allergy Problem Act (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.30.2']@classCode1..1SHALL74692.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL74702.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7471@root1..1SHALL104892.16.840.1.113883.10.20.22.4.30.2id1..*SHALL7472code1..1SHALL7477@code1..1SHALL191582.16.840.1.113883.5.6 (HL7ActClass) = CONCstatusCode1..1SHALL7485@code1..1SHALL190862.16.840.1.113883.11.20.9.19 (ProblemAct statusCode)effectiveTime1..1SHALL7498low1..1SHALL31534high0..1MAY31535entryRelationship1..*SHALL7509@typeCode1..1SHALL79152.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL14925author0..*SHOULD31145SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7469).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7470).SHALL contain exactly one [1..1] templateId (CONF:7471) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.30.2" (CONF:10489).SHALL contain at least one [1..*] id (CONF:7472).SHALL contain exactly one [1..1] code (CONF:7477).This code SHALL contain exactly one [1..1] @code="CONC" Concern (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:19158).SHALL contain exactly one [1..1] statusCode (CONF:7485).This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09 (CONF:19086).The effectiveTime/low asserts when the allergy was noted. This equates to the time the allergy was authored in the patient's chart. It is clinically rare for an allergy to be "resolved", even for patients undergoing allergy desensitization. As a result, effectiveTime/high will generally not be present.SHALL contain exactly one [1..1] effectiveTime (CONF:7498).This effectiveTime SHALL contain exactly one [1..1] low (CONF:31534).This effectiveTime MAY contain zero or one [0..1] high (CONF:31535).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31145).SHALL contain at least one [1..*] entryRelationship (CONF:7509) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7915).SHALL contain exactly one [1..1] Allergy - Intolerance Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.7.2) (CONF:14925).SEQ Table \* ARABIC238: ProblemAct statusCodeValue Set: ProblemAct statusCode 2.16.840.1.113883.11.20.9.19A ValueSet of HL7 actStatus codes for use on the concern actCodeCode SystemPrint NamecompletedActStatusCompletedabortedActStatusAbortedactiveActStatusActivesuspendedActStatusSuspendedAllergy Status Observation (DEPRECATED)[observation: templateId 2.16.840.1.113883.10.20.22.4.28.2 (open)]SEQ Table \* ARABIC239: Allergy Status Observation (DEPRECATED) ContextsContained By:Contains:Substance or Device Allergy - Intolerance Observation (V2) (optional)This template represents the status of the allergy indicating whether it is active, no longer active, or is an historic allergy. There can be only one allergy status observation per alert observation.This template has been deprecated in Consolidated CDA Release 2. Per the explanation in Volume 1, section 3.2 "Determining a Clinical Statement's Status", the status of an allergy is determined based on attributes of the Allergy Problem Act and Allergy - Intolerance Observation.SEQ Table \* ARABIC240: Allergy Status Observation (DEPRECATED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.28.2']@classCode1..1SHALL73182.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73192.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7317@root1..1SHALL104902.16.840.1.113883.10.20.22.4.28.2code1..1SHALL7320@code1..1SHALL191312.16.840.1.113883.6.1 (LOINC) = 33999-4statusCode1..1SHALL7321@code1..1SHALL190872.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD73222.16.840.1.113883.3.88.12.80.68 (Problem Status Value Set)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7318).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7319).SHALL contain exactly one [1..1] templateId (CONF:7317) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.28.2" (CONF:10490).SHALL contain exactly one [1..1] code (CONF:7320).This code SHALL contain exactly one [1..1] @code="33999-4" Status (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19131).SHALL contain exactly one [1..1] statusCode (CONF:7321).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19087).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem Status Value Set 2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:7322).SEQ Table \* ARABIC241: Problem Status Value SetValue Set: Problem Status Value Set 2.16.840.1.113883.3.88.12.80.68CodeCode SystemPrint Name55561003SNOMED CTActive73425007SNOMED CTInactive413322009SNOMED CTResolvedAssessment Scale Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.69 (open)]SEQ Table \* ARABIC242: Assessment Scale Observation ContextsContained By:Contains:Sensory and Speech Status (NEW) (optional)Mental Status Section (NEW) (optional)Mental Status Observation (NEW) (optional)Cognitive Abilities Observation (NEW) (optional)Health Concern Act (NEW) (optional)Cognitive Status Observation (V2) (optional)Functional Status Section (V2) (optional)Functional Status Observation (V2) (optional)Cognitive Status Problem Observation (DEPRECATED) (optional)Functional Status Problem Observation (DEPRECATED) (optional)Assessment Scale Supporting ObservationAn assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale (assesses coma and impaired consciousness.)SEQ Table \* ARABIC243: Assessment Scale Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.69']@classCode1..1SHALL144342.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL144352.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14436@root1..1SHALL144372.16.840.1.113883.10.20.22.4.69id1..*SHALL14438code1..1SHALL14439statusCode1..1SHALL14444@code1..1SHALL190882.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL14445value1..1SHALL14450entryRelationship0..*SHOULD14451@typeCode1..1SHALL16741COMPobservation1..1SHALL16742interpretationCode0..*MAY14459translation0..*MAY14888author0..*MAY14460derivationExpr0..1MAY14637referenceRange0..*MAY16799observationRange1..1SHALL16800text0..1SHOULD16801reference0..1SHOULD16802@value0..1MAY16803SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14434).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14435).SHALL contain exactly one [1..1] templateId (CONF:14436) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.69" (CONF:14437).SHALL contain at least one [1..*] id (CONF:14438).SHALL contain exactly one [1..1] code (CONF:14439).SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:14440).Such derivation expression can contain a text calculation of how the components total up to the summed score MAY contain zero or one [0..1] derivationExpr (CONF:14637).SHALL contain exactly one [1..1] statusCode (CONF:14444).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19088).Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) SHALL contain exactly one [1..1] effectiveTime (CONF:14445).SHALL contain exactly one [1..1] value (CONF:14450).MAY contain zero or more [0..*] interpretationCode (CONF:14459).The interpretationCode, if present, MAY contain zero or more [0..*] translation (CONF:14888).MAY contain zero or more [0..*] author (CONF:14460).SHOULD contain zero or more [0..*] entryRelationship (CONF:14451) such that itSHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:16741).SHALL contain exactly one [1..1] Assessment Scale Supporting Observation (templateId:2.16.840.1.113883.10.20.22.4.86) (CONF:16742).The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g. for a Pain Scale 1 to 10:??1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) MAY contain zero or more [0..*] referenceRange (CONF:16799).The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:16800).This observationRange SHOULD contain zero or one [0..1] text (CONF:16801).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:16802).The reference, if present, MAY contain zero or one [0..1] @value (CONF:16803).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:16804).Assessment Scale Supporting Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.86 (open)]SEQ Table \* ARABIC244: Assessment Scale Supporting Observation ContextsContained By:Contains:Assessment Scale Observation (optional)An Assessment Scale Supporting observation represents the components of a scale used in an Assessment Scale Observation. The individual parts that make up the component may be a group of cognitive or functional status observations.SEQ Table \* ARABIC245: Assessment Scale Supporting Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.86']@classCode1..1SHALL167152.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL167162.16.840.1.113883.5.1001 (ActMood) = EVNstatusCode1..1SHALL16720@code1..1SHALL190892.16.840.1.113883.5.14 (ActStatus) = completedtemplateId1..1SHALL16722@root1..1SHALL167232.16.840.1.113883.10.20.22.4.86id1..*SHALL16724value1..*SHALL16754code1..1SHALL19178@code1..1SHALL19179SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:16715).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:16716).SHALL contain exactly one [1..1] templateId (CONF:16722) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.86" (CONF:16723).SHALL contain at least one [1..*] id (CONF:16724).SHALL contain exactly one [1..1] code (CONF:19178).This code SHALL contain exactly one [1..1] @code (CONF:19179).Such that the @code SHALL be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) and represents components of the scale (CONF:19180).SHALL contain exactly one [1..1] statusCode (CONF:16720).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19089).SHALL contain at least one [1..*] value (CONF:16754).If xsi:type="CD" , MAY have a translation code to further specify the source if the instrument has an applicable code system and valueSet for the integer (CONF:14639) (CONF:16755).Authorization Activity[act: templateId 2.16.840.1.113883.10.20.1.19 (open)]SEQ Table \* ARABIC246: Authorization Activity ContextsContained By:Contains:An Authorization Activity represents authorizations or pre-authorizations currently active for the patient for the particular payer. Authorizations are represented using an act subordinate to the policy or program that provided it.??The authorization refers to the policy or program. Authorized treatments can be grouped into an organizer class, where common properties, such as the reason for the authorization, can be expressed. Subordinate acts represent what was authorized.SEQ Table \* ARABIC247: Authorization Activity Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.1.19']@classCode1..1SHALL89442.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL89452.16.840.1.113883.5.6 (HL7ActClass) = EVNtemplateId1..1SHALL8946@root1..1SHALL105292.16.840.1.113883.10.20.1.19id1..1SHALL8947entryRelationship1..*SHALL8948@typeCode1..1SHALL89492.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJSHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8944).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8945).SHALL contain exactly one [1..1] templateId (CONF:8946) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.19" (CONF:10529).SHALL contain exactly one [1..1] id (CONF:8947).SHALL contain at least one [1..*] entryRelationship (CONF:8948) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8949).The target of an authorization activity with act/entryRelationship/@typeCode="SUBJ" SHALL be a clinical statement with moodCode="PRMS" Promise (CONF:8951).The target of an authorization activity MAY contain one or more performer, to indicate the providers that have been authorized to provide treatment (CONF:8952).Boundary Observation[observation: templateId 2.16.840.1.113883.10.20.6.2.11 (open)]SEQ Table \* ARABIC248: Boundary Observation ContextsContained By:Contains:Referenced Frames Observation (required)A Boundary Observation contains a list of integer values for the referenced frames of a DICOM multiframe image SOP instance. It identifies the frame numbers within the referenced SOP instance to which the reference applies. The CDA Boundary Observation numbers frames using the same convention as DICOM, with the first frame in the referenced object being Frame 1. A Boundary Observation must be used if a referenced DICOM SOP instance is a multiframe image and the reference does not apply to all frames.SEQ Table \* ARABIC249: Boundary Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.6.2.11']@classCode1..1SHALL92822.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL92832.16.840.1.113883.5.6 (HL7ActClass) = EVNcode1..1SHALL9284@code1..1SHALL191571.2.840.10008.2.16.4 (DCM) = 113036value1..*SHALLINT9285SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9282).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9283).SHALL contain exactly one [1..1] code (CONF:9284).This code SHALL contain exactly one [1..1] @code="113036" Frames for Display (CodeSystem: DCM 1.2.840.10008.2.16.4 STATIC) (CONF:19157).Each number represents a frame for display.SHALL contain at least one [1..*] value with @xsi:type="INT" (CONF:9285).Figure SEQ Table \* ARABIC29: Sample<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.6.2.11"/><code code="113036"codeSystem="1.2.840.10008.2.16.4"displayName="Frames for Display"/><value xsi:type="INT" value="1"/></observation>Caregiver Characteristics[observation: templateId 2.16.840.1.113883.10.20.22.4.72 (open)]SEQ Table \* ARABIC250: Caregiver Characteristics ContextsContained By:Contains:Social History Section (V2) (optional)Mental Status Section (NEW) (optional)Health Concern Act (NEW) (optional)Cognitive Status Observation (V2) (optional)Functional Status Section (V2) (optional)Functional Status Observation (V2) (optional)Cognitive Status Problem Observation (DEPRECATED) (optional)Functional Status Problem Observation (DEPRECATED) (optional)This clinical statement represents a caregiver’s willingness to provide care and the abilities of that caregiver to provide assistance to a patient in relation to a specific need.SEQ Table \* ARABIC251: Caregiver Characteristics Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.72']@classCode1..1SHALL142192.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL142202.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14221@root1..1SHALL142222.16.840.1.113883.10.20.22.4.72id1..*SHALL14223participant1..*SHALL14227@typeCode1..1SHALL26451INDtime0..1MAY14830low1..1SHALL14831high0..1MAY14832participantRole1..1SHALL14228@classCode1..1SHALL14229CAREGIVERcode1..1SHALL14230statusCode1..1SHALL14233@code1..1SHALL190902.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD14599SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14219).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14220).SHALL contain exactly one [1..1] templateId (CONF:14221) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.72" (CONF:14222).SHALL contain at least one [1..*] id (CONF:14223).SHALL contain exactly one [1..1] code (CONF:14230).SHALL contain exactly one [1..1] statusCode (CONF:14233).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19090).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:14599).SHALL contain at least one [1..*] participant (CONF:14227).Such participants SHALL contain exactly one [1..1] @typeCode="IND" (CONF:26451).Such participants MAY contain zero or one [0..1] time (CONF:14830).The time, if present, SHALL contain exactly one [1..1] low (CONF:14831).The time, if present, MAY contain zero or one [0..1] high (CONF:14832).Such participants SHALL contain exactly one [1..1] participantRole (CONF:14228).This participantRole SHALL contain exactly one [1..1] @classCode="CAREGIVER" (CONF:14229).Characteristics of Home Environment (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.109 (open)]SEQ Table \* ARABIC252: Characteristics of Home Environment (NEW) ContextsContained By:Contains:Social History Section (V2) (optional)Health Concern Act (NEW) (optional)This template represents the patient's home environment including, but not limited to, type of residence (trailer, single family home, assisted living), living arrangement (e.g. alone, with parents), and housing status (e.g., evicted, homeless, home owner).Notes:SEQ Table \* ARABIC253: Characteristics of Home Environment (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.109']@classCode1..1SHALL278902.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL278912.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL27892@root1..1SHALL278932.16.840.1.113883.10.20.22.4.109id1..*SHALL27894statusCode1..1SHALL27901@code1..1SHALL279022.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALL288232.16.840.1.113883.11.20.9.49 (Residence and Accomodation Type)code1..1SHALL31352@code1..1SHALL31353224249004@codeSystem1..1SHALL313542.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:27890).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:27891).SHALL contain exactly one [1..1] templateId (CONF:27892) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.109" (CONF:27893).SHALL contain at least one [1..*] id (CONF:27894).SHALL contain exactly one [1..1] code (CONF:31352).This code SHALL contain exactly one [1..1] @code="224249004" Characteristics of Home Environment (CONF:31353).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31354).SHALL contain exactly one [1..1] statusCode (CONF:27901).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:27902).SHALL contain exactly one [1..1] value, which SHOULD be selected from ValueSet Residence and Accomodation Type 2.16.840.1.113883.11.20.9.49 DYNAMIC (CONF:28823).SEQ Table \* ARABIC254: Residence and Accomodation TypeValue Set: Residence and Accomodation Type 2.16.840.1.113883.11.20.9.49Represents the patient's type of residence, status of accommodations, living situation and environment. Valueset Source: SystemPrint Name78153003SNOMED CTcity dweller (finding)113165003SNOMED CTduplex home living (finding)160751007SNOMED CTeviction from dwelling (finding)365514004SNOMED CTfinding relating to awaiting housing or re-housing (finding)160720000SNOMED CTharassment by landlord (finding)105529008SNOMED CTlives alone (finding)60585007SNOMED CTslum area living (finding)365508006SNOMED CTunsatisfactory living conditions (finding)...Figure SEQ Table \* ARABIC30: Sample<observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.109"/> <id root="37f76c51-6411-4e1d-8a37-957fd49d2ceg"/> <code code="224249004" codeSystem="2.16.840.1.113883.6.96" displayName="Characteristics of Home Environment"/> <statusCode code="completed"/> <effectiveTime value="20130312"/>  <value xsi:type="CD" code="308899009" displayName="unsatisfactory living conditions (finding)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /></observation>Clinical Statement Reference[act: templateId 2.16.840.1.113883.10.20.22.4.112 (open)]SEQ Table \* ARABIC255: Clinical Statement Reference ContextsContained By:Contains:SEQ Table \* ARABIC256: Clinical Statement Reference Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.112']@classCode1..1SHALL314922.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL31493templateId1..1SHALL31494@root0..1MAY314952.16.840.1.113883.10.20.22.4.112id1..1SHALL31496code1..1SHALL31497SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31492).SHALL contain exactly one [1..1] @moodCode (CONF:31493).SHALL contain exactly one [1..1] templateId (CONF:31494) such that itMAY contain zero or one [0..1] @root="2.16.840.1.113883.10.20.22.4.112" (CONF:31495).SHALL contain exactly one [1..1] id (CONF:31496).SHALL contain exactly one [1..1] code (CONF:31497).Code Observations[observation: templateId 2.16.840.1.113883.10.20.6.2.13 (open)]SEQ Table \* ARABIC257: Code Observations ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)Quantity Measurement ObservationSOP Instance ObservationDICOM Template 2000 specifies that Imaging Report Elements of Value Type Code are contained in sections. The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations that consist of image references and measurements (linear, area, volume, and numeric). Coded DICOM Imaging Report Elements in this context are mapped to CDA-coded observations that are section components and are related to the SOP Instance Observations (templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT (Support) act relationship.SEQ Table \* ARABIC258: Code Observations Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.6.2.13']@classCode1..1SHALL93042.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL93052.16.840.1.113883.5.1001 (ActMood) = EVNvalue1..1SHALL9308effectiveTime0..1SHOULD9309entryRelationship0..*MAY9311@typeCode1..1SHALL93122.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SPRTobservation1..1SHALL16083entryRelationship0..*MAY9314@typeCode1..1SHALL93152.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SPRTobservation1..1SHALL16084templateId1..1SHALL15523@root1..1SHALL155242.16.840.1.113883.10.20.6.2.13code1..1SHALL19181SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9304).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9305).SHALL contain exactly one [1..1] templateId (CONF:15523).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.13" (CONF:15524).SHALL contain exactly one [1..1] code (CONF:19181).SHOULD contain zero or one [0..1] effectiveTime (CONF:9309).SHALL contain exactly one [1..1] value (CONF:9308).MAY contain zero or more [0..*] entryRelationship (CONF:9311) such that itSHALL contain exactly one [1..1] @typeCode="SPRT" Has Support (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9312).SHALL contain exactly one [1..1] SOP Instance Observation (templateId:2.16.840.1.113883.10.20.6.2.8) (CONF:16083).MAY contain zero or more [0..*] entryRelationship (CONF:9314) such that itSHALL contain exactly one [1..1] @typeCode="SPRT" Has Support (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9315).SHALL contain exactly one [1..1] Quantity Measurement Observation (templateId:2.16.840.1.113883.10.20.6.2.14) (CONF:16084).Code Observations SHALL be rendered into section/text in separate paragraphs (CONF:9310).Figure SEQ Table \* ARABIC31: Sample<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.13"/> <code code="18782-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Study observation"/> <statusCode code="completed"/> <value xsi:type="CD" code="309530007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hilar mass"/> </observation>Cognitive Status Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.74.2 (open)]SEQ Table \* ARABIC259: Cognitive Status Observation (V2) ContextsContained By:Contains:Mental Status Section (NEW) (optional)Health Concern Act (NEW) (optional)Cognitive Status Organizer (V2) (required)Assessment Scale ObservationAuthor Participant (NEW)Caregiver CharacteristicsNon-Medicinal Supply Activity (V2)This template represents a patient’s cognitive status (e.g. mood, memory, ability to make decisions) and problems that limit cognition (e.g. amnesia, dementia, aggressive behavior). The template may include assessment scale observations, identify supporting caregivers and provide information about non-medicinal supplies.SEQ Table \* ARABIC260: Cognitive Status Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.74.2']entryRelationship0..*MAY14469@typeCode1..1SHALL145952.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL14470entryRelationship0..*MAY14276@typeCode1..1SHALL145942.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL14277@classCode1..1SHALL142492.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL142502.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14255@root1..1SHALL142562.16.840.1.113883.10.20.22.4.74.2id1..*SHALL14257code1..1SHALL14591@code1..1SHALL14592311465003@codeSystem1..1SHALL308702.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96text0..1SHOULD14258statusCode1..1SHALL14254@code1..1SHALL190922.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL14261value1..1SHALL14263author0..*SHOULD14266entryRelationship0..*MAY14272@typeCode1..1SHALL145932.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL14273referenceRange0..*MAY14267SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14249).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14250).SHALL contain exactly one [1..1] templateId (CONF:14255) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.74.2" (CONF:14256).SHALL contain at least one [1..*] id (CONF:14257).SHALL contain exactly one [1..1] code (CONF:14591).This code SHALL contain exactly one [1..1] @code="311465003" Cognitive functions (CONF:14592).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:30870).SHOULD contain zero or one [0..1] text (CONF:14258).SHALL contain exactly one [1..1] statusCode (CONF:14254).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19092).SHALL contain exactly one [1..1] effectiveTime (CONF:14261).SHALL contain exactly one [1..1] value (CONF:14263).If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:14271).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:14266).MAY contain zero or more [0..*] entryRelationship (CONF:14272) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14593).SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.50.2) (CONF:14273).MAY contain zero or more [0..*] entryRelationship (CONF:14276) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14594).SHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14277).MAY contain zero or more [0..*] entryRelationship (CONF:14469) such that itSHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14595).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14470).The referenceRange could be used to represent normal or expected capability for the cognitive function being evaluated.MAY contain zero or more [0..*] referenceRange (CONF:14267).Figure SEQ Table \* ARABIC32: Cognitive Status Observation<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.74.2"/> <id root="c6b5a04b-2bf4-49d1-8336-636a3813df0a"/> <code code="311465003" displayName="Cognitive functions" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <statusCode code="completed"/> <effectiveTime value="20130311"/> <value xsi:type="CD" code="61372001" displayName="Aggressive behavior" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></value> <author> <time value="200130311"/> <assignedAuthor> .... </assignedAuthor> </author> </observation></entry>Cognitive Abilities Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.126 (open)]SEQ Table \* ARABIC261: Cognitive Abilities Observation (NEW) ContextsContained By:Contains:Mental Status Section (NEW) (optional)Health Concern Act (NEW) (optional)Assessment Scale ObservationThe Cognitive Abilities Observation conforms to the Cognitive Status Observation and represents a patient’s ability to perform specific cognitive tasks (e.g. ability to plan, logical sequencing ability, ability to think abstractly).SEQ Table \* ARABIC262: Cognitive Abilities Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.126']entryRelationship0..*MAY29266@typeCode1..1SHALL292672.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL29268@classCode1..1SHALL292462.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL292472.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL29248@root1..1SHALL292492.16.840.1.113883.10.20.22.4.126id1..*SHALL29250code1..1SHALL292512.16.840.1.113883.11.20.9.48 (Cognitive Abilities Value Set)text0..1SHOULD29252statusCode1..1SHALL29256@code1..1SHALL292572.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL29258value1..1SHALLCD292642.16.840.1.113883.11.20.9.44 (Mental and Functional Status Response Value Set)Conforms to Cognitive Status Observation (V2) template (2.16.840.1.113883.10.20.22.4.74.2).SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:29246).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:29247).SHALL contain exactly one [1..1] templateId (CONF:29248) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.126" (CONF:29249).SHALL contain at least one [1..*] id (CONF:29250).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Cognitive Abilities Value Set 2.16.840.1.113883.11.20.9.48 DYNAMIC (CONF:29251).SHOULD contain zero or one [0..1] text (CONF:29252).SHALL contain exactly one [1..1] statusCode (CONF:29256).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:29257).SHALL contain exactly one [1..1] effectiveTime (CONF:29258).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Mental and Functional Status Response Value Set 2.16.840.1.113883.11.20.9.44 DYNAMIC (CONF:29264).MAY contain zero or more [0..*] entryRelationship (CONF:29266) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:29267).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:29268).SEQ Table \* ARABIC263: Cognitive Abilities Value SetValue Set: Cognitive Abilities Value Set 2.16.840.1.113883.11.20.9.48This Value Set identifies the specific types of cognitive abilities.CodeCode SystemPrint Name61254005SNOMED CTjudgement (observable entity)395659009SNOMED CTability to comprehend (observable entity)286574007SNOMED CTability to plan (observable entity)307082005SNOMED CTability to process information (observable entity)304641000SNOMED CTability to reason (observable entity)363878000SNOMED CTability to think abstractly (observable entity)418907009SNOMED CTability to verbalize understanding (observable entity)304645009SNOMED CTlogical sequencing ability (observable entity)311465003SNOMED CTCognitive functions (observable entity)SEQ Table \* ARABIC264: Mental and Functional Status Response Value SetValue Set: Mental and Functional Status Response Value Set 2.16.840.1.113883.11.20.9.44A value set containing 2 SNOMED-CT qualifier codes that are common responses to mental and functional ability queries.CodeCode SystemPrint Name11163003SNOMED CTIntact260379002SNOMED CTImpairedFigure SEQ Table \* ARABIC33: Cognitive Abilities Observation<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.126"/> <id root="c12ecaaf-53f8-4593-8f79-359aeaa39483"/> <code xsi:type="CD" code="61254005" displayName="Judgement" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></code> <text>Judgement</text> <statusCode code="completed"/> <effectiveTime value="20130311"/> <value xsi:type="CD" code="11163003" displayName="Intact" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></value> <author> ... </observation> </entry>Cognitive Status Organizer (V2)[organizer: templateId 2.16.840.1.113883.10.20.22.4.75.2 (open)]SEQ Table \* ARABIC265: Cognitive Status Organizer (V2) ContextsContained By:Contains:Mental Status Section (NEW) (optional)Cognitive Status Observation (V2)This template groups related cognitive status observations into categories . A result organizer may be used to group questions in a Patient Health Questionnaire (PHQ). SEQ Table \* ARABIC266: Cognitive Status Organizer (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.75.2']component1..*SHALL14373observation1..1SHALL14381@classCode1..1SHALL143692.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALL143712.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14375@root1..1SHALL143762.16.840.1.113883.10.20.22.4.75.2id1..*SHALL14377code1..1SHALL14378@code0..1SHOULD14697statusCode1..1SHALL14372@code1..1SHALL190932.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="CLUSTER", which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6) STATIC (CONF:14369).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14371).SHALL contain exactly one [1..1] templateId (CONF:14375) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.75.2" (CONF:14376).SHALL contain at least one [1..*] id (CONF:14377).The code selected should indicate the category that groups the contained cognitive status observations (e.g. communication,learning and applying knowledge).SHALL contain exactly one [1..1] code (CONF:14378).This code SHOULD contain zero or one [0..1] @code (CONF:14697).Should be selected from ICF (codeSystem 2.16.840.1.113883.6.254) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96) (CONF:14698).SHALL contain exactly one [1..1] statusCode (CONF:14372).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19093).SHALL contain at least one [1..*] component (CONF:14373) such that itSHALL contain exactly one [1..1] Cognitive Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.74.2) (CONF:14381).Figure SEQ Table \* ARABIC34: Cognitive Status Organizer<entry> <organizer classCode="CLUSTER" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.75.2"/> <id root="a7bc1062-8649-42a0-833d-ekd65bd013c9"/> <code code="d3" displayName="Communication" codeSystem="2.16.840.1.113883.6.254" codeSystemName="ICF"/> <statusCode code="completed"/> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.74.2"/> ... </component> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.74.2"/> ... </component> </organizer> </entry>Cognitive Status Problem Observation (DEPRECATED)[observation: templateId 2.16.840.1.113883.10.20.22.4.73.2 (open)]SEQ Table \* ARABIC267: Cognitive Status Problem Observation (DEPRECATED) ContextsContained By:Contains:Assessment Scale ObservationCaregiver CharacteristicsNon-Medicinal Supply ActivityUSE OF COGNITIVE STATUS PROBLEM OBSERVATION IS NOT RECOMMENDED. COGNITIVE STATUS PROBLEM OBSERVATION AND COGNITIVE STATUS RESULT OBSERVATION HAVE BEEN MERGED TOGETHER WITHOUT LOSS OF EXPRESSIVITY INTO COGNITIVE STATUS OBSERVATION (TEMPLATE ID: 2.16.840.1.113883.10.20.22.4.74.2).SEQ Table \* ARABIC268: Cognitive Status Problem Observation (DEPRECATED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.73.2']entryRelationship0..*MAY14467@typeCode1..1SHALL145902.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL14468entryRelationship0..*MAY14335@typeCode1..1SHALL145892.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL14352@classCode1..1SHALL143192.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL143202.16.840.1.113883.5.1001 (ActMood) = EVN@negationInd0..1MAY14344templateId1..1SHALL14346@root1..1SHALL143472.16.840.1.113883.10.20.22.4.73id1..*SHALL14321code1..1SHALL14804@code0..1SHOULD148052.16.840.1.113883.6.96 (SNOMED CT) = 373930000text0..1SHOULD14341reference0..1SHOULD15532@value0..1SHOULD15533statusCode1..1SHALL14323@code1..1SHALL190912.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime0..1SHOULD14324low1..1SHALL26458high0..1MAY26459value1..1SHALLCD143492.16.840.1.113883.3.88.12.3221.7.4 (Problem Value Set)methodCode0..*MAY14693entryRelationship0..*MAY14331@typeCode1..1SHALL145882.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL14351SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14319).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14320).Use negationInd="true" to indicate that the problem was not observed.MAY contain zero or one [0..1] @negationInd (CONF:14344).SHALL contain exactly one [1..1] templateId (CONF:14346) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.73" (CONF:14347).SHALL contain at least one [1..*] id (CONF:14321).SHALL contain exactly one [1..1] code (CONF:14804).This code SHOULD contain zero or one [0..1] @code="373930000" Cognitive function finding (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:14805).SHOULD contain zero or one [0..1] text (CONF:14341).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15532).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15533).SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15534).SHALL contain exactly one [1..1] statusCode (CONF:14323).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19091).SHOULD contain zero or one [0..1] effectiveTime (CONF:14324).The value of effectiveTime/low represents onset date.The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:26458).If the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:26459).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:14349).MAY contain zero or more [0..*] methodCode (CONF:14693).MAY contain zero or more [0..*] entryRelationship (CONF:14331) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14588).SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (templateId:2.16.840.1.113883.10.20.22.4.50) (CONF:14351).MAY contain zero or more [0..*] entryRelationship (CONF:14335) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14589).SHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14352).MAY contain zero or more [0..*] entryRelationship (CONF:14467) such that itSHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14590).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14468).SEQ Table \* ARABIC269: Problem Value SetValue Set: Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4CodeCode SystemPrint Name50992006SNOMED CT22q partial trisomy syndrome (disorder)237931009SNOMED CT2-Ketoadipic acidemia (disorder)54470008SNOMED CT3 beta-Hydroxysteroid dehydrogenase deficiency (disorder)237950009SNOMED CT3-Methylglutaconic aciduria (disorder)296646009SNOMED CT4-quinolones overdose (disorder)41797007SNOMED CT5 10-Methylenetetrahydrofolate reductase deficiency (disorder)413380004SNOMED CTA pattern strabismus (disorder)425879009SNOMED CTAA amyloid nephropathy (disorder)274945004SNOMED CTAA amyloidosis (disorder)75100008SNOMED CTAbdominal abscess (disorder)43894001SNOMED CTAbdominal actinomycosis (disorder)233985008SNOMED CTAbdominal aortic aneurysm (disorder)253679008SNOMED CTAbdominal aortic coarctation (disorder)116289008SNOMED CTAbdominal bloating (finding)9991008SNOMED CTAbdominal colic (finding)271860004SNOMED CTAbdominal mass (finding)75879005SNOMED CTAbdominal migraine (disorder)21522001SNOMED CTAbdominal pain (finding)82661006SNOMED CTAbdominal pregnancy (disorder)72300008SNOMED CTAbdominal rigidity (finding)...Comment Activity[act: templateId 2.16.840.1.113883.10.20.22.4.64 (open)]SEQ Table \* ARABIC270: Comment Activity ContextsContained By:Contains:Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. For example, a free text description of the severity of an allergic reaction would not be recorded in a comment.SEQ Table \* ARABIC271: Comment Activity Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.64']@classCode1..1SHALL94252.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL94262.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL9427@root1..1SHALL104912.16.840.1.113883.10.20.22.4.64code1..1SHALL9428@code1..1SHALL191592.16.840.1.113883.6.1 (LOINC) = 48767-8text1..1SHALL9430reference1..1SHALL15967@value1..1SHALL15968reference/@value1..1SHALL9431author0..1MAY9433time1..1SHALL9434assignedAuthor1..1SHALL9435id1..1SHALL9436addr1..1SHALL9437SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9425).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9426).SHALL contain exactly one [1..1] templateId (CONF:9427) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.64" (CONF:10491).SHALL contain exactly one [1..1] code (CONF:9428).This code SHALL contain exactly one [1..1] @code="48767-8" Annotation Comment (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19159).SHALL contain exactly one [1..1] text (CONF:9430).This text SHALL contain exactly one [1..1] reference (CONF:15967).This reference SHALL contain exactly one [1..1] @value (CONF:15968).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15969).This text SHALL contain exactly one [1..1] reference/@value (CONF:9431).MAY contain zero or one [0..1] author (CONF:9433).The author, if present, SHALL contain exactly one [1..1] time (CONF:9434).The author, if present, SHALL contain exactly one [1..1] assignedAuthor (CONF:9435).This assignedAuthor SHALL contain exactly one [1..1] id (CONF:9436).This assignedAuthor SHALL contain exactly one [1..1] addr (CONF:9437).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10480).SHALL include assignedPerson/name or representedOrganization/name (CONF:9438).An??assignedPerson/name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:9439).Data elements defined elsewhere in the specification SHALL NOT be recorded using the Comment Activity (CONF:9429).Communication from Provider to Provider[act: templateId 2.16.840.1.113883.10.20.24.3.4 (open)]SEQ Table \* ARABIC272: Communication from Provider to Provider ContextsContained By:Contains:Patient PreferenceProvider PreferenceThis template represents the provision of any communication from one clinician to another regarding findings, assessments, plans of care, consultative advice, instructions, educational resources, etc.SEQ Table \* ARABIC273: Communication from Provider to Provider Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.4']@classCode1..1SHALL118162.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL118172.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11818@root1..1SHALL118192.16.840.1.113883.10.20.24.3.4id1..*SHALL11821statusCode1..1SHALL118222.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11823participant1..1SHALL11827@typeCode1..1SHALL118282.16.840.1.113883.5.90 (HL7ParticipationType) = IRCPparticipantRole1..1SHALL11829@classCode1..1SHALL120962.16.840.1.113883.5.110 (RoleClass) = ASSIGNEDcode1..1SHALL118302.16.840.1.113883.6.96 (SNOMED CT) = 158965000entryRelationship0..1MAY11831observation1..1SHALL11832entryRelationship0..1MAY11833observation1..1SHALL11834participant1..1SHALL11837@typeCode1..1SHALL118382.16.840.1.113883.5.90 (HL7ParticipationType) = AUTparticipantRole1..1SHALL11839@classCode1..1SHALL120972.16.840.1.113883.5.110 (RoleClass) = ASSIGNEDcode1..1SHALL121032.16.840.1.113883.6.96 (SNOMED CT) = 158965000SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:11816).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:11817).SHALL contain exactly one [1..1] templateId (CONF:11818) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.4" (CONF:11819).SHALL contain at least one [1..*] id (CONF:11821).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:11822).SHALL contain exactly one [1..1] effectiveTime (CONF:11823).SHALL contain exactly one [1..1] participant (CONF:11827) such that itSHALL contain exactly one [1..1] @typeCode="IRCP" information recipient (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:11828).SHALL contain exactly one [1..1] participantRole (CONF:11829).This participantRole SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:12096).This participantRole SHALL contain exactly one [1..1] code="158965000" Medical Practitioner (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:11830).SHALL contain exactly one [1..1] participant (CONF:11837) such that itSHALL contain exactly one [1..1] @typeCode="AUT" author (originator) (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:11838).SHALL contain exactly one [1..1] participantRole (CONF:11839).This participantRole SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:12097).This participantRole SHALL contain exactly one [1..1] code="158965000" Medical Practitioner (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:12103).MAY contain zero or one [0..1] entryRelationship (CONF:11831) such that itSHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11832).MAY contain zero or one [0..1] entryRelationship (CONF:11833) such that itSHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11834).Handoff Communication (NEW)[act: templateId 2.16.840.1.113883.10.20.22.4.141 (open)]SEQ Table \* ARABIC274: Handoff Communication (NEW) ContextsContained By:Contains:Plan of Treatment Section (V2) (optional)This template represents whether hand off communication between providers of care. SEQ Table \* ARABIC275: Handoff Communication (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.141']@classCode1..1SHALL308322.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL308332.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL30834@root1..1SHALL308352.16.840.1.113883.10.20.22.4.141code1..1SHALL30836@code1..1SHALL30837432138007@codeSystem1..1SHALL308382.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96Conforms to Communication from Provider to Provider template (2.16.840.1.113883.10.20.24.3.4).SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:30832).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:30833).SHALL contain exactly one [1..1] templateId (CONF:30834) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.141" (CONF:30835).SHALL contain exactly one [1..1] code (CONF:30836).This code SHALL contain exactly one [1..1] @code="432138007" handoff communication (procedure) (CONF:30837).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:30838).Figure SEQ Table \* ARABIC35: Sample<entry> <act moodCode="EVN" classCode="ACT">  <templateId root="2.16.840.1.113883.10.20.22.4.141" />  <templateId root="2.16.840.1.113883.10.20.24.3.4" /> <id root="F3D6FD73-B2C0-4274-BFD2-A485957734DB" /> <code code="308481009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Referral to orthopedic surgeon (procedure)" /> <text>Communication, From provider to provider: Referral to orthopedic surgeon</text> <statusCode code="completed" /> <effectiveTime value="20130712" /> <participant typeCode="IRCP"> <participantRole classCode="ASSIGNED"> <code code="158965000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Medical Practitioner" /> <addr> <streetAddressLine>1006 Health Drive</streetAddressLine> <city>Ann Arbor</city> <state>MI</state> <postalCode>97867</postalCode> <country>US</country> </addr>  <telecom value="tel:(995)555-1006" use="WP" /> <playingEntity> <name> <prefix>Dr.</prefix> <family>James</family> <given>Case</given> </name> </playingEntity> </participantRole> </participant> <participant typeCode="AUT"> <participantRole classCode="ASSIGNED"> <code code="158965000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Medical Practitioner" /> <addr> <streetAddressLine>1007 Health Drive</streetAddressLine> <city>Ann Arbor</city> <state>MI</state> <postalCode>97867</postalCode> <country>US</country> </addr>  <telecom value="tel:(995)555-1007" use="WP" /> <playingEntity> <name> <prefix>Dr.</prefix> <family>Seven</family> <given>Case</given> </name> </playingEntity> </participantRole> </participant> </act></entry>Coverage Activity (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.60.2 (open)]SEQ Table \* ARABIC276: Coverage Activity (V2) ContextsContained By:Contains:Payers Section (V2) (optional)Policy Activity (V2)A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources. A Coverage Activity contains one or more policy activities, each of which contains zero or more authorization activities. The Coverage Activity id is the Id from the patient's insurance card.??The sequenceNumber/@value shows the policy order of preference.SEQ Table \* ARABIC277: Coverage Activity (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.60.2']@classCode1..1SHALL88722.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL88732.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL8897@root1..1SHALL104922.16.840.1.113883.10.20.22.4.60.2id1..*SHALL8874code1..1SHALL8876@code1..1SHALL191602.16.840.1.113883.6.1 (LOINC) = 48768-6statusCode1..1SHALL8875@code1..1SHALL190942.16.840.1.113883.5.14 (ActStatus) = completedentryRelationship1..*SHALL8878@typeCode1..1SHALL88792.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPsequenceNumber0..1MAY17174@value1..1SHALL17175act1..1SHALL15528SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8872).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8873).SHALL contain exactly one [1..1] templateId (CONF:8897) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.60.2" (CONF:10492).SHALL contain at least one [1..*] id (CONF:8874).SHALL contain exactly one [1..1] code (CONF:8876).This code SHALL contain exactly one [1..1] @code="48768-6" Payment sources (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19160).SHALL contain exactly one [1..1] statusCode (CONF:8875).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19094).SHALL contain at least one [1..*] entryRelationship (CONF:8878) such that itSHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8879).MAY contain zero or one [0..1] sequenceNumber (CONF:17174).The sequenceNumber, if present, SHALL contain exactly one [1..1] @value (CONF:17175).SHALL contain exactly one [1..1] Policy Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.61.2) (CONF:15528).Cultural and Religious Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.111 (open)]SEQ Table \* ARABIC278: Cultural and Religious Observation (NEW) ContextsContained By:Contains:Social History Section (V2) (optional)Health Concern Act (NEW) (optional)This template represents a patient’s spiritual, religious, and cultural belief practices, such as a kosher diet or fasting ritual. religiousAffiliationCode in the document header captures only the patient’s religious affiliation.SEQ Table \* ARABIC279: Cultural and Religious Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.111']@classCode1..1SHALL279242.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL279252.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL27926@root1..1SHALL279272.16.840.1.113883.10.20.22.4.111id1..*SHALL27928code1..1SHALL27929@code1..1SHALL27930406198009@codeSystem1..1SHALL279312.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96statusCode1..1SHALL27936@code1..1SHALL279372.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALL28442SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:27924).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:27925).SHALL contain exactly one [1..1] templateId (CONF:27926) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.111" (CONF:27927).SHALL contain at least one [1..*] id (CONF:27928).SHALL contain exactly one [1..1] code (CONF:27929).This code SHALL contain exactly one [1..1] @code="406198009" personal belief pattern (observable entity) (CONF:27930).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:27931).SHALL contain exactly one [1..1] statusCode (CONF:27936).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:27937).SHALL contain exactly one [1..1] value (CONF:28442).Figure SEQ Table \* ARABIC36: Sample<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.111"/> <id root="37f76c51-6411-4e1d-8a37-957fd49d2cef"/> <code code="406198009" codeSystem="2.16.840.1.113883.6.96" displayName="personal belief pattern"/> <statusCode code="completed"/> <effectiveTime> <low value="20130312"/> </effectiveTime> <value xsi:type="ST">Does not accept blood tranfusions, or donates,or stores blood for transfusion.</value> </observation></entry>Deceased Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.79.2 (open)]SEQ Table \* ARABIC280: Deceased Observation (V2) ContextsContained By:Contains:Problem Observation (V2)This template represents the observation that a patient has died. It also represents the cause of death, indicated by an entryRelationship type of ‘CAUS’. This template allows for more specific representation of data than is available with the use of dischargeDispositionCode.SEQ Table \* ARABIC281: Deceased Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.79.2']@classCode1..1SHALL148512.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL148522.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14871@root1..1SHALL148722.16.840.1.113883.10.20.22.4.79.2id1..*SHALL14873code1..1SHALL14853@code1..1SHALL191352.16.840.1.113883.5.4 (ActCode) = ASSERTIONstatusCode1..1SHALL14854@code1..1SHALL190952.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL14855low1..1SHALL14874value1..1SHALLCD14857@code1..1SHALL151422.16.840.1.113883.6.96 (SNOMED CT) = 419099009entryRelationship0..1SHOULD14868@typeCode1..1SHALL148752.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUSobservation1..1SHALL14870SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14851).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14852).SHALL contain exactly one [1..1] templateId (CONF:14871) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.79.2" (CONF:14872).SHALL contain at least one [1..*] id (CONF:14873).SHALL contain exactly one [1..1] code (CONF:14853).This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:19135).SHALL contain exactly one [1..1] statusCode (CONF:14854).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19095).SHALL contain exactly one [1..1] effectiveTime (CONF:14855).This effectiveTime SHALL contain exactly one [1..1] low (CONF:14874).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:14857).This value SHALL contain exactly one [1..1] @code="419099009" Dead (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:15142).SHOULD contain zero or one [0..1] entryRelationship (CONF:14868) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" Is etiology for (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14875).SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:14870).Diet (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.138 (open)]SEQ Table \* ARABIC282: Diet (NEW) ContextsContained By:Contains:Nutritional Status Observation (NEW) (required)Health Concern Act (NEW) (optional)The Diet template represents the patient's nutrition habits including intake, diet requirements or diet followed.SEQ Table \* ARABIC283: Diet (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.138']@classCode1..1SHALL303242.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL303252.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL30326@root1..1SHALL303272.16.840.1.113883.10.20.22.4.138id1..*SHALL30328code1..1SHALL303292.16.840.1.113883.1.11.20.2.8 (Nutrition Assessment)statusCode1..1SHALL30332@code1..1SHALL303332.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALL30334SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:30324).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:30325).SHALL contain exactly one [1..1] templateId (CONF:30326) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.138" (CONF:30327).SHALL contain at least one [1..*] id (CONF:30328).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Nutrition Assessment 2.16.840.1.113883.1.11.20.2.8 DYNAMIC (CONF:30329).SHALL contain exactly one [1..1] statusCode (CONF:30332).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:30333).SHALL contain exactly one [1..1] value (CONF:30334).SEQ Table \* ARABIC284: Nutrition AssessmentValue Set: Nutrition Assessment 2.16.840.1.113883.1.11.20.2.8A value set of SNOMED-CT observable entity codes for diet.Valueset Source: SystemPrint Name364395008SNOMED CTdietary intake (observable)364394007SNOMED CTdietary requirements (observable)230125005SNOMED CTdiet followed (observable)Figure SEQ Table \* ARABIC37: Sample <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.138"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/> <code xsi:type="CD" code="230125005" displayName="diet followed" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <statusCode code="completed"/> <effectiveTime value="20130512"/> <value xsi:type="CD" code="386619000" displayName="low sodium diet (finding)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </value> </observation> Discharge Medication (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.35.2 (open)]SEQ Table \* ARABIC285: Discharge Medication (V2) ContextsContained By:Contains:Hospital Discharge Medications Section (entries optional) (V2) (optional)Hospital Discharge Medications Section (entries required) (V2) (required)Medication Activity (V2)The Discharge Medications entry codes medications that the patient is intended to take (or stop) after discharge.SEQ Table \* ARABIC286: Discharge Medication (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.35.2']@classCode1..1SHALL76892.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL76902.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16760@root1..1SHALL167612.16.840.1.113883.10.20.22.4.35.2code1..1SHALL7691@code1..1SHALL191612.16.840.1.113883.6.1 (LOINC) = 10183-2entryRelationship1..*SHALL7692@typeCode1..1SHALL76932.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJsubstanceAdministration1..1SHALL15525SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7689).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7690).SHALL contain exactly one [1..1] templateId (CONF:16760) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.35.2" (CONF:16761).SHALL contain exactly one [1..1] code (CONF:7691).This code SHALL contain exactly one [1..1] @code="10183-2" Discharge medication (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19161).SHALL contain at least one [1..*] entryRelationship (CONF:7692) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7693).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:15525).Figure SEQ Table \* ARABIC38: Sample<act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.35.2" /> <code code="10183-2" /> <entryRelationship typeCode="SUBJ"> <substanceAdministration classCode="SBADM" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.16.2" /> ... </substanceAdministration> </entryRelationship></act>Drug Vehicle[participantRole: templateId 2.16.840.1.113883.10.20.22.4.24 (open)]SEQ Table \* ARABIC287: Drug Vehicle ContextsContained By:Contains:Medication Activity (V2) (optional)Immunization Activity (V2) (optional)This template represents the vehicle (e.g. saline, dextrose) for administering a medication.SEQ Table \* ARABIC288: Drug Vehicle Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueparticipantRole[templateId/@root = '2.16.840.1.113883.10.20.22.4.24']@classCode1..1SHALL74902.16.840.1.113883.5.110 (RoleClass) = MANUplayingEntity1..1SHALL7492code1..1SHALL7493name0..1MAY7494templateId1..1SHALL7495@root1..1SHALL104932.16.840.1.113883.10.20.22.4.24code1..1SHALL19137@code1..1SHALL191382.16.840.1.113883.6.96 (SNOMED CT) = 412307009SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:7490).SHALL contain exactly one [1..1] templateId (CONF:7495) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.24" (CONF:10493).SHALL contain exactly one [1..1] code (CONF:19137).This code SHALL contain exactly one [1..1] @code="412307009" Drug Vehicle (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:19138).SHALL contain exactly one [1..1] playingEntity (CONF:7492).This playingEntity/code is used to supply a coded term for the drug vehicle.This playingEntity SHALL contain exactly one [1..1] code (CONF:7493).This playingEntity MAY contain zero or one [0..1] name (CONF:7494).This playingEntity/name MAY be used for the vehicle name in text, such as Normal Saline (CONF:10087).Encounter Activity (V2)[encounter: templateId 2.16.840.1.113883.10.20.22.4.49.2 (open)]SEQ Table \* ARABIC289: Encounter Activity (V2) ContextsContained By:Contains:Encounters Section (entries optional) (V2) (optional)Encounters Section (entries required) (V2) (required)Intervention Act (NEW) (optional)Encounter Diagnosis (V2)Indication (V2)Service Delivery LocationThis clinical statement describes an interaction between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.SEQ Table \* ARABIC290: Encounter Activity (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueencounter[templateId/@root = '2.16.840.1.113883.10.20.22.4.49.2']@classCode1..1SHALL87102.16.840.1.113883.5.6 (HL7ActClass) = ENC@moodCode1..1SHALL87112.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL8712@root1..1SHALL263532.16.840.1.113883.10.20.22.4.49.2id1..*SHALL8713code0..1SHOULD87142.16.840.1.113883.3.88.12.80.32 (EncounterTypeCode)originalText0..1SHOULD8719reference0..1SHOULD15970@value0..1SHOULD15971reference/@value0..1SHOULD8720effectiveTime1..1SHALL8715performer0..*MAY8725assignedEntity1..1SHALL8726code0..1MAY8727participant0..*MAY8738@typeCode1..1SHALL87402.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCparticipantRole1..1SHALL14903entryRelationship0..*MAY8722@typeCode1..1SHALL87232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL14899entryRelationship0..*MAY15492act1..1SHALL15973SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8710).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8711).SHALL contain exactly one [1..1] templateId (CONF:8712) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.49.2" (CONF:26353).SHALL contain at least one [1..*] id (CONF:8713).SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32 DYNAMIC (CONF:8714).The code, if present, SHOULD contain zero or one [0..1] originalText (CONF:8719).The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:15970).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15971).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15972).The originalText, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:8720).SHALL contain exactly one [1..1] effectiveTime (CONF:8715).MAY contain zero or more [0..*] performer (CONF:8725).The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:8726).This assignedEntity MAY contain zero or one [0..1] code (CONF:8727).MAY contain zero or more [0..*] participant (CONF:8738) such that itSHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8740).SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:14903).MAY contain zero or more [0..*] entryRelationship (CONF:8722) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8723).SHALL contain exactly one [1..1] Indication (V2) (templateId:2.16.840.1.113883.10.20.22.4.19.2) (CONF:14899).MAY contain zero or more [0..*] entryRelationship (CONF:15492) such that itSHALL contain exactly one [1..1] Encounter Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.80.2) (CONF:15973).MAY contain zero or one 0..1] sdtc:dischargeDispositionCode, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status DYNAMIC or, if access to NUBC is unavailable, from CodeSystem 2.16.840.1.113883.12.112 HL7 Discharge Disposition (CONF:9929).SEQ Table \* ARABIC291: EncounterTypeCodeValue Set: EncounterTypeCode 2.16.840.1.113883.3.88.12.80.32HITSP C80 Encounter Type Value SetCodeCode SystemPrint NameEncounter Diagnosis (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.80.2 (open)]SEQ Table \* ARABIC292: Encounter Diagnosis (V2) ContextsContained By:Contains:Encounter Activity (V2) (optional)Health Concern Act (NEW) (optional)Problem Observation (V2)This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital Discharge Diagnosis must be used. This entry requires at least one Problem Observation entry.SEQ Table \* ARABIC293: Encounter Diagnosis (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.80.2']@classCode1..1SHALL148892.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL148902.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14895@root1..1SHALL148962.16.840.1.113883.10.20.22.4.80.2code1..1SHALL19182@code1..1SHALL191832.16.840.1.113883.6.1 (LOINC) = 29308-4entryRelationship1..*SHALL14892@typeCode1..1SHALL148932.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL14898SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14889).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14890).SHALL contain exactly one [1..1] templateId (CONF:14895) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.80.2" (CONF:14896).SHALL contain exactly one [1..1] code (CONF:19182).This code SHALL contain exactly one [1..1] @code="29308-4" Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19183).SHALL contain at least one [1..*] entryRelationship (CONF:14892) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14893).SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:14898).Encounter Plan (V2)[encounter: templateId 2.16.840.1.113883.10.20.22.4.40.2 (open)]SEQ Table \* ARABIC294: Encounter Plan (V2) ContextsContained By:Contains:Plan of Treatment Section (V2) (optional)Goal Observation (NEW) (optional)Intervention Act (NEW) (optional)Patient Priority Preference (NEW)Provider Priority Preference (NEW)TThe Plan Activity Encounter represents an intent or request for an interaction between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. Such encounters may include visits, appointments, and non-face-to-face interactions. The practitioner who has primary responsibility for assessing and treating the patient at a given contact is represented by the performer. The participant would represent a support person or caregiver who participates in the patient's care. The priority of the activity encounter is communicated through Patient Priority Preference and Provider Priority Preference. The effective time indicates the time when this is intended to be fulfilled.SEQ Table \* ARABIC295: Encounter Plan (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueencounter[templateId/@root = '2.16.840.1.113883.10.20.22.4.40.2']@classCode1..1SHALL85642.16.840.1.113883.5.6 (HL7ActClass) = ENC@moodCode1..1SHALL85652.16.840.1.113883.11.20.9.23 (Plan of Care moodCode (Act/Encounter/Procedure))templateId1..1SHALL30437@root1..1SHALL304382.16.840.1.113883.10.20.22.4.40.2id1..*SHALL8567statusCode1..1SHALL30439effectiveTime1..1SHALL30440performer0..*MAY30442participant0..*MAY30443code1..1SHALL31032entryRelationship0..*MAY31033@typeCode1..1SHALL310342.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31035entryRelationship0..*MAY31036@typeCode1..1SHALL310372.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31038SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8564).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Plan of Care moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:8565).SHALL contain exactly one [1..1] templateId (CONF:30437) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.40.2" (CONF:30438).SHALL contain at least one [1..*] id (CONF:8567).Records the type of encounter.SHALL contain exactly one [1..1] code (CONF:31032).SHALL contain exactly one [1..1] statusCode (CONF:30439).SHALL contain exactly one [1..1] effectiveTime (CONF:30440).Performers represent clinicians who are responsible for assessing and treating the patient.MAY contain zero or more [0..*] performer (CONF:30442).Participants represent those in supporting roles such as caregiver, who participate in the patient's care.MAY contain zero or more [0..*] participant (CONF:30443).This entryRelationship represents the priority that a patient places on the encounter.MAY contain zero or more [0..*] entryRelationship (CONF:31033) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31034).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31035).This entryRelationship represents the priority that a provider places on the encounter.MAY contain zero or more [0..*] entryRelationship (CONF:31036) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31037).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31038).SEQ Table \* ARABIC296: Plan of Care moodCode (Act/Encounter/Procedure)Value Set: Plan of Care moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23CodeCode SystemPrint NameINTActMoodIntentARQActMoodAppointment RequestPRMSActMoodPromisePRPActMoodProposalRQOActMoodRequestFigure SEQ Table \* ARABIC39: Sample<entry> <encounter moodCode="INT" classCode="ENC"> <templateId root="2.16.840.1.113883.10.20.22.4.40.2" />  <id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d" /> <code code="425604002" displayName="case management follow up (procedure)" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"> </code> <statusCode code="new" /> <effectiveTime value="20130615" /> <performer> <assignedEntity> <id root="2a620155-9d11-439e-92a3-5d9815ff4de8" /> <code code="59058001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="General Physician" /> </assignedEntity> </performer> <participant typeCode="IRCP"> <participantRole classCode="ASSIGNED"> <code code="158965000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Medical Practitioner" /> <addr> <streetAddressLine>1006 Health Drive</streetAddressLine> <city>Ann Arbor</city> <state>MI</state> <postalCode>97867</postalCode> <country>US</country> </addr>  <telecom value="tel:(995)555-1006" use="WP" /> <playingEntity> <name> <prefix>Dr.</prefix> <family>James</family> <given>Case</given> </name> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.142" /> ... </observation> </entryRelationship> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.143" /> ... </observation> </entryRelationship> </encounter></entry>Entry Author[author: templateId entry_author (open)]SEQ Table \* ARABIC297: Entry Author ContextsContained By:Contains:SEQ Table \* ARABIC298: Entry Author Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueauthor[templateId/@root = 'entry_author']@typeCode1..1SHALL31454AUTtemplateId1..1SHALL31455time1..1SHALL31456assignedAuthor1..1SHALL31457id1..1SHALL31458assignedPerson0..1MAY31459name0..1MAY31460representedOrganization0..1MAY31461@classCode1..1SHALL31462ORGid0..*MAY31463name0..*MAY31464telecom0..*MAY31465addr0..*MAY31466SHALL contain exactly one [1..1] @typeCode="AUT" (CONF:31454).SHALL contain exactly one [1..1] templateId (CONF:31455).SHALL contain exactly one [1..1] time (CONF:31456).SHALL contain exactly one [1..1] assignedAuthor (CONF:31457).This id may be set equal to (a pointer to) an id on a participant elsewhere in the document (header or entries) or a new author participant can be described here. If the id is pointing to a participant already described elsewhere in the document, assignedAuthor/id is sufficient to identify this participant and none of the remaining details of assignedAuthor are required to be set.This assignedAuthor SHALL contain exactly one [1..1] id (CONF:31458).This assignedAuthor MAY contain zero or one [0..1] assignedPerson (CONF:31459).The assignedPerson, if present, MAY contain zero or one [0..1] name (CONF:31460).This assignedAuthor MAY contain zero or one [0..1] representedOrganization (CONF:31461).The representedOrganization, if present, SHALL contain exactly one [1..1] @classCode="ORG" (CONF:31462).The representedOrganization, if present, MAY contain zero or more [0..*] id (CONF:31463).The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:31464).The representedOrganization, if present, MAY contain zero or more [0..*] telecom (CONF:31465).The representedOrganization, if present, MAY contain zero or more [0..*] addr (CONF:31466).Figure SEQ Table \* ARABIC40: Full author example<author> <time value="20130801" /> <assignedAuthor> <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" /> <code code="163W00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Registered nurse" /> <assignedPerson> <name> <given>Nurse</given> <family>Nightingale</family> <suffix>RN</suffix> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Good Health Hospital</name> </representedOrganization> </assignedAuthor></author>Figure SEQ Table \* ARABIC41: Author pointer example<author> <time value="20130801" /> <assignedAuthor>  <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" /> </assignedAuthor></author>Estimated Date of Delivery[observation: templateId 2.16.840.1.113883.10.20.15.3.1 (closed)]SEQ Table \* ARABIC299: Estimated Date of Delivery ContextsContained By:Contains:Pregnancy Observation (optional)This clinical statement represents the anticipated date when a woman will give birth.SEQ Table \* ARABIC300: Estimated Date of Delivery Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.15.3.1']@classCode1..1SHALL4442.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL4452.16.840.1.113883.5.1001 (ActMood) = EVNstatusCode1..1SHALL448@code1..1SHALL190962.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLTS450templateId1..1SHALL16762@root1..1SHALL167632.16.840.1.113883.10.20.15.3.1code1..1SHALL19139@code1..1SHALL191402.16.840.1.113883.6.1 (LOINC) = 11778-8SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:444).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:445).SHALL contain exactly one [1..1] templateId (CONF:16762) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.1" (CONF:16763).SHALL contain exactly one [1..1] code (CONF:19139).This code SHALL contain exactly one [1..1] @code="11778-8" Estimated date of delivery (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19140).SHALL contain exactly one [1..1] statusCode (CONF:448).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19096).SHALL contain exactly one [1..1] value with @xsi:type="TS" (CONF:450).Family History Death Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.47 (open)]SEQ Table \* ARABIC301: Family History Death Observation ContextsContained By:Contains:Family History Observation (optional)This clinical statement records whether the family member is deceased.SEQ Table \* ARABIC302: Family History Death Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.47']@classCode1..1SHALL86212.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL86222.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL8623@root1..1SHALL104952.16.840.1.113883.10.20.22.4.47statusCode1..1SHALL8625@code1..1SHALL190972.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD8626@code1..1SHALL264702.16.840.1.113883.6.96 (SNOMED CT) = 419099009code1..1SHALL19141@code1..1SHALL191422.16.840.1.113883.5.4 (ActCode) = ASSERTIONSHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8621).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8622).SHALL contain exactly one [1..1] templateId (CONF:8623) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.47" (CONF:10495).SHALL contain exactly one [1..1] code (CONF:19141).This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:19142).SHALL contain exactly one [1..1] statusCode (CONF:8625).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19097).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:8626).This value SHALL contain exactly one [1..1] @code="419099009" Dead (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:26470).Family History Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.46 (open)]SEQ Table \* ARABIC303: Family History Observation ContextsContained By:Contains:Family History Organizer (required)Age ObservationFamily History Death ObservationFamily History Observations related to a particular family member are contained within a Family History Organizer. The effectiveTime in the Family History Observation is the biologically or clinically relevant time of the observation. The biologically or clinically relevant time is the time at which the observation holds (is effective) for the family member (the subject of the observation).SEQ Table \* ARABIC304: Family History Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.46']entryRelationship0..1MAY8675@typeCode1..1SHALL86762.16.840.1.113883.5.90 (HL7ParticipationType) = SUBJ@inversionInd1..1SHALL8677trueobservation1..1SHALL15526entryRelationship0..1MAY8678@typeCode1..1SHALL86792.16.840.1.113883.5.90 (HL7ParticipationType) = CAUSobservation1..1SHALL15527@classCode1..1SHALL85862.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL85872.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALL85892.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)statusCode1..1SHALL8590@code1..1SHALL190982.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD85912.16.840.1.113883.3.88.12.3221.7.4 (Problem Value Set)id1..*SHALL8592effectiveTime0..1SHOULD8593templateId1..1SHALL8599@root1..1SHALL104962.16.840.1.113883.10.20.22.4.46SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8586).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8587).SHALL contain exactly one [1..1] templateId (CONF:8599) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.46" (CONF:10496).SHALL contain at least one [1..*] id (CONF:8592).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:8589).SHALL contain exactly one [1..1] statusCode (CONF:8590).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19098).SHOULD contain zero or one [0..1] effectiveTime (CONF:8593).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:8591).MAY contain zero or one [0..1] entryRelationship (CONF:8675) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Subject (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8676).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:8677).SHALL contain exactly one [1..1] Age Observation (templateId:2.16.840.1.113883.10.20.22.4.31) (CONF:15526).MAY contain zero or one [0..1] entryRelationship (CONF:8678) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" Causal or Contributory (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8679).SHALL contain exactly one [1..1] Family History Death Observation (templateId:2.16.840.1.113883.10.20.22.4.47) (CONF:15527).SEQ Table \* ARABIC305: Problem TypeValue Set: Problem Type 2.16.840.1.113883.3.88.12.3221.7.2CodeCode SystemPrint Name404684003SNOMED CTFinding409586006SNOMED CTComplaint282291009SNOMED CTDiagnosis64572001SNOMED CTCondition248536006SNOMED CTFinding of functional performance and activity418799008SNOMED CTSymptom55607006SNOMED CTProblem373930000SNOMED CTCognitive function findingSEQ Table \* ARABIC306: Problem Value SetValue Set: Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4CodeCode SystemPrint Name50992006SNOMED CT22q partial trisomy syndrome (disorder)237931009SNOMED CT2-Ketoadipic acidemia (disorder)54470008SNOMED CT3 beta-Hydroxysteroid dehydrogenase deficiency (disorder)237950009SNOMED CT3-Methylglutaconic aciduria (disorder)296646009SNOMED CT4-quinolones overdose (disorder)41797007SNOMED CT5 10-Methylenetetrahydrofolate reductase deficiency (disorder)413380004SNOMED CTA pattern strabismus (disorder)425879009SNOMED CTAA amyloid nephropathy (disorder)274945004SNOMED CTAA amyloidosis (disorder)75100008SNOMED CTAbdominal abscess (disorder)43894001SNOMED CTAbdominal actinomycosis (disorder)233985008SNOMED CTAbdominal aortic aneurysm (disorder)253679008SNOMED CTAbdominal aortic coarctation (disorder)116289008SNOMED CTAbdominal bloating (finding)9991008SNOMED CTAbdominal colic (finding)271860004SNOMED CTAbdominal mass (finding)75879005SNOMED CTAbdominal migraine (disorder)21522001SNOMED CTAbdominal pain (finding)82661006SNOMED CTAbdominal pregnancy (disorder)72300008SNOMED CTAbdominal rigidity (finding)...Family History Organizer[organizer: templateId 2.16.840.1.113883.10.20.22.4.45 (open)]SEQ Table \* ARABIC307: Family History Organizer ContextsContained By:Contains:Family History Section (optional)Health Concern Act (NEW) (optional)Family History ObservationThe Family History Organizer associates a set of observations with a family member. For example, the Family History Organizer can group a set of observations about the patient’s father.SEQ Table \* ARABIC308: Family History Organizer Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.45']component1..*SHALL8607observation1..1SHALL16888@classCode1..1SHALL86002.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALL86012.16.840.1.113883.5.1001 (ActMood) = EVNstatusCode1..1SHALL8602@code1..1SHALL190992.16.840.1.113883.5.14 (ActStatus) = completedtemplateId1..1SHALL8604@root1..1SHALL104972.16.840.1.113883.10.20.22.4.45subject1..1SHALL8609relatedSubject1..1SHALL15244@classCode1..1SHALL152452.16.840.1.113883.5.41 (EntityClass) = PRScode1..1SHALL15246@code1..1SHALL152472.16.840.1.113883.1.11.19579 (Family Member Value Set)subject0..1SHOULD15248administrativeGenderCode1..1SHALL15974@code1..1SHALL159752.16.840.1.113883.1.11.1 (Administrative Gender (HL7 V3))birthTime0..1SHOULD15976SHALL contain exactly one [1..1] @classCode="CLUSTER" Cluster (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8600).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8601).SHALL contain exactly one [1..1] templateId (CONF:8604) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.45" (CONF:10497).SHALL contain exactly one [1..1] statusCode (CONF:8602).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19099).SHALL contain exactly one [1..1] subject (CONF:8609).This subject SHALL contain exactly one [1..1] relatedSubject (CONF:15244).This relatedSubject SHALL contain exactly one [1..1] @classCode="PRS" Person (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) (CONF:15245).This relatedSubject SHALL contain exactly one [1..1] code (CONF:15246).This code SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Family Member Value Set 2.16.840.1.113883.1.11.19579 DYNAMIC (CONF:15247).This relatedSubject SHOULD contain zero or one [0..1] subject (CONF:15248).The subject, if present, SHALL contain exactly one [1..1] administrativeGenderCode (CONF:15974).This administrativeGenderCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 STATIC (CONF:15975).The subject, if present, SHOULD contain zero or one [0..1] birthTime (CONF:15976).The subject SHOULD contain zero or more 0..] sdtc:id. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the id element (CONF:15249).The subject MAY contain zero or one sdtc:deceasedInd. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedInd element (CONF:15981).The subject MAY contain zero or one sdtc:deceasedTime. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedTime element (CONF:15982).The age of a relative at the time of a family history observation SHOULD be inferred by comparing RelatedSubject/subject/birthTime with Observation/effectiveTime (CONF:15983).SHALL contain at least one [1..*] component (CONF:8607).Such components SHALL contain exactly one [1..1] Family History Observation (templateId:2.16.840.1.113883.10.20.22.4.46) (CONF:16888).SEQ Table \* ARABIC309: Family Member Value SetValue Set: Family Member Value Set 2.16.840.1.113883.1.11.19579Family Relationships record the familial relationship of a person to another person. This value set is to be used when it is necessary to record family relationships (e.g., next of kin, or blood relations). This is a subset of the value set used for personal relationshipsCodeCode SystemPrint NameADOPTRoleCodeadopted childAUNTRoleCodeauntCHILDRoleCodeChildCHLDINLAWRoleCodechild in-lawCOUSNRoleCodecousinDOMPARTRoleCodedomestic partnerFAMMEMBRoleCodeFamily MemberCHLDFOSTRoleCodefoster childGRNDCHILDRoleCodegrandchildGRPRNRoleCodeGrandparentGPARNTRoleCodegrandparentGGRPRNRoleCodegreat grandparentHSIBRoleCodehalf-siblingMAUNTRoleCodeMaternalAuntMCOUSNRoleCodeMaternalCousinMGRPRNRoleCodeMaternalGrandparentMGGRPRNRoleCodeMaternalGreatgrandparentMUNCLERoleCodeMaternalUncleNCHILDRoleCodenatural childNPRNRoleCodenatural parent...SEQ Table \* ARABIC310: Administrative Gender (HL7 V3)Value Set: Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1Administrative Gender based upon HL7 V3 vocabulary. This value set contains only male, female and undifferentiated concepts.CodeCode SystemPrint NameFAdministrativeGenderFemaleMAdministrativeGenderMaleUNAdministrativeGenderUndifferentiatedFunctional Status Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.67.2 (open)]SEQ Table \* ARABIC311: Functional Status Observation (V2) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Functional Status Section (V2) (optional)Functional Status Organizer (V2) (required)Assessment Scale ObservationAuthor Participant (NEW)Caregiver CharacteristicsNon-Medicinal Supply Activity (V2)This template represents the patient's physical function (e.g. mobility status, activities of daily living, self-care status) and problems that limit function (dyspnea, dysphagia). The template may include assessment scale observations, identify supporting caregivers and provide information about non-medicinal supplies. This template is used to represent physical or developmental function of all patient populations and is not limited to the long-term care population.SEQ Table \* ARABIC312: Functional Status Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.67.2']entryRelationship0..1MAY14465@typeCode1..1SHALL14598COMPobservation1..1SHALL14466entryRelationship0..1MAY13895@typeCode1..1SHALL14597REFRobservation1..1SHALL13897@classCode1..1SHALL139052.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL139062.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL13889@root1..1SHALL138902.16.840.1.113883.10.20.22.4.67.2id1..*SHALL13907code1..1SHALL13908@code1..1SHALL31522364644000@codeSystem1..1SHALL315232.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96text0..1SHOULD13926statusCode1..1SHALL13929@code1..1SHALL191012.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL13930value1..1SHALL13932author0..*SHOULD13936entryRelationship0..1MAY13892@typeCode1..1SHALL14596REFRsupply1..1SHALL14218referenceRange0..*MAY13937SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:13905).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:13906).SHALL contain exactly one [1..1] templateId (CONF:13889) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.67.2" (CONF:13890).SHALL contain at least one [1..*] id (CONF:13907).SHALL contain exactly one [1..1] code (CONF:13908).This code SHALL contain exactly one [1..1] @code="364644000" functional observable (CONF:31522).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31523).SHOULD contain zero or one [0..1] text (CONF:13926).SHALL contain exactly one [1..1] statusCode (CONF:13929).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19101).SHALL contain exactly one [1..1] effectiveTime (CONF:13930).SHALL contain exactly one [1..1] value (CONF:13932).If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:14234).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:13936).MAY contain zero or one [0..1] entryRelationship (CONF:13892) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CONF:14596).SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.50.2) (CONF:14218).MAY contain zero or one [0..1] entryRelationship (CONF:13895) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CONF:14597).SHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:13897).MAY contain zero or one [0..1] entryRelationship (CONF:14465) such that itSHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:14598).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14466).referenceRange could be used to represent normal or expected capability for the function being evaluated.MAY contain zero or more [0..*] referenceRange (CONF:13937).Figure SEQ Table \* ARABIC42: Functional Status Observation<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.67.2"/> <id root="ce7cfb78-bd16-467e-8bcf-859a3034108e"/> <code code="364644000" displayName="functional observable" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <text> <reference value="#FUNC1"/> </text> <statusCode code="completed"/> <effectiveTime value="200130311"/> <value xsi:type="CD" code="129035000" displayName="independent with dressing" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></entry>Functional Status Organizer (V2)[organizer: templateId 2.16.840.1.113883.10.20.22.4.66.2 (open)]SEQ Table \* ARABIC313: Functional Status Organizer (V2) ContextsContained By:Contains:Functional Status Section (V2) (optional)Functional Status Observation (V2)Self-Care Activities (ADL and IADL) (NEW)This template groups related functional status observations into categories (e.g ambulation, self-care).SEQ Table \* ARABIC314: Functional Status Organizer (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.66.2']component1..*SHALL14359observation1..1SHALL14368@classCode1..1SHALL143552.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALL143572.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14361@root1..1SHALL143622.16.840.1.113883.10.20.22.4.66.2id1..*SHALL14363code1..1SHALL14364statusCode1..1SHALL14358@code1..1SHALL314342.16.840.1.113883.5.14 (ActStatus) = completedcomponent1..*SHALL31432observation1..1SHALL31433SHALL contain exactly one [1..1] @classCode="CLUSTER", which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6) STATIC (CONF:14355).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14357).SHALL contain exactly one [1..1] templateId (CONF:14361) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.66.2" (CONF:14362).SHALL contain at least one [1..*] id (CONF:14363).The code selected should indicate the category that groups the contained functional status evaluation observations (e.g. mobility, self-care, communication).SHALL contain exactly one [1..1] code (CONF:14364).SHOULD be selected from ICF (codeSystem 2.16.840.1.113883.6.254) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96) (CONF:31417).SHALL contain exactly one [1..1] statusCode (CONF:14358).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:31434).SHALL contain at least one [1..*] component (CONF:14359) such that itSHALL contain exactly one [1..1] Functional Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.67.2) (CONF:14368).SHALL contain at least one [1..*] component (CONF:31432) such that itSHALL contain exactly one [1..1] Self-Care Activities (ADL and IADL) (NEW) (templateId:2.16.840.1.113883.10.20.22.4.128) (CONF:31433).Figure SEQ Table \* ARABIC43: Sample <organizer classCode="CLUSTER" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.66.2"/> <id root="a7bc1062-8649-42a0-833d-eed65bd017c9"/> <code code="d5" displayName="Self-Care" codeSystem="2.16.840.1.113883.6.254" codeSystemName="ICF"/> <statusCode code="completed"/> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.67.2"/> ... </component> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.67.2"/> ... </component> <component> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.128"/> ... </component> </organizerFunctional Status Problem Observation (DEPRECATED)[observation: templateId 2.16.840.1.113883.10.20.22.4.68.2 (open)]SEQ Table \* ARABIC315: Functional Status Problem Observation (DEPRECATED) ContextsContained By:Contains:Assessment Scale ObservationCaregiver CharacteristicsNon-Medicinal Supply ActivityUSE OF FUNCTIONAL STATUS PROBLEM OBSERVATION IS NOT RECOMMENDED. FUNCTIONAL STATUS PROBLEM OBSERVATION AND FUNCTIONAL STATUS RESULT OBSERVATION HAVE BEEN MERGED TOGETHER WITHOUT LOSS OF EXPRESSIVITY INTO FUNCTIONAL STATUS OBSERVATION (TEMPLATE ID: 2.16.840.1.113883.10.20.22.4.67.2)SEQ Table \* ARABIC316: Functional Status Problem Observation (DEPRECATED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.68.2']entryRelationship0..*MAY14463@typeCode1..1SHALL145872.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL14464entryRelationship0..*MAY14298@typeCode1..1SHALL145862.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL14318@classCode1..1SHALL142822.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL142832.16.840.1.113883.5.1001 (ActMood) = EVN@negationInd0..1MAY14307templateId1..1SHALL14312@root1..1SHALL143132.16.840.1.113883.10.20.22.4.68id1..*SHALL14284code1..1SHALL14314@code0..1SHOULD143152.16.840.1.113883.6.96 (SNOMED CT) = 248536006text0..1SHOULD14304reference0..1SHOULD15552@value0..1SHOULD15553statusCode1..1SHALL14286@code1..1SHALL191002.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime0..1SHOULD14287low1..1SHALL26456high0..1MAY26457value1..1SHALLCD142912.16.840.1.113883.3.88.12.3221.7.4 (Problem Value Set)@nullFlavor0..1MAY14292methodCode0..1MAY14316entryRelationship0..*MAY14294@typeCode1..1SHALL145842.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL14317SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14282).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14283).Use negationInd="true" to indicate that the problem was not observed.MAY contain zero or one [0..1] @negationInd (CONF:14307).SHALL contain exactly one [1..1] templateId (CONF:14312) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.68" (CONF:14313).SHALL contain at least one [1..*] id (CONF:14284).SHALL contain exactly one [1..1] code (CONF:14314).This code SHOULD contain zero or one [0..1] @code="248536006" finding of functional performance and activity (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:14315).SHOULD contain zero or one [0..1] text (CONF:14304).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15552).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15553).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15554).SHALL contain exactly one [1..1] statusCode (CONF:14286).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19100).SHOULD contain zero or one [0..1] effectiveTime (CONF:14287).The value of effectiveTime/low represents onset date.The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:26456).If the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:26457).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:14291).This value MAY contain zero or one [0..1] @nullFlavor (CONF:14292).If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”.??If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element (CONF:14293).MAY contain zero or one [0..1] methodCode (CONF:14316).MAY contain zero or more [0..*] entryRelationship (CONF:14294) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14584).SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (templateId:2.16.840.1.113883.10.20.22.4.50) (CONF:14317).MAY contain zero or more [0..*] entryRelationship (CONF:14298) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14586).SHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:14318).MAY contain zero or more [0..*] entryRelationship (CONF:14463) such that itSHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14587).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:14464).SEQ Table \* ARABIC317: Problem Value SetValue Set: Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4CodeCode SystemPrint Name50992006SNOMED CT22q partial trisomy syndrome (disorder)237931009SNOMED CT2-Ketoadipic acidemia (disorder)54470008SNOMED CT3 beta-Hydroxysteroid dehydrogenase deficiency (disorder)237950009SNOMED CT3-Methylglutaconic aciduria (disorder)296646009SNOMED CT4-quinolones overdose (disorder)41797007SNOMED CT5 10-Methylenetetrahydrofolate reductase deficiency (disorder)413380004SNOMED CTA pattern strabismus (disorder)425879009SNOMED CTAA amyloid nephropathy (disorder)274945004SNOMED CTAA amyloidosis (disorder)75100008SNOMED CTAbdominal abscess (disorder)43894001SNOMED CTAbdominal actinomycosis (disorder)233985008SNOMED CTAbdominal aortic aneurysm (disorder)253679008SNOMED CTAbdominal aortic coarctation (disorder)116289008SNOMED CTAbdominal bloating (finding)9991008SNOMED CTAbdominal colic (finding)271860004SNOMED CTAbdominal mass (finding)75879005SNOMED CTAbdominal migraine (disorder)21522001SNOMED CTAbdominal pain (finding)82661006SNOMED CTAbdominal pregnancy (disorder)72300008SNOMED CTAbdominal rigidity (finding)...Health Concern Act (NEW)[act: templateId 2.16.840.1.113883.10.20.22.4.132 (open)]SEQ Table \* ARABIC318: Health Concern Act (NEW) ContextsContained By:Contains:Health Concerns Section (NEW) (required)Goal Observation (NEW) (optional)Allergy - Intolerance Observation (V2)Assessment Scale ObservationCaregiver CharacteristicsCharacteristics of Home Environment (NEW)Cognitive Abilities Observation (NEW)Cognitive Status Observation (V2)Cultural and Religious Observation (NEW)Current Smoking Status (V2)Diet (NEW)Encounter Diagnosis (V2)Family History OrganizerFunctional Status Observation (V2)Highest Pressure Ulcer StageHospital Admission Diagnosis (V2)Mental Status Observation (NEW)Number of Pressure Ulcers ObservationNutritional Status Observation (NEW)Patient Priority Preference (NEW)Postprocedure Diagnosis (V2)Pregnancy ObservationPreoperative Diagnosis (V2)Problem Observation (V2)Prognosis ObservationProvider Priority Preference (NEW)Reaction Observation (V2)Result Observation (V2)Result Organizer (V2)Self-Care Activities (ADL and IADL) (NEW)Sensory and Speech Status (NEW)Social History Observation (V2)Substance or Device Allergy - Intolerance Observation (V2)Tobacco Use (V2)Vital Sign Observation (V2)Wound Observation (NEW)This template represents a health concern. It is a wrapper for health concerns derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). Health concerns require intervention(s) to increase the likelihood of achieving the patient’s or providers’ goals of care.Where a Health Concern template contains an entryRelationship to another template, rather than including the full content of the template, the id of the template may be set equal to (a pointer to) an ID on an entry elsewhere in the document.SEQ Table \* ARABIC319: Health Concern Act (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.132']entryRelationship0..*MAY31190@typeCode1..1SHALL311912.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31192entryRelationship0..*MAY31368@typeCode1..1SHALL313692.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31370entryRelationship0..*MAY31374@typeCode1..1SHALL313752.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31376entryRelationship0..*MAY31193@typeCode1..1SHALL311942.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31195entryRelationship0..*MAY31234@typeCode1..1SHALL312682.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31273entryRelationship0..*MAY31233@typeCode1..1SHALL312672.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31271entryRelationship0..*MAY31371@typeCode1..1SHALL313722.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31373entryRelationship0..*MAY31244@typeCode1..1SHALL313002.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31301entryRelationship0..*MAY31245@typeCode1..1SHALL313032.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31304entryRelationship0..*MAY31236@typeCode1..1SHALL312702.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL31277entryRelationship0..*MAY31237@typeCode1..1SHALL312792.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRorganizer1..1SHALL31280entryRelationship0..*MAY31238@typeCode1..1SHALL312822.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31283entryRelationship0..*MAY31239@typeCode1..1SHALL312852.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31286@classCode1..1SHALL307502.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL307512.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL30752@root1..1SHALL307532.16.840.1.113883.10.20.22.4.132id1..1SHALL30754code1..1SHALL30755@code1..1SHALL30756CONC@codeSystem1..1SHALL307572.16.840.1.113883.5.6 (HL7ActClass) = 2.16.840.1.113883.5.6statusCode1..1SHALL30758effectiveTime0..1MAY30759entryRelationship0..*MAY30761@typeCode1..1SHALL307622.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31001entryRelationship0..*MAY31007@typeCode1..1SHALL310082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31186entryRelationship0..*MAY31157@typeCode1..1SHALL311582.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRentryRelationship0..*MAY31160@typeCode1..1SHALL311612.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPentryRelationship0..*MAY31232@typeCode1..1SHALL312642.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31265entryRelationship0..*MAY31235@typeCode1..1SHALL312692.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31275entryRelationship0..*MAY31240@typeCode1..1SHALL312882.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31289entryRelationship0..*MAY31241@typeCode1..1SHALL312912.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL31292entryRelationship0..*MAY31242@typeCode1..1SHALL312942.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31295entryRelationship0..*MAY31243@typeCode1..1SHALL312972.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31298entryRelationship0..*MAY31246@typeCode1..1SHALL313062.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL31307entryRelationship0..*MAY31247@typeCode1..1SHALL313092.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31310entryRelationship0..*MAY31248@typeCode1..1SHALL313122.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL31313entryRelationship0..*MAY31249@typeCode1..1SHALL313152.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31316entryRelationship0..*MAY31250@typeCode1..1SHALL313182.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31319entryRelationship0..*MAY31251@typeCode1..1SHALL313212.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31322entryRelationship0..*MAY31252@typeCode1..1SHALL313242.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31325entryRelationship0..*MAY31253@typeCode1..1SHALL313272.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31328entryRelationship0..*MAY31254typeId0..1MAY313302.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31331entryRelationship0..*MAY31255@typeCode1..1SHALL313332.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31334entryRelationship0..*MAY31256@typeCode1..1SHALL313362.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31337entryRelationship0..*MAY31257@typeCode1..1SHALL313392.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31340entryRelationship0..*MAY31365@typeCode1..1SHALL313662.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SPRTobservation1..1SHALL31367entryRelationship0..*MAY31377@typeCode1..1SHALL313782.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31379entryRelationship0..*MAY31380@typeCode1..1SHALL313812.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRorganizer1..1SHALL31382entryRelationship0..*MAY31442@typeCode1..1SHALL314432.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL31444entryRelationship0..*MAY31445@typeCode1..1SHALL314462.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL31447SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30750).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:30751).SHALL contain exactly one [1..1] templateId (CONF:30752) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.132" (CONF:30753).SHALL contain exactly one [1..1] id (CONF:30754).SHALL contain exactly one [1..1] code (CONF:30755).This code SHALL contain exactly one [1..1] @code="CONC" Concern (CONF:30756).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.6" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30757).SHALL contain exactly one [1..1] statusCode (CONF:30758).MAY contain zero or one [0..1] effectiveTime (CONF:30759).MAY contain zero or more [0..*] entryRelationship (CONF:30761) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30762).SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:31001).MAY contain zero or more [0..*] entryRelationship (CONF:31007) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31008).SHALL contain exactly one [1..1] Allergy - Intolerance Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.7.2) (CONF:31186).This entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern RELATES TO Health Concern).MAY contain zero or more [0..*] entryRelationship (CONF:31157) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31158).SHALL contain exactly one 1..1] Health Concern Act (NEW) (templateId: 2.16.840.1.113883.10.20.22.4.132] (CONF:31159).This entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern).MAY contain zero or more [0..*] entryRelationship (CONF:31160) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31161).SHALL contain exactly one 1..1] Health Concern Act (NEW) (templateId:2.16.840.1.113883.10.20.22.4.132) (CONF:31162).MAY contain zero or more [0..*] entryRelationship (CONF:31190) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31191).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:31192).MAY contain zero or more [0..*] entryRelationship (CONF:31193) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31194).SHALL contain exactly one [1..1] Cognitive Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.74.2) (CONF:31195).MAY contain zero or more [0..*] entryRelationship (CONF:31232) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31264).SHALL contain exactly one [1..1] Self-Care Activities (ADL and IADL) (NEW) (templateId:2.16.840.1.113883.10.20.22.4.128) (CONF:31265).MAY contain zero or more [0..*] entryRelationship (CONF:31233) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31267).SHALL contain exactly one [1..1] Cognitive Abilities Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.126) (CONF:31271).MAY contain zero or more [0..*] entryRelationship (CONF:31234) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31268).SHALL contain exactly one [1..1] Cognitive Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.74.2) (CONF:31273).MAY contain zero or more [0..*] entryRelationship (CONF:31235) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31269).SHALL contain exactly one [1..1] Current Smoking Status (V2) (templateId:2.16.840.1.113883.10.20.22.4.78.2) (CONF:31275).MAY contain zero or more [0..*] entryRelationship (CONF:31236) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31270).SHALL contain exactly one [1..1] Encounter Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.80.2) (CONF:31277).MAY contain zero or more [0..*] entryRelationship (CONF:31237) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers To (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31279).SHALL contain exactly one [1..1] Family History Organizer (templateId:2.16.840.1.113883.10.20.22.4.45) (CONF:31280).MAY contain zero or more [0..*] entryRelationship (CONF:31238) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31282).SHALL contain exactly one [1..1] Functional Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.67.2) (CONF:31283).MAY contain zero or more [0..*] entryRelationship (CONF:31239) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31285).SHALL contain exactly one [1..1] Functional Status Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.67.2) (CONF:31286).MAY contain zero or more [0..*] entryRelationship (CONF:31240) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31288).SHALL contain exactly one [1..1] Highest Pressure Ulcer Stage (templateId:2.16.840.1.113883.10.20.22.4.77) (CONF:31289).MAY contain zero or more [0..*] entryRelationship (CONF:31241) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31291).SHALL contain exactly one [1..1] Hospital Admission Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.34.2) (CONF:31292).MAY contain zero or more [0..*] entryRelationship (CONF:31242) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31294).SHALL contain exactly one [1..1] Mental Status Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.125) (CONF:31295).MAY contain zero or more [0..*] entryRelationship (CONF:31243) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31297).SHALL contain exactly one [1..1] Number of Pressure Ulcers Observation (templateId:2.16.840.1.113883.10.20.22.4.76) (CONF:31298).MAY contain zero or more [0..*] entryRelationship (CONF:31244) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31300).SHALL contain exactly one [1..1] Diet (NEW) (templateId:2.16.840.1.113883.10.20.22.4.138) (CONF:31301).MAY contain zero or more [0..*] entryRelationship (CONF:31245) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31303).SHALL contain exactly one [1..1] Diet (NEW) (templateId:2.16.840.1.113883.10.20.22.4.138) (CONF:31304).MAY contain zero or more [0..*] entryRelationship (CONF:31246) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31306).SHALL contain exactly one [1..1] Postprocedure Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.51.2) (CONF:31307).MAY contain zero or more [0..*] entryRelationship (CONF:31247) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31309).SHALL contain exactly one [1..1] Pregnancy Observation (templateId:2.16.840.1.113883.10.20.15.3.8) (CONF:31310).MAY contain zero or more [0..*] entryRelationship (CONF:31248) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31312).SHALL contain exactly one [1..1] Preoperative Diagnosis (V2) (templateId:2.16.840.1.113883.10.20.22.4.65.2) (CONF:31313).MAY contain zero or more [0..*] entryRelationship (CONF:31249) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31315).SHALL contain exactly one [1..1] Prognosis Observation (templateId:2.16.840.1.113883.10.20.22.4.113) (CONF:31316).MAY contain zero or more [0..*] entryRelationship (CONF:31250) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31318).SHALL contain exactly one [1..1] Reaction Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.9.2) (CONF:31319).MAY contain zero or more [0..*] entryRelationship (CONF:31251) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31321).SHALL contain exactly one [1..1] Result Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.2.2) (CONF:31322).MAY contain zero or more [0..*] entryRelationship (CONF:31252) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31324).SHALL contain exactly one [1..1] Sensory and Speech Status (NEW) (templateId:2.16.840.1.113883.10.20.22.4.127) (CONF:31325).MAY contain zero or more [0..*] entryRelationship (CONF:31253) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31327).SHALL contain exactly one [1..1] Social History Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.38.2) (CONF:31328).MAY contain zero or more [0..*] entryRelationship (CONF:31254) such that itMAY contain zero or one [0..1] typeId="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31330).SHALL contain exactly one [1..1] Substance or Device Allergy - Intolerance Observation (V2) (templateId:2.16.840.1.113883.10.20.24.3.90.2) (CONF:31331).MAY contain zero or more [0..*] entryRelationship (CONF:31255) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31333).SHALL contain exactly one [1..1] Tobacco Use (V2) (templateId:2.16.840.1.113883.10.20.22.4.85.2) (CONF:31334).MAY contain zero or more [0..*] entryRelationship (CONF:31256) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31336).SHALL contain exactly one [1..1] Vital Sign Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.27.2) (CONF:31337).MAY contain zero or more [0..*] entryRelationship (CONF:31257) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31339).SHALL contain exactly one [1..1] Wound Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.114) (CONF:31340).This entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.MAY contain zero or more [0..*] entryRelationship (CONF:31365) such that itSHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31366).SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:31367).MAY contain zero or more [0..*] entryRelationship (CONF:31368) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31369).SHALL contain exactly one [1..1] Caregiver Characteristics (templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:31370).MAY contain zero or more [0..*] entryRelationship (CONF:31371) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31372).SHALL contain exactly one [1..1] Cultural and Religious Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.111) (CONF:31373).MAY contain zero or more [0..*] entryRelationship (CONF:31374) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31375).SHALL contain exactly one [1..1] Characteristics of Home Environment (NEW) (templateId:2.16.840.1.113883.10.20.22.4.109) (CONF:31376).MAY contain zero or more [0..*] entryRelationship (CONF:31377) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31378).SHALL contain exactly one [1..1] Nutritional Status Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.124) (CONF:31379).MAY contain zero or more [0..*] entryRelationship (CONF:31380) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31381).SHALL contain exactly one [1..1] Result Organizer (V2) (templateId:2.16.840.1.113883.10.20.22.4.1.2) (CONF:31382).This entryRelationship represents the priority that the patient puts on the health concern.MAY contain zero or more [0..*] entryRelationship (CONF:31442) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31443).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31444).This entryRelationship represents the priority that the provider puts on the health concern.MAY contain zero or more [0..*] entryRelationship (CONF:31445) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31446).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31447).Health Status Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.5.2 (open)]SEQ Table \* ARABIC320: Health Status Observation (V2) ContextsContained By:Contains:Health Concerns Section (NEW) (optional)Problem Section (entries required) (V2) (optional)Problem Section (entries optional) (V2) (optional)This template represents??information about the overall health status of the patient. To represent the impact of a specific problem or concern related to the patient's expected health outcome use the Prognosis Observation Template 2.16.840.1.113883.10.20.22.4.113.SEQ Table \* ARABIC321: Health Status Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.5.2']@classCode1..1SHALL90572.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL90722.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16756@root1..1SHALL167572.16.840.1.113883.10.20.22.4.5.2code1..1SHALL19143@code1..1SHALL191442.16.840.1.113883.6.1 (LOINC) = 11323-3text0..1SHOULD9270reference0..1SHOULD15529@value0..1SHOULD15530statusCode1..1SHALL9074@code1..1SHALL191032.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD90752.16.840.1.113883.1.11.20.12.2 (HealthStatus (V2))SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9057).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9072).SHALL contain exactly one [1..1] templateId (CONF:16756) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.5.2" (CONF:16757).SHALL contain exactly one [1..1] code (CONF:19143).This code SHALL contain exactly one [1..1] @code="11323-3" Health status (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19144).SHOULD contain zero or one [0..1] text (CONF:9270).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15529).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15530).SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15531).SHALL contain exactly one [1..1] statusCode (CONF:9074).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19103).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet HealthStatus (V2) 2.16.840.1.113883.1.11.20.12.2 DYNAMIC (CONF:9075).SEQ Table \* ARABIC322: HealthStatus (V2)Value Set: HealthStatus (V2) 2.16.840.1.113883.1.11.20.12.2Represents the general health status of the patient.CodeCode SystemPrint Name81323004SNOMED CTAlive and well313386006SNOMED CTIn remission162467007SNOMED CTSymptom free161901003SNOMED CTChronically ill271593001SNOMED CTSeverely ill21134002SNOMED CTDisabled161045001SNOMED CTSeverely disabled135818000SNOMED CTGeneral health poor135815002SNOMED CTGeneral health good135816001SNOMED CTGeneral health excellentHighest Pressure Ulcer Stage[observation: templateId 2.16.840.1.113883.10.20.22.4.77 (open)]SEQ Table \* ARABIC323: Highest Pressure Ulcer Stage ContextsContained By:Contains:Health Concern Act (NEW) (optional)Physical Exam Section (V2) (optional)This observation contains a description of the wound tissue of the most severe or highest staged pressure ulcer observed on a patient.SEQ Table \* ARABIC324: Highest Pressure Ulcer Stage Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.77']@classCode1..1SHALL147262.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL147272.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14728@root1..1SHALL147292.16.840.1.113883.10.20.22.4.77id1..*SHALL14730code1..1SHALL14731@code1..1SHALL147322.16.840.1.113883.6.96 (SNOMED CT) = 420905001value1..1SHALL14733SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14726).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14727).SHALL contain exactly one [1..1] templateId (CONF:14728) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.77" (CONF:14729).SHALL contain at least one [1..*] id (CONF:14730).SHALL contain exactly one [1..1] code (CONF:14731).This code SHALL contain exactly one [1..1] @code="420905001" Highest Pressure Ulcer Stage (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:14732).SHALL contain exactly one [1..1] value (CONF:14733).Hospital Admission Diagnosis (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.34.2 (open)]SEQ Table \* ARABIC325: Hospital Admission Diagnosis (V2) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Hospital Admission Diagnosis Section (V2) (optional)Problem Observation (V2)This template represents problems or diagnoses identified by the clinician at the time of the patient’s admission.SEQ Table \* ARABIC326: Hospital Admission Diagnosis (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.34.2']@classCode1..1SHALL76712.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL76722.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16747@root1..1SHALL167482.16.840.1.113883.10.20.22.4.34.2code1..1SHALL19145@code1..1SHALL191462.16.840.1.113883.6.1 (LOINC) = 46241-6entryRelationship1..*SHALL7674@typeCode1..1SHALL76752.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL15535SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7671).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7672).SHALL contain exactly one [1..1] templateId (CONF:16747) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.34.2" (CONF:16748).SHALL contain exactly one [1..1] code (CONF:19145).This code SHALL contain exactly one [1..1] @code="46241-6" Admission diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19146).SHALL contain at least one [1..*] entryRelationship (CONF:7674) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7675).SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15535).Hospital Discharge Diagnosis (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.33.2 (open)]SEQ Table \* ARABIC327: Hospital Discharge Diagnosis (V2) ContextsContained By:Contains:Hospital Discharge Diagnosis Section (V2) (optional)Problem Observation (V2)This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization. It requires at least one Problem Observation entry. SEQ Table \* ARABIC328: Hospital Discharge Diagnosis (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.33.2']@classCode1..1SHALL76632.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL76642.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16764@root1..1SHALL167652.16.840.1.113883.10.20.22.4.33.2code1..1SHALL19147@code1..1SHALL191482.16.840.1.113883.6.1 (LOINC) = 11535-2entryRelationship1..*SHALL7666@typeCode1..1SHALL76672.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL15536SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7663).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7664).SHALL contain exactly one [1..1] templateId (CONF:16764) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.33.2" (CONF:16765).SHALL contain exactly one [1..1] code (CONF:19147).This code SHALL contain exactly one [1..1] @code="11535-2" Hospital discharge diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19148).SHALL contain at least one [1..*] entryRelationship (CONF:7666) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7667).SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15536).Immunization Activity (V2)[substanceAdministration: templateId 2.16.840.1.113883.10.20.22.4.52.2 (open)]SEQ Table \* ARABIC329: Immunization Activity (V2) ContextsContained By:Contains:Immunizations Section (entries optional) (V2) (optional)Immunizations Section (entries required) (V2) (required)Intervention Act (NEW) (optional)Author Participant (NEW)Drug VehicleImmunization Medication Information (V2)Immunization Refusal ReasonIndication (V2)Instruction (V2)Medication Dispense (V2)Medication Supply Order (V2)Precondition for Substance AdministrationReaction Observation (V2)Substance Administered Act (NEW)An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur. Immunization Activities in "INT" mood are reflections of immunizations a clinician intends a patient to receive. Immunization Activities in "EVN" mood reflect immunizations actually received.An Immunization Activity is very similar to a Medication Activity with some key differentiators. The drug code system is constrained to CVX codes. Administration timing is less complex. Patient refusal reasons should be captured. All vaccines administered should be fully documented in the patient's permanent medical record. Healthcare providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates: 1) Date of administration 2) Vaccine manufacturer 3) Vaccine lot number 4) Name and title of the person who administered the vaccine and the address of the clinic or facility where the permanent record will reside 5) Vaccine information statement (VIS) a. date printed on the VIS b. date VIS given to patient or parent/guardian.This information should be included in an Immunization Activity when available.Notes: reference: Table \* ARABIC330: Immunization Activity (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValuesubstanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.22.4.52.2']participant0..*MAY8850@typeCode1..1SHALL88512.16.840.1.113883.5.90 (HL7ParticipationType) = CSMparticipantRole1..1SHALL15547@classCode1..1SHALL88262.16.840.1.113883.5.6 (HL7ActClass) = SBADM@moodCode1..1SHALL88272.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)@negationInd1..1SHALL8985templateId1..1SHALL8828@root1..1SHALL104982.16.840.1.113883.10.20.22.4.52.2id1..*SHALL8829code0..1MAY8830text0..1SHOULD8831reference0..1SHOULD15543@value0..1SHOULD15544statusCode1..1SHALL88332.16.840.1.113883.1.11.159331 (ActStatus)effectiveTime1..1SHALL8834repeatNumber0..1MAY8838routeCode0..1MAY88392.16.840.1.113883.3.88.12.3221.8.7 (Medication Route FDA Value Set)approachSiteCode0..1MAYSET<CD>88402.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)doseQuantity0..1SHOULD8841@unit0..1SHOULD88422.16.840.1.113883.1.11.12839 (UnitsOfMeasureCaseSensitive)administrationUnitCode0..1MAY88462.16.840.1.113883.3.88.12.3221.8.11 (Medication Product Form Value Set)consumable1..1SHALL8847manufacturedProduct1..1SHALL15546performer0..1SHOULD8849entryRelationship0..*MAY8853@typeCode1..1SHALL88542.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL15537entryRelationship0..1MAY8856@typeCode1..1SHALL88572.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL8858trueact1..1SHALL31392entryRelationship0..1MAY8860@typeCode1..1SHALL88612.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL15539entryRelationship0..1MAY8863@typeCode1..1SHALL88642.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL15540entryRelationship0..1MAY8866@typeCode1..1SHALL88672.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUSobservation1..1SHALL15541entryRelationship0..1MAY8988@typeCode1..1SHALL89892.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL15542precondition0..*MAY8869@typeCode1..1SHALL88702.16.840.1.113883.5.1002 (HL7ActRelationshipType) = PRCNcriterion1..1SHALL15548author0..*SHOULD31151entryRelationship0..*MAY31510@typeCode1..1SHALL315112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP@inversionInd1..1SHALL31512truesequenceNumber0..1MAY31513act1..1SHALL31514SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8826).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC (CONF:8827).Use negationInd="true" to indicate that the immunization was not given.SHALL contain exactly one [1..1] @negationInd (CONF:8985).SHALL contain exactly one [1..1] templateId (CONF:8828) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.52.2" (CONF:10498).SHALL contain at least one [1..*] id (CONF:8829).SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc, the field is generally not used, and there is no defined value set.MAY contain zero or one [0..1] code (CONF:8830).SHOULD contain zero or one [0..1] text (CONF:8831).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15543).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15544).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1 (CONF:15545).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ActStatus 2.16.840.1.113883.1.11.159331 DYNAMIC (CONF:8833).SHALL contain exactly one [1..1] effectiveTime (CONF:8834).In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. To indicate a given immunization's ordering in a series, use the nested Substance Administered Act. MAY contain zero or one [0..1] repeatNumber (CONF:8838).MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:8839).MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:8840).SHOULD contain zero or one [0..1] doseQuantity (CONF:8841).The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:8842).MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC (CONF:8846).SHALL contain exactly one [1..1] consumable (CONF:8847).This consumable SHALL contain exactly one [1..1] Immunization Medication Information (V2) (templateId:2.16.840.1.113883.10.20.22.4.54.2) (CONF:15546).SHOULD contain zero or one [0..1] performer (CONF:8849).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31151).MAY contain zero or more [0..*] participant (CONF:8850) such that itSHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8851).SHALL contain exactly one [1..1] Drug Vehicle (templateId:2.16.840.1.113883.10.20.22.4.24) (CONF:15547).MAY contain zero or more [0..*] entryRelationship (CONF:8853) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8854).SHALL contain exactly one [1..1] Indication (V2) (templateId:2.16.840.1.113883.10.20.22.4.19.2) (CONF:15537).MAY contain zero or one [0..1] entryRelationship (CONF:8856) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8857).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:8858).SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31392).MAY contain zero or one [0..1] entryRelationship (CONF:8860) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8861).SHALL contain exactly one [1..1] Medication Supply Order (V2) (templateId:2.16.840.1.113883.10.20.22.4.17.2) (CONF:15539).MAY contain zero or one [0..1] entryRelationship (CONF:8863) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8864).SHALL contain exactly one [1..1] Medication Dispense (V2) (templateId:2.16.840.1.113883.10.20.22.4.18.2) (CONF:15540).MAY contain zero or one [0..1] entryRelationship (CONF:8866) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8867).SHALL contain exactly one [1..1] Reaction Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.9.2) (CONF:15541).MAY contain zero or one [0..1] entryRelationship (CONF:8988) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8989).SHALL contain exactly one [1..1] Immunization Refusal Reason (templateId:2.16.840.1.113883.10.20.22.4.53) (CONF:15542).MAY contain zero or more [0..*] entryRelationship (CONF:31510) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31511).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:31512).MAY contain zero or one [0..1] sequenceNumber (CONF:31513).SHALL contain exactly one [1..1] Substance Administered Act (NEW) (templateId:2.16.840.1.113883.10.20.22.4.118) (CONF:31514).MAY contain zero or more [0..*] precondition (CONF:8869) such that itSHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8870).SHALL contain exactly one [1..1] Precondition for Substance Administration (templateId:2.16.840.1.113883.10.20.22.4.25) (CONF:15548).SEQ Table \* ARABIC331: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentSEQ Table \* ARABIC332: ActStatusValue Set: ActStatus 2.16.840.1.113883.1.11.159331Contains the names (codes) for each of the states in the state-machine of the RIM Act class.CodeCode SystemPrint NamenormalActStatusnormalabortedActStatusabortedactiveActStatusactivecancelledActStatuscancelledcompletedActStatuscompletedheldActStatusheldnewActStatusnewsuspendedActStatussuspendednullifiedActStatusnullifiedobsoleteActStatusobsoleteSEQ Table \* ARABIC333: Medication Route FDA Value SetValue Set: Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7Route of Administration value set is based upon FDA Drug Registration and Listing Database (FDA Orange Book) which are used in FDA structured product and labelling (SPL).CodeCode SystemPrint NameC38192FDA RouteOfAdministrationAURICULAR (OTIC)C38193FDA RouteOfAdministrationBUCCALC38194FDA RouteOfAdministrationCONJUNCTIVALC38675FDA RouteOfAdministrationCUTANEOUSC38197FDA RouteOfAdministrationDENTALC38633FDA RouteOfAdministrationELECTRO-OSMOSISC38205FDA RouteOfAdministrationENDOCERVICALC38206FDA RouteOfAdministrationENDOSINUSIALC38208FDA RouteOfAdministrationENDOTRACHEALC38209FDA RouteOfAdministrationENTERALC38210FDA RouteOfAdministrationEPIDURALC38211FDA RouteOfAdministrationEXTRA-AMNIOTICC38212FDA RouteOfAdministrationEXTRACORPOREALC38200FDA RouteOfAdministrationHEMODIALYSISC38215FDA RouteOfAdministrationINFILTRATIONC38219FDA RouteOfAdministrationINTERSTITIALC38220FDA RouteOfAdministrationINTRA-ABDOMINALC38221FDA RouteOfAdministrationINTRA-AMNIOTICC38222FDA RouteOfAdministrationINTRA-ARTERIALC38223FDA RouteOfAdministrationINTRA-ARTICULAR...SEQ Table \* ARABIC334: Body Site Value SetValue Set: Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9Body site value set is based upon the concepts descending from the SNOMED CT Anatomical Structure (91723000) hierarchy.CodeCode SystemPrint Name56244007SNOMED CT10 to 19 percent of body surface (body structure)37491003SNOMED CT12 nm filaments (cell structure)78777002SNOMED CT20 to 29 percent of body surface (body structure)12423009SNOMED CT30 to 39 percent of body surface (body structure)36849000SNOMED CT40 to 49 percent of body surface (body structure)305024009SNOMED CT5/6 interchondral joint (body structure)76152003SNOMED CT50 to 59 percent of body surface (body structure)305005006SNOMED CT6/7 interchondral joint (body structure)91551007SNOMED CT60 to 69 percent of body surface (body structure)64700008SNOMED CT7 nm filaments (cell structure)305006007SNOMED CT7/8 interchondral joint (body structure)75324005SNOMED CT70 to 79 percent of body surface (body structure)305007003SNOMED CT8/9 interchondral joint (body structure)19738007SNOMED CT80 to 89 percent of body surface (body structure)19904008SNOMED CT9 nm filaments (cell structure)91035006SNOMED CT90 percent of body surface or more (body structure)51878007SNOMED CTA band (cell structure)416949008SNOMED CTAbdomen and/or pelvis structure (body structure)108350001SNOMED CTAbdomen, excluding retroperitoneal region (body structure)43701009SNOMED CTAbdominal air sac (body structure)...SEQ Table \* ARABIC335: UnitsOfMeasureCaseSensitiveValue Set: UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839CodeCode SystemPrint Name10*UCUMthe number ten for arbitrary powers10^UCUMthe number ten for arbitrary powers[pi]UCUMthe number pi%UCUMpercent[ppth]UCUMparts per thousand[ppm]UCUMparts per million[ppb]UCUMparts per billion[pptr]UCUMparts per trillionmolUCUMmolesrUCUMsteradianHzUCUMHertzNUCUMNewtonPaUCUMPascalJUCUMJouleWUCUMWattAUCUMAmp?reVUCUMVoltFUCUMFaradOhmUCUMOhmSUCUMSiemens...SEQ Table \* ARABIC336: Medication Product Form Value SetValue Set: Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11This is the physical form of the product as presented to the individual. For example: tablet, capsule, liquid or ointment. NCI concept code for pharmaceutical dosage form: C42636CodeCode SystemPrint NameC42887FDA RouteOfAdministrationAEROSOLC42888FDA RouteOfAdministrationAEROSOL, FOAMC42960FDA RouteOfAdministrationAEROSOL, METEREDC42971FDA RouteOfAdministrationAEROSOL, POWDERC42889FDA RouteOfAdministrationAEROSOL, SPRAYC42892FDA RouteOfAdministrationBAR, CHEWABLEC42890FDA RouteOfAdministrationBEADC43451FDA RouteOfAdministrationBEAD, IMPLANT, EXTENDED RELEASEC42891FDA RouteOfAdministrationBLOCKC25158FDA RouteOfAdministrationCAPSULEC42895FDA RouteOfAdministrationCAPSULE, COATEDC42896FDA RouteOfAdministrationCAPSULE, COATED PELLETSC42917FDA RouteOfAdministrationCAPSULE, COATED, EXTENDED RELEASEC42902FDA RouteOfAdministrationCAPSULE, DELAYED RELEASEC42904FDA RouteOfAdministrationCAPSULE, DELAYED RELEASE PELLETSC42916FDA RouteOfAdministrationCAPSULE, EXTENDED RELEASEC42928FDA RouteOfAdministrationCAPSULE, FILM COATED, EXTENDED RELEASEC42936FDA RouteOfAdministrationCAPSULE, GELATIN COATEDC42954FDA RouteOfAdministrationCAPSULE, LIQUID FILLEDC45414FDA RouteOfAdministrationCEMENT...Immunization Medication Information[manufacturedProduct: templateId 2.16.840.1.113883.10.20.22.4.54 (open)]SEQ Table \* ARABIC337: Immunization Medication Information ContextsContained By:Contains:Medication Supply Order (V2) (optional)Medication Dispense (V2) (optional)The Immunization Medication Information represents product information about the immunization substance. The vaccine manufacturer and vaccine lot number are typically recorded in the medical record and should be included if known.Notes: reference: Table \* ARABIC338: Immunization Medication Information Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValuemanufacturedProduct[templateId/@root = '2.16.840.1.113883.10.20.22.4.54']@classCode1..1SHALL90022.16.840.1.113883.5.110 (RoleClass) = MANUtemplateId1..1SHALL9004@root1..1SHALL104992.16.840.1.113883.10.20.22.4.54id0..*MAY9005manufacturedMaterial1..1SHALL9006code1..1SHALL90072.16.840.1.113883.3.88.12.80.22 (Vaccine Administered Value Set)originalText0..1SHOULD9008reference0..1SHOULD15555@value0..1SHOULD15556translation0..*MAYSET<PQR>9011lotNumberText0..1SHOULD9014manufacturerOrganization0..1SHOULD9012SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:9002).SHALL contain exactly one [1..1] templateId (CONF:9004) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.54" (CONF:10499).MAY contain zero or more [0..*] id (CONF:9005).SHALL contain exactly one [1..1] manufacturedMaterial (CONF:9006).This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Vaccine Administered Value Set 2.16.840.1.113883.3.88.12.80.22 DYNAMIC (CONF:9007).This code SHOULD contain zero or one [0..1] originalText (CONF:9008).The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:15555).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15556).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15557).This code MAY contain zero or more [0..*] translation (CONF:9011).Translations can be used to represent generic product name, packaged product code, etc (CONF:16887).This manufacturedMaterial SHOULD contain zero or one [0..1] lotNumberText (CONF:9014).SHOULD contain zero or one [0..1] manufacturerOrganization (CONF:9012).SEQ Table \* ARABIC339: Vaccine Administered Value SetValue Set: Vaccine Administered Value Set 2.16.840.1.113883.3.88.12.80.22Valueset Source: SystemPrint Name143CDC Vaccine Code (CVX)Adenovirus types 4 and 754CDC Vaccine Code (CVX)adenovirus, type 455CDC Vaccine Code (CVX)adenovirus, type 782CDC Vaccine Code (CVX)adenovirus, unspecified formulation24CDC Vaccine Code (CVX)anthrax19CDC Vaccine Code (CVX)BCG27CDC Vaccine Code (CVX)botulinum antitoxin26CDC Vaccine Code (CVX)cholera29CDC Vaccine Code (CVX)CMVIG56CDC Vaccine Code (CVX)dengue fever12CDC Vaccine Code (CVX)diphtheria antitoxin28CDC Vaccine Code (CVX)DT (pediatric)20CDC Vaccine Code (CVX)DTaP106CDC Vaccine Code (CVX)DTaP, 5 pertussis antigens107CDC Vaccine Code (CVX)DTaP, unspecified formulation146CDC Vaccine Code (CVX)DTaP,IPV,Hib,HepB110CDC Vaccine Code (CVX)DTaP-Hep B-IPV50CDC Vaccine Code (CVX)DTaP-Hib120CDC Vaccine Code (CVX)DTaP-Hib-IPV130CDC Vaccine Code (CVX)DTaP-IPV...Immunization Medication Information (V2)[manufacturedProduct: templateId 2.16.840.1.113883.10.20.22.4.54.2 (open)]SEQ Table \* ARABIC340: Immunization Medication Information (V2) ContextsContained By:Contains:Immunization Activity (V2) (required)The Immunization Medication Information represents product information about the immunization substance. The vaccine manufacturer and vaccine lot number are typically recorded in the medical record and should be included if known.Notes: reference: Table \* ARABIC341: Immunization Medication Information (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValuemanufacturedProduct[templateId/@root = '2.16.840.1.113883.10.20.22.4.54.2']@classCode1..1SHALL90022.16.840.1.113883.5.110 (RoleClass) = MANUtemplateId1..1SHALL9004@root1..1SHALL104992.16.840.1.113883.10.20.22.4.54id0..*MAY9005manufacturedMaterial1..1SHALL9006code1..1SHALL9007Temp-ValueSet-medications (Medication Consumable)translation0..*MAY315432.16.840.1.113883.3.88.12.80.22 (Vaccine Administered Value Set)lotNumberText0..1SHOULD9014manufacturerOrganization0..1SHOULD9012SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:9002).SHALL contain exactly one [1..1] templateId (CONF:9004) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.54" (CONF:10499).MAY contain zero or more [0..*] id (CONF:9005).SHALL contain exactly one [1..1] manufacturedMaterial (CONF:9006).This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Medication Consumable Temp-ValueSet-medications DYNAMIC (CONF:9007).This code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Vaccine Administered Value Set 2.16.840.1.113883.3.88.12.80.22 (CONF:31543).This manufacturedMaterial SHOULD contain zero or one [0..1] lotNumberText (CONF:9014).SHOULD contain zero or one [0..1] manufacturerOrganization (CONF:9012).SEQ Table \* ARABIC342: Medication ConsumableValue Set: Medication Consumable Temp-ValueSet-medicationsA value set of RxNorm codes, intensionally defined to include those whose RxNorm Term Type is SCD (semantic clinical drug), SBD (semantic brand drug), GPCK (generic pack), BPCK (brand pack), SCDG (semantic clinical drug group), SBDG (semantic brand drug group), SCDF (semantic clinical drug form), or SBDF (semantic brand drug form). (Final VSAC URL pending)Valueset Source: SystemPrint Name978727RxNorm0.2 ML Dalteparin Sodium 12500 UNT/ML Prefilled Syringe [Fragmin]827318RxNormAcetaminophen 250 MG / Aspirin 250 MG / Caffeine 65 MG Oral Capsule199274RxNormAspirin 300 MG Oral Capsule362867RxNormCefotetan Injectable Solution [Cefotan]...SEQ Table \* ARABIC343: Vaccine Administered Value SetValue Set: Vaccine Administered Value Set 2.16.840.1.113883.3.88.12.80.22Valueset Source: SystemPrint Name143CDC Vaccine Code (CVX)Adenovirus types 4 and 754CDC Vaccine Code (CVX)adenovirus, type 455CDC Vaccine Code (CVX)adenovirus, type 782CDC Vaccine Code (CVX)adenovirus, unspecified formulation24CDC Vaccine Code (CVX)anthrax19CDC Vaccine Code (CVX)BCG27CDC Vaccine Code (CVX)botulinum antitoxin26CDC Vaccine Code (CVX)cholera29CDC Vaccine Code (CVX)CMVIG56CDC Vaccine Code (CVX)dengue fever12CDC Vaccine Code (CVX)diphtheria antitoxin28CDC Vaccine Code (CVX)DT (pediatric)20CDC Vaccine Code (CVX)DTaP106CDC Vaccine Code (CVX)DTaP, 5 pertussis antigens107CDC Vaccine Code (CVX)DTaP, unspecified formulation146CDC Vaccine Code (CVX)DTaP,IPV,Hib,HepB110CDC Vaccine Code (CVX)DTaP-Hep B-IPV50CDC Vaccine Code (CVX)DTaP-Hib120CDC Vaccine Code (CVX)DTaP-Hib-IPV130CDC Vaccine Code (CVX)DTaP-IPV...Immunization Refusal Reason[observation: templateId 2.16.840.1.113883.10.20.22.4.53 (open)]SEQ Table \* ARABIC344: Immunization Refusal Reason ContextsContained By:Contains:Immunization Activity (V2) (optional)The Immunization Refusal Reason Observation documents the rationale for the patient declining an immunization.SEQ Table \* ARABIC345: Immunization Refusal Reason Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.53']@classCode1..1SHALL89912.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL89922.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL8993@root1..1SHALL105002.16.840.1.113883.10.20.22.4.53id1..*SHALL8994code1..1SHALL89952.16.840.1.113883.1.11.19717 (No Immunization Reason Value Set)statusCode1..1SHALL8996@code1..1SHALL191042.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8991).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8992).SHALL contain exactly one [1..1] templateId (CONF:8993) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.53" (CONF:10500).SHALL contain at least one [1..*] id (CONF:8994).SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet No Immunization Reason Value Set 2.16.840.1.113883.1.11.19717 DYNAMIC (CONF:8995).SHALL contain exactly one [1..1] statusCode (CONF:8996).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19104).SEQ Table \* ARABIC346: No Immunization Reason Value SetValue Set: No Immunization Reason Value Set 2.16.840.1.113883.1.11.19717CodeCode SystemPrint NameIMMUNEActReasonImmunityMEDPRECActReasonMedical precautionOSTOCKActReasonOut of stockPATOBJActReasonPatient objectionPHILISOPActReasonPhilosophical objectionRELIGActReasonReligious objectionVACEFFActReasonVaccine efficacy concernsVACSAFActReasonVaccine safety concernsIndication (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.19.2 (open)]SEQ Table \* ARABIC347: Indication (V2) ContextsContained By:Contains:Medication Activity (V2) (optional)Procedure Activity Act (V2) (optional)Procedure Activity Procedure (V2) (optional)Procedure Activity Observation (V2) (optional)Immunization Activity (V2) (optional)Encounter Activity (V2) (optional)Procedure Indications Section (V2) (optional)The Indication Observation documents the rationale for an activity. The id element references a problem or result recorded elsewhere in the document A code and value to record the problem type or result observation??in the Indication Observation. For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section or if the indication is for Warfarin may require close monitoring with an International Normalized Ratio(INR).SEQ Table \* ARABIC348: Indication (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.19.2']@classCode1..1SHALL74802.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL74812.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7482@root1..1SHALL105022.16.840.1.113883.10.20.22.4.19.2id1..1SHALL7483statusCode1..1SHALL7487@code1..1SHALL191052.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime0..1SHOULD7488value0..1SHOULDCD7489@code0..1SHOULD159852.16.840.1.113883.3.88.12.3221.7.4 (Problem Value Set)text0..1SHOULD30817code1..1SHALL312292.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7480).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7481).SHALL contain exactly one [1..1] templateId (CONF:7482) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.19.2" (CONF:10502).SHALL contain exactly one [1..1] id (CONF:7483).Where the observation/id??is equal to an ID in the problem act or in the laboratory result organizer to signify that the link to the indication (CONF:16885).SHALL contain exactly one [1..1] code (ValueSet: Problem Type 2.16.840.1.113883.3.88.12.3221.7.2) (CONF:31229).SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12 (CONF:30815).Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency.??Local and/or regional codes for laboratory results SHOULD also be allowed (CONF:30816).SHOULD contain zero or one [0..1] text (CONF:30817).SHALL contain exactly one [1..1] statusCode (CONF:7487).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19105).SHOULD contain zero or one [0..1] effectiveTime (CONF:7488).SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:7489).The value, if present, SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:15985).SEQ Table \* ARABIC349: Problem Value SetValue Set: Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4CodeCode SystemPrint Name50992006SNOMED CT22q partial trisomy syndrome (disorder)237931009SNOMED CT2-Ketoadipic acidemia (disorder)54470008SNOMED CT3 beta-Hydroxysteroid dehydrogenase deficiency (disorder)237950009SNOMED CT3-Methylglutaconic aciduria (disorder)296646009SNOMED CT4-quinolones overdose (disorder)41797007SNOMED CT5 10-Methylenetetrahydrofolate reductase deficiency (disorder)413380004SNOMED CTA pattern strabismus (disorder)425879009SNOMED CTAA amyloid nephropathy (disorder)274945004SNOMED CTAA amyloidosis (disorder)75100008SNOMED CTAbdominal abscess (disorder)43894001SNOMED CTAbdominal actinomycosis (disorder)233985008SNOMED CTAbdominal aortic aneurysm (disorder)253679008SNOMED CTAbdominal aortic coarctation (disorder)116289008SNOMED CTAbdominal bloating (finding)9991008SNOMED CTAbdominal colic (finding)271860004SNOMED CTAbdominal mass (finding)75879005SNOMED CTAbdominal migraine (disorder)21522001SNOMED CTAbdominal pain (finding)82661006SNOMED CTAbdominal pregnancy (disorder)72300008SNOMED CTAbdominal rigidity (finding)...SEQ Table \* ARABIC350: Problem TypeValue Set: Problem Type 2.16.840.1.113883.3.88.12.3221.7.2CodeCode SystemPrint Name404684003SNOMED CTFinding409586006SNOMED CTComplaint282291009SNOMED CTDiagnosis64572001SNOMED CTCondition248536006SNOMED CTFinding of functional performance and activity418799008SNOMED CTSymptom55607006SNOMED CTProblem373930000SNOMED CTCognitive function findingInstruction (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.20.2 (open)]SEQ Table \* ARABIC351: Instruction (V2) ContextsContained By:Contains:Medication Activity (V2) (optional)Plan of Treatment Section (V2) (optional)Procedure Activity Act (V2) (optional)Procedure Activity Procedure (V2) (optional)Procedure Activity Observation (V2) (optional)Non-Medicinal Supply Activity (V2) (optional)Immunization Activity (V2) (optional)Medication Supply Order (V2) (optional)Intervention Act (NEW) (optional)Instructions Section (V2) (optional)The Instruction template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The act/code defines the type of instruction. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through act/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode.SEQ Table \* ARABIC352: Instruction (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.20.2']@classCode1..1SHALL73912.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL73922.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL7393@root1..1SHALL105032.16.840.1.113883.10.20.22.4.20.2code1..1SHALL168842.16.840.1.113883.11.20.9.34 (Patient Education)text0..1SHOULD7395reference0..1SHOULD15577@value0..1SHOULD15578statusCode1..1SHALL7396@code1..1SHALL191062.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7391).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7392).SHALL contain exactly one [1..1] templateId (CONF:7393) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.20.2" (CONF:10503).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Patient Education 2.16.840.1.113883.11.20.9.34 DYNAMIC (CONF:16884).SHOULD contain zero or one [0..1] text (CONF:7395).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15577).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15578).This @value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15579).SHALL contain exactly one [1..1] statusCode (CONF:7396).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19106).SEQ Table \* ARABIC353: Patient EducationValue Set: Patient Education 2.16.840.1.113883.11.20.9.34CodeCode SystemPrint Name311401005SNOMED CTPatient Education171044003SNOMED CTImmunization Education243072006SNOMED CTCancer EducationIntervention Act (NEW)[act: templateId 2.16.840.1.113883.10.20.22.4.131 (open)]SEQ Table \* ARABIC354: Intervention Act (NEW) ContextsContained By:Contains:Interventions Section (V2) (optional)Act Plan (V2)Advance Directive Observation (V2)Encounter Activity (V2)Encounter Plan (V2)Goal Observation (NEW)Immunization Activity (V2)Instruction (V2)Medication Activity (V2)Non-Medicinal Supply Activity (V2)Nutrition Recommendations (NEW)Observation Plan (V2)Procedure Activity Act (V2)Procedure Activity Observation (V2)Procedure Activity Procedure (V2)Procedure Plan (V2)Substance Administration Plan (V2)Supply Plan (V2)This template represents an intervention.The Intervention Act template is a wrapper for interventions.Where an Intervention template contains an entryRelationship to another template, rather than including the full content of the template, the id of the template may be set equal to (a pointer to) an ID on an entry elsewhere in the document.SEQ Table \* ARABIC355: Intervention Act (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.131']entryRelationship0..*MAY31180@typeCode1..1SHALL311812.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL31182entryRelationship0..*MAY30980@typeCode1..1SHALL309812.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL30982id1..1SHALL30983entryRelationship0..*MAY31171@typeCode1..1SHALL311722.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRencounter1..1SHALL31173entryRelationship0..*MAY31183@typeCode1..1SHALL311842.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRencounter1..1SHALL31185entryRelationship0..*MAY30984@typeCode1..1SHALL309852.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsubstanceAdministration1..1SHALL30986entryRelationship0..*MAY31174typeId0..1MAY311752.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL31176@classCode1..1SHALL309712.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL309722.16.840.1.113883.11.20.9.54 (Intervention moodCode (Act/Encounter/Procedure))templateId1..1SHALL30973@root1..1SHALL309742.16.840.1.113883.10.20.22.4.131id1..1SHALL30975code1..1SHALL30976@code1..1SHALL30977CODE_FOR_INTERVENTION@codeSystem1..1SHALL30978CODE_SYSTEMstatusCode1..1SHALL30979entryRelationship0..*MAY30988@typeCode1..1SHALL309892.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsubstanceAdministration1..1SHALL30990entryRelationship0..*MAY30991@typeCode1..1SHALL309922.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL30993entryRelationship0..*SHOULD30998@typeCode1..1SHALL309992.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL31000entryRelationship0..*MAY31154@typeCode1..1SHALL311552.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRentryRelationship0..*MAY31164@typeCode1..1SHALL311652.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31166entryRelationship0..*MAY31168@typeCode1..1SHALL311692.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRprocedure1..1SHALL31170entryRelationship0..*MAY31177@typeCode1..1SHALL311782.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL31179entryRelationship0..*MAY31399@typeCode1..1SHALL314002.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31401entryRelationship0..*MAY31402@typeCode1..1SHALL314032.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRprocedure1..1SHALL31404entryRelationship0..*MAY31407@typeCode1..1SHALL314082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsubstanceAdministration1..1SHALL31409entryRelationship0..*MAY31410@typeCode1..1SHALL314112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL31412entryRelationship0..*MAY31413procedure1..1SHALL31414entryRelationship0..*MAY31415@typeCode1..1SHALL314162.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUSSHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30971).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Intervention moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.54 (CONF:30972).SHALL contain exactly one [1..1] templateId (CONF:30973).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.131" (CONF:30974).SHALL contain exactly one [1..1] id (CONF:30975).SHALL contain exactly one [1..1] code (CONF:30976).This code SHALL contain exactly one [1..1] @code="CODE_FOR_INTERVENTION" (CONF:30977).This code SHALL contain exactly one [1..1] @codeSystem="CODE_SYSTEM" (CONF:30978).SHALL contain exactly one [1..1] statusCode (CONF:30979).MAY contain zero or more [0..*] entryRelationship (CONF:30980) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30981).SHALL contain exactly one [1..1] Advance Directive Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.48.2) (CONF:30982).This id may be set equal to (pointer) an ID on an entry elsewhere in the document.This observation SHALL contain exactly one [1..1] id (CONF:30983).MAY contain zero or more [0..*] entryRelationship (CONF:30984) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30985).SHALL contain exactly one [1..1] Immunization Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.52.2) (CONF:30986).MAY contain zero or more [0..*] entryRelationship (CONF:30988) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30989).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:30990).MAY contain zero or more [0..*] entryRelationship (CONF:30991) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30992).SHALL contain exactly one [1..1] Procedure Activity Act (V2) (templateId:2.16.840.1.113883.10.20.22.4.12.2) (CONF:30993).This entryRelationship represents the relationship between an Intervention Act and a Goal Observation (Intervention HAS REASON Goal).SHOULD contain zero or more [0..*] entryRelationship (CONF:30998) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30999).SHALL contain exactly one [1..1] Goal Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.121) (CONF:31000).This entryRelationship represents the relationship between two Intervention Acts (Intervention RELATES TO Intervention).MAY contain zero or more [0..*] entryRelationship (CONF:31154) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31155).SHALL contain exactly 1..1] Intervention Act (NEW) (templateId:2.16.840.1.113883.10.20.4.131) (CONF:31156).MAY contain zero or more [0..*] entryRelationship (CONF:31164) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31165).SHALL contain exactly one [1..1] Procedure Activity Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.13.2) (CONF:31166).MAY contain zero or more [0..*] entryRelationship (CONF:31168) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31169).SHALL contain exactly one [1..1] Procedure Activity Procedure (V2) (templateId:2.16.840.1.113883.10.20.22.4.14.2) (CONF:31170).MAY contain zero or more [0..*] entryRelationship (CONF:31171) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31172).SHALL contain exactly one [1..1] Encounter Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.49.2) (CONF:31173).MAY contain zero or more [0..*] entryRelationship (CONF:31174) such that itMAY contain zero or one [0..1] typeId="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31175).SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31176).MAY contain zero or more [0..*] entryRelationship (CONF:31177) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31178).SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.50.2) (CONF:31179).MAY contain zero or more [0..*] entryRelationship (CONF:31180) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31181).SHALL contain exactly one [1..1] Act Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.39.2) (CONF:31182).MAY contain zero or more [0..*] entryRelationship (CONF:31183) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31184).SHALL contain exactly one [1..1] Encounter Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.40.2) (CONF:31185).MAY contain zero or more [0..*] entryRelationship (CONF:31399) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31400).SHALL contain exactly one [1..1] Observation Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.44.2) (CONF:31401).MAY contain zero or more [0..*] entryRelationship (CONF:31402) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31403).SHALL contain exactly one [1..1] Procedure Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.41.2) (CONF:31404).MAY contain zero or more [0..*] entryRelationship (CONF:31407) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31408).SHALL contain exactly one [1..1] Substance Administration Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.42.2) (CONF:31409).MAY contain zero or more [0..*] entryRelationship (CONF:31410) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31411).SHALL contain exactly one [1..1] Supply Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.43.2) (CONF:31412).MAY contain zero or more [0..*] entryRelationship (CONF:31413) such that itSHALL contain exactly one [1..1] Nutrition Recommendations (NEW) (templateId:2.16.840.1.113883.10.20.22.4.130) (CONF:31414).This entryRelationship represents the relationship between an Intervention Act and an Outcome Observation (Intervention Act IS CAUSE OF Outcome Observation).MAY contain zero or more [0..*] entryRelationship (CONF:31415) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" Is etiology for (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31416).SEQ Table \* ARABIC356: Intervention moodCode (Act/Encounter/Procedure)Value Set: Intervention moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.54CodeCode SystemPrint NameAPTActMoodAppointmentARQActMoodAppointment RequestEVNActMoodEventINTActMoodIntentPRMSActMoodPromisePRPActMoodProposalRQOActMoodRequestMedical Equipment Organizer (NEW)[organizer: templateId 2.16.840.1.113883.10.20.22.4.135 (open)]SEQ Table \* ARABIC357: Medical Equipment Organizer (NEW) ContextsContained By:Contains:Medical Equipment Section (V2) (optional)Medical (General) History Section (V2) (optional)Medical Device Applied (NEW)This clinical statement represents a set of current or historical medical devices/equipment in use or ordered. It may contain information applicable to all of the contained devices/equipment over time. For example, all nebulizer applied from 2003 to 2012 represents historical devices, and nebulizer between 2013 to current represents current device(s) in use. An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown The component ‘Medical Device Applied’ template with a moodCode of “EVN” represents Medical Device(s) Applied to a patient. This template with a moodCode of “INT” and a child Non-medicinal Supply Activity represents ordered medical device(s).SEQ Table \* ARABIC358: Medical Equipment Organizer (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.135']@classCode1..1SHALL310202.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALL310212.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL31022@root1..1SHALL310232.16.840.1.113883.10.20.22.4.135id1..*SHALL31024code1..1SHALL31025@code0..1SHOULD303492.16.840.1.113883.6.96 (SNOMED CT)statusCode1..1SHALL31026@code1..1SHALL310292.16.840.1.113883.11.20.9.39 (Result Status)component1..*SHALL31027procedure1..1SHALL30350SHALL contain exactly one [1..1] @classCode="CLUSTER" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:31020).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:31021).SHALL contain exactly one [1..1] templateId (CONF:31022) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.135" (CONF:31023).SHALL contain at least one [1..*] id (CONF:31024).SHALL contain exactly one [1..1] code (CONF:31025).This code SHOULD contain zero or one [0..1] @code (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:30349).SHALL contain exactly one [1..1] statusCode (CONF:31026).This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC (CONF:31029).SHALL contain at least one [1..*] component (CONF:31027) such that itSHALL contain exactly one [1..1] Medical Device Applied (NEW) (templateId:2.16.840.1.113883.10.20.22.4.115) (CONF:30350).SEQ Table \* ARABIC359: Result StatusValue Set: Result Status 2.16.840.1.113883.11.20.9.39CodeCode SystemPrint NameabortedActStatusabortedactiveActStatusactivecancelledActStatuscancelledcompletedActStatuscompletedheldActStatusheldsuspendedActStatussuspendedFigure SEQ Table \* ARABIC44: Sample<organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.135" />  <id nullFlavor="NA" /> <code nullFlavor="OTH"> <originalText>Medical Equipment History</originalText> </code> <statusCode code="completed" />  <effectiveTime> <low value="20110616" /> <high nullFlavor="NA" /> </effectiveTime> <component> <procedure classCode="PROC" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.115" />  <templateId root="2.16.840.1.113883.10.20.22.4.14" /> ... </procedure> </component> <component> <procedure classCode="PROC" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.115" />  <templateId root="2.16.840.1.113883.10.20.22.4.14" /> ... </procedure> </component></organizer>Medication Activity (V2)[substanceAdministration: templateId 2.16.840.1.113883.10.20.22.4.16.2 (open)]SEQ Table \* ARABIC360: Medication Activity (V2) ContextsContained By:Contains:Medications Section (entries required) (V2) (required)Medications Section (entries optional) (V2) (optional)Reaction Observation (V2) (optional)Procedure Activity Act (V2) (optional)Procedure Activity Procedure (V2) (optional)Procedure Activity Observation (V2) (optional)Discharge Medication (V2) (required)Admission Medication (V2) (required)Medications Administered Section (V2) (optional)Anesthesia Section (V2) (optional)Intervention Act (NEW) (optional)Author Participant (NEW)Drug Monitoring Act (NEW)Drug VehicleIndication (V2)Instruction (V2)Medication Dispense (V2)Medication Information (V2)Medication Supply Order (V2)Reaction Observation (V2)Substance Administered Act (NEW)A medication activity describes substance administrations that have actually occurred (e.g. pills ingested or injections given) or are intended to occur (e.g. "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. For example, a clinician may intend for a??patient to be administered Lisinopril??20 mg PO for blood pressure control.??However, what was actually administered was Lisinopril 10 mg.??In the latter case, the Medication activities in the "EVN" mood would reflect actual use.At a minimum, a medication activity shall include an effectiveTime indicating the duration of the administration. Ambulatory medication lists generally provide a summary of use for a given medication over time - a medication activity in event mood with the duration reflecting when the medication started and stopped. Ongoing medications will not have a stop date (or a stop date with a suitable NULL value). Ambulatory medication lists will generally also have a frequency (e.g. a medication is being taken twice a day). Inpatient medications generally record each administration as a separate act.The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable and the interval of administration. Thus, a patient consuming a single "metoprolol 25mg tablet" per administration will have a doseQuantity of "1", whereas a patient consuming "metoprolol" will have a dose of "25 mg". SEQ Table \* ARABIC361: Medication Activity (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValuesubstanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.22.4.16.2']participant0..*MAY7523@typeCode1..1SHALL75242.16.840.1.113883.5.90 (HL7ParticipationType) = CSMparticipantRole1..1SHALL16086entryRelationship0..*MAY7536@typeCode1..1SHALL75372.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL16087entryRelationship0..1MAY7539@typeCode1..1SHALL75402.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL7542trueact1..1SHALL31387@classCode1..1SHALL74962.16.840.1.113883.5.6 (HL7ActClass) = SBADM@moodCode1..1SHALL74972.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALL7499@root1..1SHALL105042.16.840.1.113883.10.20.22.4.16.2id1..*SHALL7500code0..1MAY7506text0..1SHOULD7501reference0..1SHOULD15977@value0..1SHOULD15978statusCode1..1SHALL75072.16.840.1.113883.1.11.159331 (ActStatus)effectiveTime1..1SHALL7508low1..1SHALL7511high1..1SHALL7512effectiveTime0..1SHOULD7513@operator1..1SHALL9106ArepeatNumber0..1MAY7555routeCode0..1MAY75142.16.840.1.113883.3.88.12.3221.8.7 (Medication Route FDA Value Set)approachSiteCode0..1MAYSET<CD>75152.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)doseQuantity0..1SHOULD7516@unit0..1SHOULD75262.16.840.1.113883.1.11.12839 (UnitsOfMeasureCaseSensitive)rateQuantity0..1MAY7517@unit1..1SHALL75252.16.840.1.113883.1.11.12839 (UnitsOfMeasureCaseSensitive)maxDoseQuantity0..1MAYRTO<PQ, PQ>7518administrationUnitCode0..1MAY75192.16.840.1.113883.3.88.12.3221.8.11 (Medication Product Form Value Set)consumable1..1SHALL7520manufacturedProduct1..1SHALL16085performer0..1MAY7522entryRelationship0..1MAY7543@typeCode1..1SHALL75472.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL16089entryRelationship0..*MAY7549@typeCode1..1SHALL75532.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL16090entryRelationship0..1MAY7552@typeCode1..1SHALL75442.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUSobservation1..1SHALL16091entryRelationship0..1MAY30820@typeCode1..1SHALL30821COMPact1..1SHALL30822author0..*SHOULD31150entryRelationship0..*MAY31515@typeCode1..1SHALL315162.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP@inversionInd1..1SHALL31517truesequenceNumber0..1MAY31518act1..1SHALL31519precondition0..*MAY31520SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7496).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:7497).SHALL contain exactly one [1..1] templateId (CONF:7499) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16.2" (CONF:10504).SHALL contain at least one [1..*] id (CONF:7500).SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc, the field is generally not used, and there is no defined value set.MAY contain zero or one [0..1] code (CONF:7506).SHOULD contain zero or one [0..1] text (CONF:7501).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15977).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15978).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15979).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ActStatus 2.16.840.1.113883.1.11.159331 DYNAMIC (CONF:7507).This effectiveTime represents the medication duration (i.e. the time the medication was started and stopped).SHALL contain exactly one [1..1] effectiveTime (CONF:7508) such that itSHALL contain exactly one [1..1] low (CONF:7511).SHALL contain exactly one [1..1] high (CONF:7512).This effectiveTime represents the medication frequency (e.g. administration times per day).SHOULD contain zero or one [0..1] effectiveTime (CONF:7513) such that itSHALL contain exactly one [1..1] @operator="A" (CONF:9106).SHALL contain exactly one 1..1] @xsi:type=”PIVLTS” or “EIVLTS” (CONF:28499).In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. To indicate a given medication's ordering in a series, use the nested Substance Administered Act. MAY contain zero or one [0..1] repeatNumber (CONF:7555).MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:7514).MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:7515).SHOULD contain zero or one [0..1] doseQuantity (CONF:7516).The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:7526).Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g. "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g. "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:16878).Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g. is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g. "25" and "mg", specifying the amount of product given per administration (CONF:16879).MAY contain zero or one [0..1] rateQuantity (CONF:7517).The rateQuantity, if present, SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:7525).MAY contain zero or one [0..1] maxDoseQuantity (CONF:7518).MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC (CONF:7519).SHALL contain exactly one [1..1] consumable (CONF:7520).This consumable SHALL contain exactly one [1..1] Medication Information (V2) (templateId:2.16.840.1.113883.10.20.22.4.23.2) (CONF:16085).MAY contain zero or one [0..1] performer (CONF:7522).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31150).MAY contain zero or more [0..*] participant (CONF:7523) such that itSHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:7524).SHALL contain exactly one [1..1] Drug Vehicle (templateId:2.16.840.1.113883.10.20.22.4.24) (CONF:16086).MAY contain zero or more [0..*] entryRelationship (CONF:7536) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7537).SHALL contain exactly one [1..1] Indication (V2) (templateId:2.16.840.1.113883.10.20.22.4.19.2) (CONF:16087).MAY contain zero or one [0..1] entryRelationship (CONF:7539) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7540).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7542).SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31387).MAY contain zero or one [0..1] entryRelationship (CONF:7543) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7547).SHALL contain exactly one [1..1] Medication Supply Order (V2) (templateId:2.16.840.1.113883.10.20.22.4.17.2) (CONF:16089).MAY contain zero or more [0..*] entryRelationship (CONF:7549) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7553).SHALL contain exactly one [1..1] Medication Dispense (V2) (templateId:2.16.840.1.113883.10.20.22.4.18.2) (CONF:16090).MAY contain zero or one [0..1] entryRelationship (CONF:7552) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7544).SHALL contain exactly one [1..1] Reaction Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.9.2) (CONF:16091).MAY contain zero or one [0..1] entryRelationship (CONF:30820) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:30821).SHALL contain exactly one [1..1] Drug Monitoring Act (NEW) (templateId:2.16.840.1.113883.10.20.22.4.123) (CONF:30822).MAY contain zero or more [0..*] entryRelationship (CONF:31515) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31516).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:31517).MAY contain zero or one [0..1] sequenceNumber (CONF:31518).SHALL contain exactly one [1..1] Substance Administered Act (NEW) (templateId:2.16.840.1.113883.10.20.22.4.118) (CONF:31519).MAY contain zero or more [0..*] precondition (CONF:31520).Medication Activity SHOULD include doseQuantity OR rateQuantity (CONF:30800).SEQ Table \* ARABIC362: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentSEQ Table \* ARABIC363: ActStatusValue Set: ActStatus 2.16.840.1.113883.1.11.159331Contains the names (codes) for each of the states in the state-machine of the RIM Act class.CodeCode SystemPrint NamenormalActStatusnormalabortedActStatusabortedactiveActStatusactivecancelledActStatuscancelledcompletedActStatuscompletedheldActStatusheldnewActStatusnewsuspendedActStatussuspendednullifiedActStatusnullifiedobsoleteActStatusobsoleteSEQ Table \* ARABIC364: Medication Route FDA Value SetValue Set: Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7Route of Administration value set is based upon FDA Drug Registration and Listing Database (FDA Orange Book) which are used in FDA structured product and labelling (SPL).CodeCode SystemPrint NameC38192FDA RouteOfAdministrationAURICULAR (OTIC)C38193FDA RouteOfAdministrationBUCCALC38194FDA RouteOfAdministrationCONJUNCTIVALC38675FDA RouteOfAdministrationCUTANEOUSC38197FDA RouteOfAdministrationDENTALC38633FDA RouteOfAdministrationELECTRO-OSMOSISC38205FDA RouteOfAdministrationENDOCERVICALC38206FDA RouteOfAdministrationENDOSINUSIALC38208FDA RouteOfAdministrationENDOTRACHEALC38209FDA RouteOfAdministrationENTERALC38210FDA RouteOfAdministrationEPIDURALC38211FDA RouteOfAdministrationEXTRA-AMNIOTICC38212FDA RouteOfAdministrationEXTRACORPOREALC38200FDA RouteOfAdministrationHEMODIALYSISC38215FDA RouteOfAdministrationINFILTRATIONC38219FDA RouteOfAdministrationINTERSTITIALC38220FDA RouteOfAdministrationINTRA-ABDOMINALC38221FDA RouteOfAdministrationINTRA-AMNIOTICC38222FDA RouteOfAdministrationINTRA-ARTERIALC38223FDA RouteOfAdministrationINTRA-ARTICULAR...SEQ Table \* ARABIC365: Body Site Value SetValue Set: Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9Body site value set is based upon the concepts descending from the SNOMED CT Anatomical Structure (91723000) hierarchy.CodeCode SystemPrint Name56244007SNOMED CT10 to 19 percent of body surface (body structure)37491003SNOMED CT12 nm filaments (cell structure)78777002SNOMED CT20 to 29 percent of body surface (body structure)12423009SNOMED CT30 to 39 percent of body surface (body structure)36849000SNOMED CT40 to 49 percent of body surface (body structure)305024009SNOMED CT5/6 interchondral joint (body structure)76152003SNOMED CT50 to 59 percent of body surface (body structure)305005006SNOMED CT6/7 interchondral joint (body structure)91551007SNOMED CT60 to 69 percent of body surface (body structure)64700008SNOMED CT7 nm filaments (cell structure)305006007SNOMED CT7/8 interchondral joint (body structure)75324005SNOMED CT70 to 79 percent of body surface (body structure)305007003SNOMED CT8/9 interchondral joint (body structure)19738007SNOMED CT80 to 89 percent of body surface (body structure)19904008SNOMED CT9 nm filaments (cell structure)91035006SNOMED CT90 percent of body surface or more (body structure)51878007SNOMED CTA band (cell structure)416949008SNOMED CTAbdomen and/or pelvis structure (body structure)108350001SNOMED CTAbdomen, excluding retroperitoneal region (body structure)43701009SNOMED CTAbdominal air sac (body structure)...SEQ Table \* ARABIC366: UnitsOfMeasureCaseSensitiveValue Set: UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839CodeCode SystemPrint Name10*UCUMthe number ten for arbitrary powers10^UCUMthe number ten for arbitrary powers[pi]UCUMthe number pi%UCUMpercent[ppth]UCUMparts per thousand[ppm]UCUMparts per million[ppb]UCUMparts per billion[pptr]UCUMparts per trillionmolUCUMmolesrUCUMsteradianHzUCUMHertzNUCUMNewtonPaUCUMPascalJUCUMJouleWUCUMWattAUCUMAmp?reVUCUMVoltFUCUMFaradOhmUCUMOhmSUCUMSiemens...SEQ Table \* ARABIC367: Medication Product Form Value SetValue Set: Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11This is the physical form of the product as presented to the individual. For example: tablet, capsule, liquid or ointment. NCI concept code for pharmaceutical dosage form: C42636CodeCode SystemPrint NameC42887FDA RouteOfAdministrationAEROSOLC42888FDA RouteOfAdministrationAEROSOL, FOAMC42960FDA RouteOfAdministrationAEROSOL, METEREDC42971FDA RouteOfAdministrationAEROSOL, POWDERC42889FDA RouteOfAdministrationAEROSOL, SPRAYC42892FDA RouteOfAdministrationBAR, CHEWABLEC42890FDA RouteOfAdministrationBEADC43451FDA RouteOfAdministrationBEAD, IMPLANT, EXTENDED RELEASEC42891FDA RouteOfAdministrationBLOCKC25158FDA RouteOfAdministrationCAPSULEC42895FDA RouteOfAdministrationCAPSULE, COATEDC42896FDA RouteOfAdministrationCAPSULE, COATED PELLETSC42917FDA RouteOfAdministrationCAPSULE, COATED, EXTENDED RELEASEC42902FDA RouteOfAdministrationCAPSULE, DELAYED RELEASEC42904FDA RouteOfAdministrationCAPSULE, DELAYED RELEASE PELLETSC42916FDA RouteOfAdministrationCAPSULE, EXTENDED RELEASEC42928FDA RouteOfAdministrationCAPSULE, FILM COATED, EXTENDED RELEASEC42936FDA RouteOfAdministrationCAPSULE, GELATIN COATEDC42954FDA RouteOfAdministrationCAPSULE, LIQUID FILLEDC45414FDA RouteOfAdministrationCEMENT...Medication Dispense (V2)[supply: templateId 2.16.840.1.113883.10.20.22.4.18.2 (open)]SEQ Table \* ARABIC368: Medication Dispense (V2) ContextsContained By:Contains:Medication Activity (V2) (optional)Immunization Activity (V2) (optional)Immunization Medication InformationMedication Information (V2)Medication Supply Order (V2)This template records the act of supplying medications (i.e., dispensing).SEQ Table \* ARABIC369: Medication Dispense (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.18.2']product0..1MAY9331manufacturedProduct1..1SHALL15608@classCode1..1SHALL74512.16.840.1.113883.5.6 (HL7ActClass) = SPLY@moodCode1..1SHALL74522.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7453@root1..1SHALL105052.16.840.1.113883.10.20.22.4.18.2id1..*SHALL7454statusCode1..1SHALL74552.16.840.1.113883.3.88.12.80.64 (Medication Fill Status)effectiveTime0..1SHOULD7456repeatNumber0..1SHOULD7457quantity0..1SHOULD7458product0..1MAY7459manufacturedProduct1..1SHALL15607performer0..1MAY7461assignedEntity1..1SHALL7467addr0..1SHOULD7468entryRelationship0..1MAY7473@typeCode1..1SHALL74742.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRsupply1..1SHALL15606SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7451).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7452).SHALL contain exactly one [1..1] templateId (CONF:7453) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.18.2" (CONF:10505).SHALL contain at least one [1..*] id (CONF:7454).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet Medication Fill Status 2.16.840.1.113883.3.88.12.80.64 DYNAMIC (CONF:7455).SHOULD contain zero or one [0..1] effectiveTime (CONF:7456).SHOULD contain zero or one [0..1] repeatNumber (CONF:7457).In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a dispense act means that the current dispensation is the 3rd (CONF:16876).SHOULD contain zero or one [0..1] quantity (CONF:7458).MAY contain zero or one [0..1] product (CONF:7459) such that itSHALL contain exactly one [1..1] Medication Information (V2) (templateId:2.16.840.1.113883.10.20.22.4.23.2) (CONF:15607).MAY contain zero or one [0..1] product (CONF:9331) such that itSHALL contain exactly one [1..1] Immunization Medication Information (templateId:2.16.840.1.113883.10.20.22.4.54) (CONF:15608).MAY contain zero or one [0..1] performer (CONF:7461).The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:7467).This assignedEntity SHOULD contain zero or one [0..1] addr (CONF:7468).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10565).MAY contain zero or one [0..1] entryRelationship (CONF:7473) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7474).SHALL contain exactly one [1..1] Medication Supply Order (V2) (templateId:2.16.840.1.113883.10.20.22.4.17.2) (CONF:15606).A supply act SHALL contain one product/Medication Information or one product/Immunization Medication Information template (CONF:9333).SEQ Table \* ARABIC370: Medication Fill StatusValue Set: Medication Fill Status 2.16.840.1.113883.3.88.12.80.64CodeCode SystemPrint NameabortedActStatusAbortedcompletedActStatusCompletedMedication Information (V2)[manufacturedProduct: templateId 2.16.840.1.113883.10.20.22.4.23.2 (open)]SEQ Table \* ARABIC371: Medication Information (V2) ContextsContained By:Contains:Medication Activity (V2) (required)Medication Supply Order (V2) (optional)Medication Dispense (V2) (optional)The medication can be recorded as a pre-coordinated product strength, product form, or product concentration (e.g., “metoprolol 25mg tablet”, “amoxicillin 400mg/5mL suspension”) or not pre-coordinated (e.g., “metoprolol product”).SEQ Table \* ARABIC372: Medication Information (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValuemanufacturedProduct[templateId/@root = '2.16.840.1.113883.10.20.22.4.23.2']@classCode1..1SHALL74082.16.840.1.113883.5.110 (RoleClass) = MANUtemplateId1..1SHALL7409@root1..1SHALL105062.16.840.1.113883.10.20.22.4.23.2id0..*MAY7410manufacturedMaterial1..1SHALL7411code1..1SHALL7412Temp-ValueSet-medications (Medication Consumable)manufacturerOrganization0..1MAY7416SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:7408).SHALL contain exactly one [1..1] templateId (CONF:7409) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.23.2" (CONF:10506).MAY contain zero or more [0..*] id (CONF:7410).SHALL contain exactly one [1..1] manufacturedMaterial (CONF:7411).This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Medication Consumable Temp-ValueSet-medications DYNAMIC (CONF:7412).MAY contain zero or one [0..1] manufacturerOrganization (CONF:7416).SEQ Table \* ARABIC373: Medication ConsumableValue Set: Medication Consumable Temp-ValueSet-medicationsA value set of RxNorm codes, intensionally defined to include those whose RxNorm Term Type is SCD (semantic clinical drug), SBD (semantic brand drug), GPCK (generic pack), BPCK (brand pack), SCDG (semantic clinical drug group), SBDG (semantic brand drug group), SCDF (semantic clinical drug form), or SBDF (semantic brand drug form). (Final VSAC URL pending)Valueset Source: SystemPrint Name978727RxNorm0.2 ML Dalteparin Sodium 12500 UNT/ML Prefilled Syringe [Fragmin]827318RxNormAcetaminophen 250 MG / Aspirin 250 MG / Caffeine 65 MG Oral Capsule199274RxNormAspirin 300 MG Oral Capsule362867RxNormCefotetan Injectable Solution [Cefotan]...Medication Supply Order (V2)[supply: templateId 2.16.840.1.113883.10.20.22.4.17.2 (open)]SEQ Table \* ARABIC374: Medication Supply Order (V2) ContextsContained By:Contains:Medication Activity (V2) (optional)Immunization Activity (V2) (optional)Medication Dispense (V2) (optional)Immunization Medication InformationInstruction (V2)Medication Information (V2)This template records the intent to supply a patient with medications.SEQ Table \* ARABIC375: Medication Supply Order (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.17.2']product0..1MAY9334manufacturedProduct1..1SHALL16094entryRelationship0..1MAY7442@typeCode1..1SHALL74442.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL7445trueact1..1SHALL31391product0..1MAY7439manufacturedProduct1..1SHALL16093@classCode1..1SHALL74272.16.840.1.113883.5.6 (HL7ActClass) = SPLY@moodCode1..1SHALL74282.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL7429@root1..1SHALL105072.16.840.1.113883.10.20.22.4.17.2id1..*SHALL7430statusCode1..1SHALL7432effectiveTime0..1SHOULDIVL_TS15143high1..1SHALL15144repeatNumber0..1SHOULD7434quantity0..1SHOULD7436author0..1MAY7438SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7427).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7428).SHALL contain exactly one [1..1] templateId (CONF:7429) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.17.2" (CONF:10507).SHALL contain at least one [1..*] id (CONF:7430).SHALL contain exactly one [1..1] statusCode (CONF:7432).SHOULD contain zero or one [0..1] effectiveTime (CONF:15143) such that itSHALL contain exactly one [1..1] high (CONF:15144).SHOULD contain zero or one [0..1] repeatNumber (CONF:7434).In "INT" (intent) mood, the repeatNumber defines the number of allowed fills. For example, a repeatNumber of "3" means that the substance can be supplied up to 3 times (or, can be dispensed, with 2 refills) (CONF:16869).SHOULD contain zero or one [0..1] quantity (CONF:7436).MAY contain zero or one [0..1] product (CONF:7439) such that itSHALL contain exactly one [1..1] Medication Information (V2) (templateId:2.16.840.1.113883.10.20.22.4.23.2) (CONF:16093).MAY contain zero or one [0..1] product (CONF:9334) such that itSHALL contain exactly one [1..1] Immunization Medication Information (templateId:2.16.840.1.113883.10.20.22.4.54) (CONF:16094).A supply act SHALL contain one product/Medication Information or one product/Immunization Medication Information template (CONF:16870).MAY contain zero or one [0..1] author (CONF:7438).MAY contain zero or one [0..1] entryRelationship (CONF:7442).The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7444).The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7445).The entryRelationship, if present, SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31391).Medication Use - None Known (obsolete)[observation: templateId 2.16.840.1.113883.10.20.22.4.29.obsolete (open)]SEQ Table \* ARABIC376: Medication Use - None Known (obsolete) ContextsContained By:Contains:This template is obsolete and will be deleted completely in the future.The recommended approach to stating no known medications is to use the appropriate nullFlavor instead of this template. See ""Unknown Information"" in Section 1.SEQ Table \* ARABIC377: Medication Use - None Known (obsolete) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.29.obsolete']Mental Status Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.125 (open)]SEQ Table \* ARABIC378: Mental Status Observation (NEW) ContextsContained By:Contains:Mental Status Section (NEW) (optional)Health Concern Act (NEW) (optional)Assessment Scale ObservationAuthor Participant (NEW)This template represents observations relating intellectual, mental powers and state of mind. Mental Status observations in a clinical note often have a psychological focus (e.g . level of consciousness, mood, anxiety level, reasoning ability). SEQ Table \* ARABIC379: Mental Status Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.125']entryRelationship0..*MAY29207@typeCode1..1SHALL292082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL29209@classCode1..1SHALL291822.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL291832.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL29186@root1..1SHALL291872.16.840.1.113883.10.20.22.4.125id1..*SHALL29188code1..1SHALL291892.16.840.1.113883.11.20.9.43 (Mental Status Observation Type)statusCode1..1SHALL29194@code1..1SHALL291952.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL29196value1..1SHALLCD292022.16.840.1.113883.11.20.9.44 (Mental and Functional Status Response Value Set)author0..*SHOULD31435SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:29182).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:29183).SHALL contain exactly one [1..1] templateId (CONF:29186) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.125" (CONF:29187).SHALL contain at least one [1..*] id (CONF:29188).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Mental Status Observation Type 2.16.840.1.113883.11.20.9.43 DYNAMIC (CONF:29189).SHALL contain exactly one [1..1] statusCode (CONF:29194).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:29195).SHALL contain exactly one [1..1] effectiveTime (CONF:29196).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Mental and Functional Status Response Value Set 2.16.840.1.113883.11.20.9.44 DYNAMIC (CONF:29202).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31435).MAY contain zero or more [0..*] entryRelationship (CONF:29207) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:29208).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:29209).SEQ Table \* ARABIC380: Mental Status Observation TypeValue Set: Mental Status Observation Type 2.16.840.1.113883.11.20.9.43A value set of observable entity codes for types of mental status.CodeCode SystemPrint Name43173001SNOMED CTorientation, function (observable entity)405051006SNOMED CTlevel of anxiety (observable entity)363871006SNOMED CTmental state (observable entity)85256008SNOMED CTmood, function (observable entity)285231000SNOMED CTmental function (observable entity)6942003SNOMED CTlevel of consciousness (observable entity)SEQ Table \* ARABIC381: Mental and Functional Status Response Value SetValue Set: Mental and Functional Status Response Value Set 2.16.840.1.113883.11.20.9.44A value set containing 2 SNOMED-CT qualifier codes that are common responses to mental and functional ability queries.CodeCode SystemPrint Name11163003SNOMED CTIntact260379002SNOMED CTImpairedFigure SEQ Table \* ARABIC45: Mental Status Observation<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.125"/> <id root="c12ecaaf-53f8-4593-8f79-359aeaa3948b"/> <code xsi:type="CD" code="285231000" displayName="Mental Function" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <statusCode code="completed"/> <effectiveTime value="20130311"/> <value xsi:type="CD" code="11163003" displayName="Intact" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </value> <author> <time value="200130311"/> <assignedAuthor> <id extension="KP00017" root="2.16.840.1.113883.19.5"/> <addr> <streetAddressLine>1003 Health Care Drive</streetAddressLine> <city>Ann Arbor</city> <state>MI</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Assigned</given> <family>Amanda</family> </name> </assignedPerson> </assignedAuthor> </author> </observation></entry>Non-Medicinal Supply Activity[supply: templateId 2.16.840.1.113883.10.20.22.4.50 (open)]SEQ Table \* ARABIC382: Non-Medicinal Supply Activity ContextsContained By:Contains:Cognitive Status Problem Observation (DEPRECATED) (optional)Functional Status Problem Observation (DEPRECATED) (optional)Product InstanceThis template records non-medicinal supplies provided, such as medical equipmentSEQ Table \* ARABIC383: Non-Medicinal Supply Activity Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.50']@classCode1..1SHALL87452.16.840.1.113883.5.6 (HL7ActClass) = SPLY@moodCode1..1SHALL87462.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALL8747@root1..1SHALL105092.16.840.1.113883.10.20.22.4.50id1..*SHALL8748statusCode1..1SHALL8749quantity0..1SHOULD8751participant0..1MAY8752@typeCode1..1SHALL87542.16.840.1.113883.5.90 (HL7ParticipationType) = PRDparticipantRole1..1SHALL15900effectiveTime0..1SHOULDIVL_TS15498SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8745).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:8746).SHALL contain exactly one [1..1] templateId (CONF:8747) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.50" (CONF:10509).SHALL contain at least one [1..*] id (CONF:8748).SHALL contain exactly one [1..1] statusCode (CONF:8749).SHOULD contain zero or one [0..1] effectiveTime (CONF:15498).The effectiveTime, if present, SHOULD contain zero or one 0..1] high (CONF:16867).SHOULD contain zero or one [0..1] quantity (CONF:8751).MAY contain zero or one [0..1] participant (CONF:8752) such that itSHALL contain exactly one [1..1] @typeCode="PRD" Product (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8754).SHALL contain exactly one [1..1] Product Instance (templateId:2.16.840.1.113883.10.20.22.4.37) (CONF:15900).SEQ Table \* ARABIC384: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentNon-Medicinal Supply Activity (V2)[supply: templateId 2.16.840.1.113883.10.20.22.4.50.2 (open)]SEQ Table \* ARABIC385: Non-Medicinal Supply Activity (V2) ContextsContained By:Contains:Mental Status Section (NEW) (optional)Medical Device Applied (NEW) (optional)Cognitive Status Observation (V2) (optional)Functional Status Section (V2) (optional)Functional Status Observation (V2) (optional)Intervention Act (NEW) (optional)Instruction (V2)Product InstanceThis template represents non-medicinal supplies, such as medical equipment. - NOTES: RENT OR OWN EXPIRATION DATESEQ Table \* ARABIC386: Non-Medicinal Supply Activity (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.50.2']entryRelationship0..1MAY30277@typeCode1..1SHALL30278SUBJ@inversionInd1..1SHALL30279TRUEact1..1SHALL31393@classCode1..1SHALL87452.16.840.1.113883.5.6 (HL7ActClass) = SPLY@moodCode1..1SHALL87462.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALL8747@root1..1SHALL105092.16.840.1.113883.10.20.22.4.50.2id1..*SHALL8748statusCode1..1SHALL8749effectiveTime0..1SHOULDIVL_TS15498quantity0..1SHOULD8751participant0..1MAY8752@typeCode1..1SHALL87542.16.840.1.113883.5.90 (HL7ParticipationType) = PRDparticipantRole1..1SHALL15900SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8745).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:8746).SHALL contain exactly one [1..1] templateId (CONF:8747) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.50.2" (CONF:10509).SHALL contain at least one [1..*] id (CONF:8748).SHALL contain exactly one [1..1] statusCode (CONF:8749).SHOULD contain zero or one [0..1] effectiveTime (CONF:15498).The effectiveTime, if present, SHOULD contain zero or one 0..1] high (CONF:16867).SHOULD contain zero or one [0..1] quantity (CONF:8751).MAY contain zero or one [0..1] participant (CONF:8752) such that itSHALL contain exactly one [1..1] @typeCode="PRD" Product (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8754).SHALL contain exactly one [1..1] Product Instance (templateId:2.16.840.1.113883.10.20.22.4.37) (CONF:15900).MAY contain zero or one [0..1] entryRelationship (CONF:30277) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CONF:30278).SHALL contain exactly one [1..1] @inversionInd="TRUE" (CONF:30279).SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31393).SEQ Table \* ARABIC387: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentFigure SEQ Table \* ARABIC46: Sample<?xml version="1.0" encoding="UTF-8"?><supply classCode="SPLY" moodCode="RQO"> <templateId root="2.16.840.1.113883.10.20.22.4.50"/>  <id root="2413773c-2372-4299-bbe6-5b0f60664446"/> <statusCode code="completed"/> <effectiveTime xsi:type="IVL_TS"> <high value="20130703"/> </effectiveTime> <quantity value="1"/> <participant typeCode="PRD"> <participantRole classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.37" />  <id root="742aee30-21c5-11e1-bfc2-0800200c9a66" /> <playingDevice> <code code="44668000" displayName="Pump" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText>Pumps</originalText> </code> </playingDevice> <scopingEntity> <id root="eb936010-7b17-11db-9fe1-0800200c9b65" /> <desc>Good Health Durable Medical Equipment</desc> </scopingEntity> </participantRole> </participant></supply>Number of Pressure Ulcers Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.76 (open)]SEQ Table \* ARABIC388: Number of Pressure Ulcers Observation ContextsContained By:Contains:Health Concern Act (NEW) (optional)Physical Exam Section (V2) (optional)This clinical statement enumerates the number of pressure ulcers observed in a particular stage.SEQ Table \* ARABIC389: Number of Pressure Ulcers Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.76']@classCode1..1SHALL147052.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL147062.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14707@root1..1SHALL147082.16.840.1.113883.10.20.22.4.76id1..*SHALL14709statusCode1..1SHALL14714@code1..1SHALL191082.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL14715author0..1MAY14717entryRelationship1..1SHALL14718@typeCode1..1SHALL147192.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL14720@classCode1..1SHALL147212.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL147222.16.840.1.113883.5.1001 (ActMood) = EVNvalue1..1SHALLCD147252.16.840.1.113883.11.20.9.35 (Pressure Ulcer Stage)code1..1SHALL14767@code1..1SHALL147682264892003value1..1SHALLINT14771SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14705).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14706).SHALL contain exactly one [1..1] templateId (CONF:14707) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.76" (CONF:14708).SHALL contain at least one [1..*] id (CONF:14709).SHALL contain exactly one [1..1] code (CONF:14767).This code SHALL contain exactly one [1..1] @code="2264892003" number of pressure ulcers (CONF:14768).SHALL contain exactly one [1..1] statusCode (CONF:14714).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19108).SHALL contain exactly one [1..1] effectiveTime (CONF:14715).SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:14771).MAY contain zero or one [0..1] author (CONF:14717).SHALL contain exactly one [1..1] entryRelationship (CONF:14718).This entryRelationship SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14719).This entryRelationship SHALL contain exactly one [1..1] observation (CONF:14720).This observation SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14721).This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14722).This observation SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 STATIC (CONF:14725).SEQ Table \* ARABIC390: Pressure Ulcer StageValue Set: Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35CodeCode SystemPrint Name421076008SNOMED CTPressure Ulcer Stage 1420324007SNOMED CTPressure Ulcer Stage 2421927004SNOMED CTPressure Ulcer Stage 3420597008SNOMED CTPressure Ulcer Stage 4421594008SNOMED CTNonstageable pressureNutritional Status Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.124 (open)]SEQ Table \* ARABIC391: Nutritional Status Observation (NEW) ContextsContained By:Contains:Nutrition Section (NEW) (optional)Health Concern Act (NEW) (optional)Diet (NEW)This template describes the overall nutritional status of the patient and findings related to nutritional status. SEQ Table \* ARABIC392: Nutritional Status Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.124']entryRelationship1..*SHALL30323@typeCode1..1SHALL30335SUBJobservation1..1SHALL30336@classCode1..1SHALL298412.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL298422.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL29843@root1..1SHALL298442.16.840.1.113883.10.20.22.4.124id1..*SHALL29845code1..1SHALL29846@code1..1SHALL2989787276001@codeSystem1..1SHALL298982.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96statusCode1..1SHALL29852@code1..1SHALL298532.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALL298542.16.840.1.113883.1.11.20.2.7 (Nutritional Status)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:29841).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:29842).SHALL contain exactly one [1..1] templateId (CONF:29843) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.124" (CONF:29844).SHALL contain at least one [1..*] id (CONF:29845).SHALL contain exactly one [1..1] code (CONF:29846).This code SHALL contain exactly one [1..1] @code="87276001" nutritional status (observable entity) (CONF:29897).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:29898).SHALL contain exactly one [1..1] statusCode (CONF:29852).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:29853).SHALL contain exactly one [1..1] value, which SHOULD be selected from ValueSet Nutritional Status 2.16.840.1.113883.1.11.20.2.7 DYNAMIC (CONF:29854).SHALL contain at least one [1..*] entryRelationship (CONF:30323) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CONF:30335).SHALL contain exactly one [1..1] Diet (NEW) (templateId:2.16.840.1.113883.10.20.22.4.138) (CONF:30336).SEQ Table \* ARABIC393: Nutritional StatusValue Set: Nutritional Status 2.16.840.1.113883.1.11.20.2.7A Value Set of codes representing nutrition problems.CodeCode SystemPrint Name371597004SNOMED CTemaciated (finding)284670008SNOMED CTnutritionally compromised (finding)248325000SNOMED CTundernourished (finding)248324001SNOMED CTwell nourished (finding)75051000SNOMED CTFood intolerance (finding)414285001SNOMED CTFood allergy (disorder)414915002SNOMED CTObese (finding)288939007SNOMED CTSwallowing difficulty (finding)175130015SNOMED CTbiting/chewing (masticatory) difficulty2647146015SNOMED CTBreastfeeding difficulty61578001SNOMED CTAltered GI function95907004SNOMED CTFood-medication interaction107647005SNOMED CTWeight factors, nutrition diagnosis2483342006SNOMED CTunderweightFigure SEQ Table \* ARABIC47: Sample<observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.124"/> <id root="c12ecaaf-53f8-4593-8f79-359aeaa3948b"/> <code xsi:type="CD" code="87276001" displayName="nutritional status " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"> <originalText>Nutritional Status</originalText> </code> <statusCode code="completed"/> <effectiveTime value="20130512"/> <value xsi:type="CD" code="248324001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="well nourished"/> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.138"/> ... </observation> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.138"/> ... </entryRelationship> Observation Plan (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.44.2 (open)]SEQ Table \* ARABIC394: Observation Plan (V2) ContextsContained By:Contains:Plan of Treatment Section (V2) (optional)Goal Observation (NEW) (optional)Intervention Act (NEW) (optional)Patient Priority Preference (NEW)Provider Priority Preference (NEW)The Plan Activity Observation represents an intended goal (e.g.pulse oximetry 95%), milestones, or planned outcomes (e.g. patient will exercise 3 times a week). Overarching goals and beliefs are also represented in this template. The importance of the the planned outcome/goal to the patient and provider is communicated through Patient Priority Preference and Provider Priority Preference. The effective time indicates the time when the goal or outcome is created. SEQ Table \* ARABIC395: Observation Plan (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.44.2']@classCode1..1SHALL85812.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL85822.16.840.1.113883.11.20.9.25 (Plan of Care moodCode (Observation))templateId1..1SHALL30451@root1..1SHALL304522.16.840.1.113883.10.20.22.4.44.2id1..*SHALL8584statusCode1..1SHALL30453effectiveTime1..1SHALL30454performer0..*MAY30456participant0..*MAY30457code1..1SHALL31030value0..*MAY31031entryRelationship0..*MAY31073@typeCode1..1SHALL310742.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31075entryRelationship0..*MAY31076@typeCode1..1SHALL310772.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31078SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8581).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Plan of Care moodCode (Observation) 2.16.840.1.113883.11.20.9.25 STATIC 2011-09-30 (CONF:8582).SHALL contain exactly one [1..1] templateId (CONF:30451) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.44.2" (CONF:30452).SHALL contain at least one [1..*] id (CONF:8584).SHALL contain exactly one [1..1] code (CONF:31030).SHALL contain exactly one [1..1] statusCode (CONF:30453).SHALL contain exactly one [1..1] effectiveTime (CONF:30454).MAY contain zero or more [0..*] value (CONF:31031).Performers represent clinicians who are responsible for assessing and treating the patient.MAY contain zero or more [0..*] performer (CONF:30456).Participants represent those in supporting roles such as caregiver, who participate in the patient's care.MAY contain zero or more [0..*] participant (CONF:30457).This entryRelationship represents the priority that the patient places on the observation.MAY contain zero or more [0..*] entryRelationship (CONF:31073) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31074).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31075).This entryRelationship represents the priority that a provider places on the observation.MAY contain zero or more [0..*] entryRelationship (CONF:31076) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31077).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31078).SEQ Table \* ARABIC396: Plan of Care moodCode (Observation)Value Set: Plan of Care moodCode (Observation) 2.16.840.1.113883.11.20.9.25CodeCode SystemPrint NameINTActMoodIntentGOLActMoodGoalPRMSActMoodPromisePRPActMoodProposalRQOActMoodRequestFigure SEQ Table \* ARABIC48: Sample<entry> <observation classCode="OBS" moodCode="GOL">  <templateId root="2.16.840.1.113883.10.20.22.4.44.2"/> <id root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1"/>  <code code="252465000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pulse oximetry"/> <text>Care Goal: Pulse Oximetry greater than 92%</text> <statusCode code="active"/> <effectiveTime value="20130615"/> <value xsi:type="IVL_PQ"> <low value="92" unit="%"/> </value> <participant typeCode="IND"> <participantRole classCode="IND"> <code code="MTH" codeSystem="2.16.840.1.113883.5.111" displayName="Mother"/> </participantRole> </participant> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.142"/> ... </observation> </entryRelationship> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.143"/> <id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/> ... </observation> </entryRelationship> </observation></entry>Goal Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.121 (open)]SEQ Table \* ARABIC397: Goal Observation (NEW) ContextsContained By:Contains:Goals Section (NEW) (required)Intervention Act (NEW) (optional)Outcome Observation (NEW) (required)Act Plan (V2)Encounter Plan (V2)Health Concern Act (NEW)Observation Plan (V2)Outcome Observation (NEW)Patient Priority Preference (NEW)Procedure Plan (V2)Provider Priority Preference (NEW)Substance Administration Plan (V2)Supply Plan (V2)This template represents patient care goals.??A Goal Observation template may have components that are acts, encounters, observations, procedures, substance administrations or supplies. These components are related to the goal by entryRelationships to various Plan Activity templates.SEQ Table \* ARABIC398: Goal Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.121']entryRelationship0..*MAY30770@typeCode1..1SHALL307712.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPact1..1SHALL30772entryRelationship0..*MAY30704@typeCode1..1SHALL307052.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPencounter1..1SHALL30706entryRelationship0..*SHOULD30701@typeCode1..1SHALL307022.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRact1..1SHALL30703entryRelationship0..*MAY30707@typeCode1..1SHALL307082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL30709templateId1..1SHALL8583@root1..1SHALL105122.16.840.1.113883.10.20.22.4.121@classCode1..1SHALL304182.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL304192.16.840.1.113883.5.1001 (ActMood) = GOLentryRelationship0..*MAY30710@typeCode1..1SHALL307112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPprocedure1..1SHALL30712entryRelationship0..*MAY30713@typeCode1..1SHALL307142.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPsubstanceAdministration1..1SHALL30715entryRelationship0..*MAY30716@typeCode1..1SHALL307172.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPsupply1..1SHALL30718code1..1SHALL30784entryRelationship0..1SHOULD30785@typeCode1..1SHALL307862.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL30787entryRelationship0..*SHOULD30788@typeCode1..1SHALL307892.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL30790author1..*SHALL30995entryRelationship0..*MAY31448@typeCode1..1SHALL314492.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPentryRelationship0..*MAY31451@typeCode1..1SHALL314522.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31453Conforms to Observation Plan (V2) template (2.16.840.1.113883.10.20.22.4.44.2).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30418).SHALL contain exactly one [1..1] @moodCode="GOL" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:30419).SHALL contain exactly one [1..1] templateId (CONF:8583) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.121" (CONF:10512).SHALL contain exactly one [1..1] code (CONF:30784).If the author is set to the recordTarget (patient), this is a patient goal.??If the author is set to a provider, this is a provider goal. If both patient and provider are set as authors, this is a negotiated goal.SHALL contain at least one [1..*] author (CONF:30995).This entryRelationship represents the relationship "Goal REFERS TO Health Concern".SHOULD contain zero or more [0..*] entryRelationship (CONF:30701) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30702).SHALL contain exactly one [1..1] Health Concern Act (NEW) (templateId:2.16.840.1.113883.10.20.22.4.132) (CONF:30703).This entryRelationship represents an encounter component of the goal.MAY contain zero or more [0..*] entryRelationship (CONF:30704) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30705).SHALL contain exactly one [1..1] Encounter Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.40.2) (CONF:30706).This entryRelationship represents an observation component of the goal.MAY contain zero or more [0..*] entryRelationship (CONF:30707) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30708).SHALL contain exactly one [1..1] Observation Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.44.2) (CONF:30709).This entryRelationship represents a procedure component of the goal.MAY contain zero or more [0..*] entryRelationship (CONF:30710) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30711).SHALL contain exactly one [1..1] Procedure Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.41.2) (CONF:30712).This entryRelationship represents an substance administration component of the goal.MAY contain zero or more [0..*] entryRelationship (CONF:30713) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30714).SHALL contain exactly one [1..1] Substance Administration Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.42.2) (CONF:30715).This entryRelationship represents a supply component of the goal.MAY contain zero or more [0..*] entryRelationship (CONF:30716) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30717).SHALL contain exactly one [1..1] Supply Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.43.2) (CONF:30718).This entryRelationship represents an act component of the goal.MAY contain zero or more [0..*] entryRelationship (CONF:30770) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30771).SHALL contain exactly one [1..1] Act Plan (V2) (templateId:2.16.840.1.113883.10.20.22.4.39.2) (CONF:30772).This entryRelationship represents the priority that the patient puts on the goal.SHOULD contain zero or one [0..1] entryRelationship (CONF:30785) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30786).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:30787).This entryRelationship represents the priority that a provider puts on the goal.SHOULD contain zero or more [0..*] entryRelationship (CONF:30788) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:30789).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:30790).This entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone.MAY contain zero or more [0..*] entryRelationship (CONF:31448) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31449).SHALL contain exactly one 1..1] Goal Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.121) (CONF:31450).This entryRelationship represents the relationship between a Goal Observation and an Outcome Observation (Goal Observation RELATES TO Outcome Observation).TODO* Not 100% convinced that we need this relationship - could be redundant.??Need to do sample file and rethink.MAY contain zero or more [0..*] entryRelationship (CONF:31451) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31452).SHALL contain exactly one [1..1] Outcome Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.144) (CONF:31453).Figure SEQ Table \* ARABIC49: Sample<observation classCode="OBS" moodCode="GOL"><templateId root="2.16.840.1.113883.10.20.22.4.44.2"/><templateId root="2.16.840.1.113883.10.20.22.4.121"/><id root="9450c526-8cc5-45af-b1fd-15c21a45235a"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/><statusCode code="active"/><effectiveTime value="20130701"/><priorityCode code="394849002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"displayName="High Priority"/><value xsi:type="CD" code="408365002" codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED CT" displayName="Able to use medication (clinical finding)"/><entryRelationship typeCode="COMP"><substanceAdministration classCode="SBADM" moodCode="INT"><templateId root="2.16.840.1.113883.10.20.22.4.42.2"/><id root="b8a4eae5-5b6b-480a-9b44-0431a7635890"/><statusCode code="active"/><routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1"codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/><consumable><manufacturedProduct classCode="MANU"><manufacturedMaterial><code code="67866001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"displayName="Insulin (substance)"/></manufacturedMaterial></manufacturedProduct></consumable></substanceAdministration></entryRelationship></observation><observation classCode="OBS" moodCode="GOL"><templateId root="2.16.840.1.113883.10.20.22.4.44.2"/><templateId root="2.16.840.1.113883.10.20.22.4.121"/><id root="286471bb-1e39-40e9-9906-f8620b09ccb6"/><code code="252465000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED"displayName="Pulse oximetry"/><statusCode code="active"/><effectiveTime value="20130701"/><value xsi:type="IVL_PQ"><low value="92" unit="%"/></value>...</observation>Patient Preference[observation: templateId 2.16.840.1.113883.10.20.24.3.83 (open)]SEQ Table \* ARABIC399: Patient Preference ContextsContained By:Contains:Communication from Provider to Provider (optional)Preferences are choices made by patients relative to options for care or treatment (including scheduling, care experience, and meeting of personal health goals) and the sharing and disclosure of their health information.SEQ Table \* ARABIC400: Patient Preference Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.83']@classCode1..1SHALL111182.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL111192.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11120@root1..1SHALL111212.16.840.1.113883.10.20.24.3.83code1..1SHALL11123@code1..1SHALL111242.16.840.1.113883.5.8 (ActReason) = PATvalue1..1SHALLCD11125id1..1SHALL11355SHALL contain exactly one [1..1] @classCode="OBS", which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6) STATIC (CONF:11118).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:11119).SHALL contain exactly one [1..1] templateId (CONF:11120).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.83" (CONF:11121).SHALL contain exactly one [1..1] id (CONF:11355).SHALL contain exactly one [1..1] code (CONF:11123).This code SHALL contain exactly one [1..1] @code="PAT" Patient Request (CodeSystem: ActReason 2.16.840.1.113883.5.8 STATIC) (CONF:11124).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11125).Patient Priority Preference (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.142 (open)]SEQ Table \* ARABIC401: Patient Priority Preference (NEW) ContextsContained By:Contains:Problem Observation (V2) (optional)Goal Observation (NEW) (optional)Act Plan (V2) (optional)Encounter Plan (V2) (optional)Procedure Plan (V2) (optional)Observation Plan (V2) (optional)Supply Plan (V2) (optional)Substance Administration Plan (V2) (optional)Health Concern Act (NEW) (optional)Author Participant (NEW)This template represents patient preferences.Preferences are choices made by patients relative to options for care or treatment (including scheduling, care experience, and meeting of personal health goals) and the sharing and disclosure of their health information.SEQ Table \* ARABIC402: Patient Priority Preference (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.142']@classCode1..1SHALL309592.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL309602.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL30961@root1..1SHALL309622.16.840.1.113883.10.20.22.4.142id1..1SHALL30963code1..1SHALL30964@code1..1SHALL30965PAT@codeSystem0..1MAY309662.16.840.1.113883.5.8 (ActReason) = 2.16.840.1.113883.5.8priorityCode0..1SHOULD309672.16.840.1.113883.11.20.9.57 (Priority Order)value1..1SHALLCD309682.16.840.1.113883.11.20.9.60 (Priority Level)author0..*SHOULD30969SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30959).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:30960).SHALL contain exactly one [1..1] templateId (CONF:30961).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.142" (CONF:30962).SHALL contain exactly one [1..1] id (CONF:30963).SHALL contain exactly one [1..1] code (CONF:30964).This code SHALL contain exactly one [1..1] @code="PAT" Patient request (CONF:30965).This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.5.8" (CodeSystem: ActReason 2.16.840.1.113883.5.8) (CONF:30966).SHOULD contain zero or one [0..1] priorityCode, which SHOULD be selected from ValueSet Priority Order 2.16.840.1.113883.11.20.9.57 (CONF:30967).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Priority Level 2.16.840.1.113883.11.20.9.60 (CONF:30968).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:30969).SEQ Table \* ARABIC403: Priority OrderValue Set: Priority Order 2.16.840.1.113883.11.20.9.57CodeCode SystemPrint Name255216001SNOMED CTFirst81170007SNOMED CTSecond70905002SNOMED CTThird29970001SNOMED CTFourth32088001SNOMED CTFifth53046009SNOMED CTSixth86777004SNOMED CTSeventh51601003SNOMED CTEighth58584009SNOMED CTNinth28226006SNOMED CTTenthSEQ Table \* ARABIC404: Priority LevelValue Set: Priority Level 2.16.840.1.113883.11.20.9.60CodeCode SystemPrint Name394849002SNOMED CTHigh priority394848005SNOMED CTNormal priority441808003SNOMED CTDelayed priorityPatient Referral Activity Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.140 (open)]SEQ Table \* ARABIC405: Patient Referral Activity Observation (NEW) ContextsContained By:Contains:Reason for Referral Section (V2) (optional)This clinical statement represents the clinical Purpose of the referral, such as Request for Consultation and Request for Procedure.SEQ Table \* ARABIC406: Patient Referral Activity Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.140']@classCode1..1SHALL308842.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL308852.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt) = INTtemplateId1..1SHALL30886@root1..1SHALL308872.16.840.1.113883.10.20.22.4.140id1..*SHALL30888code1..1SHALL308892.16.840.1.113883.11.20.9.56 (Referral Types Valueset)qualifier0..1MAY30896statusCode1..1SHALL308922.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode) = completedeffectiveTime0..1SHOULD30893low1..1SHALL30895SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:30884).SHALL contain exactly one [1..1] @moodCode="INT" (ValueSet: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03) (CONF:30885).SHALL contain exactly one [1..1] templateId (CONF:30886) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.140" (CONF:30887).SHALL contain at least one [1..*] id (CONF:30888).SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Referral Types Valueset 2.16.840.1.113883.11.20.9.56 DYNAMIC (CONF:30889) such that itMAY contain zero or one [0..1] qualifier (CONF:30896).Note: May include context qualifiers. E.g. 'Request for '.SHALL contain exactly one [1..1] statusCode="completed" (ValueSet: ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC) (CONF:30892).SHOULD contain zero or one [0..1] effectiveTime (CONF:30893).The effectiveTime/low represents the date/time of the referral activity.The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:30895).SEQ Table \* ARABIC407: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentSEQ Table \* ARABIC408: Referral Types ValuesetValue Set: Referral Types Valueset 2.16.840.1.113883.11.20.9.56CodeCode SystemPrint Name44383000SNOMED CTPatient referral for consultation308539001SNOMED CTRequest procedure183877003SNOMED CTPrivate referral408293001SNOMED CTEarlier referral for specialist review 44383000SNOMED CTPatient referral for consultation307834000SNOMED CTReferral by person308292007SNOMED CTTransfer of careSEQ Table \* ARABIC409: ProcedureAct statusCodeValue Set: ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22A ValueSet of HL7 actStatus codes for use with a procedure activityCodeCode SystemPrint NamecompletedActStatusCompletedactiveActStatusActiveabortedActStatusAbortedcancelledActStatusCancelledFigure SEQ Table \* ARABIC50: Sample<observation classCode="OBS" moodCode="INT">  <templateId root="2.16.840.1.113883.10.20.22.4.140" /> <id root="70bdd7db-e02d-4eff-9829-35e3b7d9e154" /> <code code="44383000" displayName="Patient referral for consultation" codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96"> <qualifier> <name code="106227002" displayName="General information qualifier" codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96" /> <value code="103320006" displayName="Request for" codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96" /> </qualifier> </code> <statusCode code="completed" /></observation>Physician of Record Participant (V2)[entry: templateId 2.16.840.1.113883.10.20.6.2.2.2 (open)]SEQ Table \* ARABIC410: Physician of Record Participant (V2) ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)US Realm Person Name (PN.US.FIELDED)This encounterParticipant is the attending physician and is usually different from the Physician Reading Study Performer defined in documentationOf/serviceEvent.SEQ Table \* ARABIC411: Physician of Record Participant (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueentry[templateId/@root = '2.16.840.1.113883.10.20.6.2.2.2']@typeCode1..1SHALL88812.16.840.1.113883.5.90 (HL7ParticipationType) = ATNDtemplateId1..1SHALL16072@root1..1SHALL160732.16.840.1.113883.10.20.6.2.2.2assignedEntity1..1SHALL8886id1..*SHALL8887@root1..1SHALL312042.16.840.1.113883.4.6code1..1SHALL8888representedOrganization0..1MAY16074name0..1SHOULD16075assignedPerson0..1SHOULD30928name1..1SHALL30929SHALL contain exactly one [1..1] @typeCode="ATND" Attender (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8881).SHALL contain exactly one [1..1] templateId (CONF:16072) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.2.2" (CONF:16073).SHALL contain exactly one [1..1] assignedEntity (CONF:8886).This assignedEntity SHALL contain at least one [1..*] id (CONF:8887).MISSING NARRATIVE FOR PRIMITIVE??(CONF:31203).SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:31204).This assignedEntity SHALL contain exactly one [1..1] code (CONF:8888).SHALL contain a valid DICOM Organizational Role from DICOM CID 7452??(Value Set 1.2.840.10008.6.1.516)(@codeSystem is 1.2.840.10008.2.16.4) or an appropriate national health care provider coding system (e.g., NUCC in the U.S., where @codeSystem is 2.16.840.1.113883.6.101)Footnote: DICOM Part 16 (NEMA PS3.16), page 631 in the 2011 edition. See (CONF:8889).This assignedEntity MAY contain zero or one [0..1] representedOrganization (CONF:16074).The representedOrganization, if present, SHOULD contain zero or one [0..1] name (CONF:16075).This assignedEntity SHOULD contain zero or one [0..1] assignedPerson (CONF:30928).The assignedPerson, if present, SHALL contain exactly one [1..1] US Realm Person Name (PN.US.FIELDED) (templateId:2.16.840.1.113883.10.20.22.5.1.1) (CONF:30929).Figure SEQ Table \* ARABIC51: Sample<encounterParticipant typeCode="ATND"> <templateId root="2.16.840.1.113883.10.20.6.2.2.2" /> <assignedEntity> <id extension="44444444" root="2.16.840.1.113883.4.6" /> <code code="208D00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="General Practice" /> <addr nullFlavor="NI" /> <telecom nullFlavor="NI" /> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Fay</given> <family>Family</family> </name> </assignedPerson> </assignedEntity></encounterParticipant>Policy Activity (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.61.2 (closed)]SEQ Table \* ARABIC412: Policy Activity (V2) ContextsContained By:Contains:Coverage Activity (V2) (required)A policy activity represents the policy or program providing the coverage. The person for whom payment is being provided (i.e., the patient) is the covered party. The subscriber of the policy or program is represented as a participant that is the holder the coverage. The payer is represented as the performer of the policy activity.SEQ Table \* ARABIC413: Policy Activity (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.61.2']@classCode1..1SHALL88982.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL88992.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL8900@root1..1SHALL105162.16.840.1.113883.10.20.22.4.61.2id1..*SHALL8901code1..1SHALL8903@code0..1SHOULD191852.16.840.1.113883.3.88.12.3221.5.2 (Health Insurance Type Value Set)statusCode1..1SHALL8902@code1..1SHALL191092.16.840.1.113883.5.14 (ActStatus) = completedperformer1..1SHALL8906@typeCode1..1SHALL89072.16.840.1.113883.5.90 (HL7ParticipationType) = PRFtemplateId1..1SHALL16808@root1..1SHALL168092.16.840.1.113883.10.20.22.4.87assignedEntity1..1SHALL8908id1..*SHALL8909code0..1SHOULD8914@code1..1SHALL159922.16.840.1.113883.1.11.10416 (HL7FinanciallyResponsiblePartyType)addr0..1MAY8910telecom0..*MAY8911representedOrganization0..1SHOULD8912name0..1SHOULD8913performer0..1SHOULD89612.16.840.1.113883.5.90 (HL7ParticipationType) = PRFtemplateId1..1SHALL16810@root1..1SHALL168112.16.840.1.113883.10.20.22.4.88time0..1SHOULD8963assignedEntity1..1SHALL8962code1..1SHALL8968@code1..1SHALL160962.16.840.1.113883.5.110 (RoleClass) = GUARaddr0..1SHOULD8964telecom0..*SHOULD8965participant1..1SHALL8916@typeCode1..1SHALL89172.16.840.1.113883.5.90 (HL7ParticipationType) = COVtemplateId1..1SHALL16812@root1..1SHALL168142.16.840.1.113883.10.20.22.4.89time0..1SHOULD8918low0..1SHOULD8919high0..1SHOULD8920participantRole1..1SHALL8921id1..*SHALL8922code1..1SHALL8923@code0..1SHOULD160782.16.840.1.113883.1.11.18877 (Coverage Role Type Value Set)addr0..1SHOULD8956playingEntity0..1SHOULD8932name1..1SHALL8930sdtc:birthTime1..1SHALL31344participant0..1SHOULD8934@typeCode1..1SHALL89352.16.840.1.113883.5.90 (HL7ParticipationType) = HLDtemplateId1..1SHALL16813@root1..1SHALL168152.16.840.1.113883.10.20.22.4.90time0..1MAY8938participantRole1..1SHALL8936id1..*SHALL8937addr0..1SHOULD8925entryRelationship1..*SHALL8939@typeCode1..1SHALL89402.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRSHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8898).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8899).SHALL contain exactly one [1..1] templateId (CONF:8900) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.61.2" (CONF:10516).This id is a unique identifier for the policy or program providing the coverageSHALL contain at least one [1..*] id (CONF:8901).SHALL contain exactly one [1..1] code (CONF:8903).This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC (CONF:19185).SHALL contain exactly one [1..1] statusCode (CONF:8902).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19109).This performer represents the Payer.SHALL contain exactly one [1..1] performer (CONF:8906) such that itSHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8907).SHALL contain exactly one [1..1] templateId (CONF:16808).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.87" Payer Performer (CONF:16809).SHALL contain exactly one [1..1] assignedEntity (CONF:8908).This assignedEntity SHALL contain at least one [1..*] id (CONF:8909).This assignedEntity SHOULD contain zero or one [0..1] code (CONF:8914).The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet HL7FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416 DYNAMIC (CONF:15992).This assignedEntity MAY contain zero or one [0..1] addr (CONF:8910).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10481).This assignedEntity MAY contain zero or more [0..*] telecom (CONF:8911).This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8912).The representedOrganization, if present, SHOULD contain zero or one [0..1] name (CONF:8913).This performer represents the Guarantor.SHOULD contain zero or one [0..1] performer="PRF" Performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8961) such that itSHALL contain exactly one [1..1] templateId (CONF:16810).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.88" Guarantor Performer (CONF:16811).SHOULD contain zero or one [0..1] time (CONF:8963).SHALL contain exactly one [1..1] assignedEntity (CONF:8962).This assignedEntity SHALL contain exactly one [1..1] code (CONF:8968).This code SHALL contain exactly one [1..1] @code="GUAR" Guarantor (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:16096).This assignedEntity SHOULD contain zero or one [0..1] addr (CONF:8964).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10482).This assignedEntity SHOULD contain zero or more [0..*] telecom (CONF:8965).SHOULD include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:8967).SHALL contain exactly one [1..1] participant (CONF:8916) such that itSHALL contain exactly one [1..1] @typeCode="COV" Coverage target (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8917).SHALL contain exactly one [1..1] templateId (CONF:16812).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.89" Covered Party Participant (CONF:16814).SHOULD contain zero or one [0..1] time (CONF:8918).The time, if present, SHOULD contain zero or one [0..1] low (CONF:8919).The time, if present, SHOULD contain zero or one [0..1] high (CONF:8920).SHALL contain exactly one [1..1] participantRole (CONF:8921).This participantRole SHALL contain at least one [1..*] id (CONF:8922).This id is a unique identifier for??the covered party member. Implementers SHOULD use the same GUID for each instance of a member identifier from the same health plan (CONF:8984).This participantRole SHALL contain exactly one [1..1] code (CONF:8923).This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877 DYNAMIC (CONF:16078).This participantRole SHOULD contain zero or one [0..1] addr (CONF:8956).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10484).This participantRole SHOULD contain zero or one [0..1] playingEntity (CONF:8932).If the covered party’s name is recorded differently in the health plan and in the registration/medication summary (due to marriage or for other reasons), use the name as it is recorded in the health plan.The playingEntity, if present, SHALL contain exactly one [1..1] name (CONF:8930).If the covered party’s date of birth is recorded differently in the health plan and in the registration/medication summary, use the date of birth as it is recorded in the health plan.The playingEntity, if present, SHALL contain exactly one [1..1] sdtc:birthTime (CONF:31344).The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the birthTime element (CONF:31345).SHOULD contain zero or one [0..1] participant (CONF:8934) such that itSHALL contain exactly one [1..1] @typeCode="HLD" Holder (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8935).SHALL contain exactly one [1..1] templateId (CONF:16813).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.90" Policy Holder Participant (CONF:16815).MAY contain zero or one [0..1] time (CONF:8938).SHALL contain exactly one [1..1] participantRole (CONF:8936).This participantRole SHALL contain at least one [1..*] id (CONF:8937).This id is a unique identifier for the subscriber of the coverage (CONF:10120).This participantRole SHOULD contain zero or one [0..1] addr (CONF:8925).The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10483).When the Subscriber is the patient, the participant element describing the subscriber SHALL NOT be present. This information will be recorded instead in the data elements used to record member information (CONF:17139).SHALL contain at least one [1..*] entryRelationship (CONF:8939) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8940).The target of a policy activity with act/entryRelationship/@typeCode="REFR" SHALL be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) OR an act, with act@classCode="ACT"] and act@moodCode="DEF"], representing a description of the coverage plan (CONF:8942).A description of the coverage plan SHALL contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:8943).SEQ Table \* ARABIC414: Health Insurance Type Value SetValue Set: Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2CodeCode SystemPrint Name12Insurance Type CodeMedicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan13Insurance Type CodeMedicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan14Insurance Type CodeMedicare Secondary, No-fault Insurance including Auto is Primary15Insurance Type CodeMedicare Secondary Worker's Compensation16Insurance Type CodeMedicare Secondary Public Health Service (PHS)or Other Federal Agency41Insurance Type CodeMedicare Secondary Black Lung42Insurance Type CodeMedicare Secondary Veteran's Administration43Insurance Type CodeMedicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)47Insurance Type CodeMedicare Secondary, Other Liability Insurance is PrimaryAPInsurance Type CodeAuto Insurance PolicyC1Insurance Type CodeCommercialCOInsurance Type CodeConsolidated Omnibus Budget Reconciliation Act (COBRA)CPInsurance Type CodeMedicare Conditionally PrimaryDInsurance Type CodeDisabilityDBInsurance Type CodeDisability BenefitsEPInsurance Type CodeExclusive Provider OrganizationFFInsurance Type CodeFamily or FriendsGPInsurance Type CodeGroup PolicyHMInsurance Type CodeHealth Maintenance Organization (HMO)HNInsurance Type CodeHealth Maintenance Organization (HMO) - Medicare Risk...SEQ Table \* ARABIC415: HL7FinanciallyResponsiblePartyTypeValue Set: HL7FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416RoleClass 2.16.840.1.113883.5.110 SystemPrint NameGUARRoleClassGuarantorEMPRoleClassEmployeeINVSBJRoleClassInvestigation SubjectSEQ Table \* ARABIC416: Coverage Role Type Value SetValue Set: Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877CodeCode SystemPrint NamePostprocedure Diagnosis (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.51.2 (open)]SEQ Table \* ARABIC417: Postprocedure Diagnosis (V2) ContextsContained By:Contains:Postprocedure Diagnosis Section (V2) (optional)Health Concern Act (NEW) (optional)Problem Observation (V2)This template represents the diagnosis or diagnoses discovered or confirmed during the procedure. They may be the same as preprocedure diagnoses or indications.SEQ Table \* ARABIC418: Postprocedure Diagnosis (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.51.2']@classCode1..1SHALL8756ACT@moodCode1..1SHALL8757EVNtemplateId1..1SHALL16766@root1..1SHALL167672.16.840.1.113883.10.20.22.4.51.2code1..1SHALL19151@code1..1SHALL191522.16.840.1.113883.6.1 (LOINC) = 59769-0entryRelationship1..*SHALL8759@typeCode1..1SHALL87602.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL15583SHALL contain exactly one [1..1] @classCode="ACT" (CONF:8756).SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:8757).SHALL contain exactly one [1..1] templateId (CONF:16766) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.51.2" (CONF:16767).SHALL contain exactly one [1..1] code (CONF:19151).This code SHALL contain exactly one [1..1] @code="59769-0" Postprocedure diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19152).SHALL contain at least one [1..*] entryRelationship (CONF:8759).Such entryRelationships SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8760).Such entryRelationships SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15583).Precondition for Substance Administration[criterion: templateId 2.16.840.1.113883.10.20.22.4.25 (open)]SEQ Table \* ARABIC419: Precondition for Substance Administration ContextsContained By:Contains:Immunization Activity (V2) (optional)A criterion for administration can be used to record that the medication is to be administered only when the associated criteria are met.SEQ Table \* ARABIC420: Precondition for Substance Administration Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuecriterion[templateId/@root = '2.16.840.1.113883.10.20.22.4.25']value0..1SHOULDCD7369templateId1..1SHALL7372@root1..1SHALL105172.16.840.1.113883.10.20.22.4.25text0..1MAY7373code0..1SHOULD16854SHALL contain exactly one [1..1] templateId (CONF:7372) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.25" (CONF:10517).SHOULD contain zero or one [0..1] code (CONF:16854).MAY contain zero or one [0..1] text (CONF:7373).SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:7369).Pregnancy Observation[observation: templateId 2.16.840.1.113883.10.20.15.3.8 (open)]SEQ Table \* ARABIC421: Pregnancy Observation ContextsContained By:Contains:Social History Section (V2) (optional)Health Concern Act (NEW) (optional)Estimated Date of DeliveryThis clinical statement represents current and/or prior pregnancy dates enabling investigators to determine if the subject of the case report was pregnant during the course of a condition.SEQ Table \* ARABIC422: Pregnancy Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.15.3.8']entryRelationship0..1MAY458@typeCode1..1SHALL4592.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL15584@classCode1..1SHALL4512.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL4522.16.840.1.113883.5.1001 (ActMood) = EVNstatusCode1..1SHALL455@code1..1SHALL191102.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD457@code1..1SHALL264602.16.840.1.113883.6.96 (SNOMED CT) = 77386006effectiveTime0..1SHOULD2018templateId1..1SHALL16768@root1..1SHALL168682.16.840.1.113883.10.20.15.3.8code1..1SHALL19153@code1..1SHALL191542.16.840.1.113883.5.4 (ActCode) = ASSERTIONSHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:451).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:452).SHALL contain exactly one [1..1] templateId (CONF:16768) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.8" (CONF:16868).SHALL contain exactly one [1..1] code (CONF:19153).This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:19154).SHALL contain exactly one [1..1] statusCode (CONF:455).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19110).SHOULD contain zero or one [0..1] effectiveTime (CONF:2018).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:457).This value SHALL contain exactly one [1..1] @code="77386006" Pregnant (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:26460).MAY contain zero or one [0..1] entryRelationship (CONF:458) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:459).SHALL contain exactly one [1..1] Estimated Date of Delivery (templateId:2.16.840.1.113883.10.20.15.3.1) (CONF:15584).Preoperative Diagnosis (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.65.2 (open)]SEQ Table \* ARABIC423: Preoperative Diagnosis (V2) ContextsContained By:Contains:Preoperative Diagnosis Section (V2) (optional)Health Concern Act (NEW) (optional)Problem Observation (V2)This template represents the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.SEQ Table \* ARABIC424: Preoperative Diagnosis (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.65.2']@classCode1..1SHALL10090ACT@moodCode1..1SHALL10091EVNtemplateId1..1SHALL16770@root1..1SHALL167712.16.840.1.113883.10.20.22.4.65.2code1..1SHALL19155@code1..1SHALL191562.16.840.1.113883.6.1 (LOINC) = 10219-4entryRelationship1..*SHALL10093@typeCode1..1SHALL100942.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL15605SHALL contain exactly one [1..1] @classCode="ACT" (CONF:10090).SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:10091).SHALL contain exactly one [1..1] templateId (CONF:16770) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.65.2" (CONF:16771).SHALL contain exactly one [1..1] code (CONF:19155).This code SHALL contain exactly one [1..1] @code="10219-4" Preoperative Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19156).SHALL contain at least one [1..*] entryRelationship (CONF:10093).Such entryRelationships SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:10094).Such entryRelationships SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15605).Pressure Ulcer Observation (DEPRECATED)[observation: templateId 2.16.840.1.113883.10.20.22.4.70.2 (open)]SEQ Table \* ARABIC425: Pressure Ulcer Observation (DEPRECATED) ContextsContained By:Contains:THIS TEMPLATE HAS BEEN DEPRECATED AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE THE WOUND OBSERVATION TEMPLATE INSTEAD.The pressure ulcer observation contains details about the pressure ulcer such as the stage of the ulcer, location, and dimensions. If the pressure ulcer is a diagnosis, you may find this on the problem list. An example of how this would appear is in the Problem Section.SEQ Table \* ARABIC426: Pressure Ulcer Observation (DEPRECATED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.70.2']@classCode1..1SHALL143832.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL143842.16.840.1.113883.5.1001 (ActMood) = EVN@negationInd0..1MAY14385templateId1..1SHALL14387@root1..1SHALL143882.16.840.1.113883.10.20.22.4.70.2id1..*SHALL14389code1..1SHALL14759@code1..1SHALL147602.16.840.1.113883.5.4 (ActCode) = ASSERTIONtext0..1SHOULD14391reference0..1SHOULD14392@value1..1SHALL15585statusCode1..1SHALL14394@code1..1SHALL191112.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL14395value1..1SHALLCD143962.16.840.1.113883.11.20.9.35 (Pressure Ulcer Stage)targetSiteCode0..*SHOULD14797@code1..1SHALL147982.16.840.1.113883.11.20.9.36 (Pressure Point )qualifier0..1SHOULD14799name1..1SHALL14800@code0..1SHOULD148012.16.840.1.113883.6.96 (SNOMED CT) = 272741003value1..1SHALL14802@code0..1SHOULD148032.16.840.1.113883.11.20.9.37 (TargetSite Qualifiers )entryRelationship0..1SHOULD14410@typeCode1..1SHALL144112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL14619@classCode1..1SHALL146852.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL146862.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALL14620@code1..1SHALL146212.16.840.1.113883.6.96 (SNOMED CT) = 401238003value1..1SHALLPQ14622entryRelationship0..1SHOULD14601@typeCode1..1SHALL14602COMPobservation1..1SHALL14623@classCode1..1SHALL146872.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL146882.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALL14624@code1..1SHALL146252.16.840.1.113883.6.96 (SNOMED CT) = 401239006value1..1SHALLPQ14626entryRelationship0..1SHOULD14605@typeCode1..1SHALL14606COMPobservation1..1SHALL14627@classCode1..1SHALL146892.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL146902.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALL14628@code1..1SHALL146292.16.840.1.113883.6.96 (SNOMED CT) = 425094009value1..1SHALLPQ14630SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14383).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14384).Use negationInd="true" to indicate that the problem was not observed.MAY contain zero or one [0..1] @negationInd (CONF:14385).SHALL contain exactly one [1..1] templateId (CONF:14387) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.70.2" (CONF:14388).SHALL contain at least one [1..*] id (CONF:14389).SHALL contain exactly one [1..1] code (CONF:14759).This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:14760).SHOULD contain zero or one [0..1] text (CONF:14391).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:14392).The reference, if present, SHALL contain exactly one [1..1] @value (CONF:15585).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15586).SHALL contain exactly one [1..1] statusCode (CONF:14394).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19111).SHALL contain exactly one [1..1] effectiveTime (CONF:14395).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 STATIC (CONF:14396).SHOULD contain zero or more [0..*] targetSiteCode (CONF:14797).The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Pressure Point 2.16.840.1.113883.11.20.9.36 STATIC (CONF:14798).The targetSiteCode, if present, SHOULD contain zero or one [0..1] qualifier (CONF:14799).The qualifier, if present, SHALL contain exactly one [1..1] name (CONF:14800).This name SHOULD contain zero or one [0..1] @code="272741003" laterality (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:14801).The qualifier, if present, SHALL contain exactly one [1..1] value (CONF:14802).This value SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet TargetSite Qualifiers 2.16.840.1.113883.11.20.9.37 STATIC (CONF:14803).SHOULD contain zero or one [0..1] entryRelationship (CONF:14410) such that itSHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:14411).SHALL contain exactly one [1..1] observation (CONF:14619).This observation SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14685).This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14686).This observation SHALL contain exactly one [1..1] code (CONF:14620).This code SHALL contain exactly one [1..1] @code="401238003" Length of Wound (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:14621).This observation SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:14622).SHOULD contain zero or one [0..1] entryRelationship (CONF:14601) such that itSHALL contain exactly one [1..1] @typeCode="COMP" (CONF:14602).SHALL contain exactly one [1..1] observation (CONF:14623).This observation SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14687).This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14688).This observation SHALL contain exactly one [1..1] code (CONF:14624).This code SHALL contain exactly one [1..1] @code="401239006" Width of Wound (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:14625).This observation SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:14626).SHOULD contain zero or one [0..1] entryRelationship (CONF:14605) such that itSHALL contain exactly one [1..1] @typeCode="COMP" (CONF:14606).SHALL contain exactly one [1..1] observation (CONF:14627).This observation SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14689).This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14690).This observation SHALL contain exactly one [1..1] code (CONF:14628).This code SHALL contain exactly one [1..1] @code="425094009" Depth of Wound (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:14629).This observation SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:14630).SEQ Table \* ARABIC427: Pressure Ulcer StageValue Set: Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35CodeCode SystemPrint Name421076008SNOMED CTPressure Ulcer Stage 1420324007SNOMED CTPressure Ulcer Stage 2421927004SNOMED CTPressure Ulcer Stage 3420597008SNOMED CTPressure Ulcer Stage 4421594008SNOMED CTNonstageable pressureSEQ Table \* ARABIC428: Pressure Point Value Set: Pressure Point 2.16.840.1.113883.11.20.9.36CodeCode SystemPrint Name43631005SNOMED CToccipital region structure23747009SNOMED CTskin structure of chin91774008SNOMED CTstructure of right shoulder7874003SNOMED CTstructure of scapular region of back; 272741003 = laterality; 24028007 = right (qualifier value)368149001SNOMED CTright elbow region structure368148009SNOMED CT left elbow region structure87141009SNOMED CTsacral vertebra structure122495006SNOMED CTthoracic spine structure122496007SNOMED CT lumbar spine structure287579007SNOMED CTright hip region structure387679003SNOMED CTleft hip region structure396993003SNOMED CTright posterior iliac crest396994009SNOMED CTleft posterior iliac crest46862004SNOMED CTbuttock structure;272741003 = laterality;7771000 = left6757004SNOMED CTstructure of right knee82169009SNOMED CTstructure of left knee76853006SNOMED CTheel structure; 272741003 = laterality; 24028007 = right 182304008SNOMED CTmedial aspect of ankle; 272741003 = laterality; 24028007 = right182305009SNOMED CTlateral aspect of ankle; 272741003 = laterality; 24028007 = right43631005SNOMED CToccipital region structure...SEQ Table \* ARABIC429: TargetSite Qualifiers Value Set: TargetSite Qualifiers 2.16.840.1.113883.11.20.9.37CodeCode SystemPrint Name255549009SNOMED CTanterior7771000SNOMED CTleft255561001SNOMED CTmedial255551008SNOMED CTposterior24028007SNOMED CTrightProblem Concern Act (Condition) (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.3.2 (open)]SEQ Table \* ARABIC430: Problem Concern Act (Condition) (V2) ContextsContained By:Contains:Problem Section (entries required) (V2) (required)Problem Section (entries optional) (V2) (optional)Author Participant (NEW)Problem Observation (V2)This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list. So long as the underlying condition is of concern to the provider (i.e. so long as the condition, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”. Only when the underlying condition is no longer of concern is the statusCode set to “completed”. The effectiveTime reflects the time that the underlying condition was felt to be a concern – it may or may not correspond to the effectiveTime of the condition (e.g. even five years later, the clinician may remain concerned about a prior heart attack).The statusCode of the Problem Concern Act (Condition) is the definitive indication of the status of the concern, whereas the effectiveTime of the nested Problem Observation is the definitive indication of whether or not the underlying condition is resolved.The effectiveTime/low of the Problem Concern Act (Condition) asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. The effectiveTime/high asserts when the concern was completed (e.g. when the clinician deemed there is no longer any need to track the underlying condition).SEQ Table \* ARABIC431: Problem Concern Act (Condition) (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.3.2']@classCode1..1SHALL90242.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL90252.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16772@root1..1SHALL167732.16.840.1.113883.10.20.22.4.3.2id1..*SHALL9026code1..1SHALL9027@code1..1SHALL191842.16.840.1.113883.5.6 (HL7ActClass) = CONCstatusCode1..1SHALL9029@code1..1SHALL315252.16.840.1.113883.11.20.9.19 (ProblemAct statusCode)effectiveTime1..1SHALL9030low1..1SHALL9032high0..1MAY9033entryRelationship1..*SHALL9034@typeCode1..1SHALL90352.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL15980author0..*SHOULD31146SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9024).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9025).SHALL contain exactly one [1..1] templateId (CONF:16772) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.3.2" (CONF:16773).SHALL contain at least one [1..*] id (CONF:9026).SHALL contain exactly one [1..1] code (CONF:9027).This code SHALL contain exactly one [1..1] @code="CONC" Concern (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:19184).SHALL contain exactly one [1..1] statusCode (CONF:9029).This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-10 (CONF:31525).The effectiveTime/low asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. The effectiveTime/high asserts when the concern was completed (e.g. when the clinician deemed there is no longer any need to track the underlying condition).SHALL contain exactly one [1..1] effectiveTime (CONF:9030).This effectiveTime SHALL contain exactly one [1..1] low (CONF:9032).This effectiveTime MAY contain zero or one [0..1] high (CONF:9033).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31146).SHALL contain at least one [1..*] entryRelationship (CONF:9034) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9035).SHALL contain exactly one [1..1] Problem Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.4.2) (CONF:15980).SEQ Table \* ARABIC432: ProblemAct statusCodeValue Set: ProblemAct statusCode 2.16.840.1.113883.11.20.9.19A ValueSet of HL7 actStatus codes for use on the concern actCodeCode SystemPrint NamecompletedActStatusCompletedabortedActStatusAbortedactiveActStatusActivesuspendedActStatusSuspendedFigure SEQ Table \* ARABIC52: Sample<act classCode="ACT" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.3.2" /> <id root="ceef9062-c4fa-4215-bf86-b5a66899ea95" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" /> <statusCode code="completed" /> <effectiveTime> <low value="20080103" />  <high value="20080222" /> </effectiveTime> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.4.2" /> ... </observation> </entryRelationship> <entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.114" />  <templateId root="2.16.840.1.113883.10.20.22.4.4" /> ... </observation> </entry></act>Problem Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.4.2 (open)]SEQ Table \* ARABIC433: Problem Observation (V2) ContextsContained By:Contains:Problem Concern Act (Condition) (V2) (required)Hospital Discharge Diagnosis (V2) (required)Hospital Admission Diagnosis (V2) (required)History of Past Illness Section (V2) (optional)Procedure Findings Section (V2) (optional)Complications Section (V2) (optional)Postprocedure Diagnosis (V2) (required)Preoperative Diagnosis (V2) (required)Deceased Observation (V2) (optional)Encounter Diagnosis (V2) (required)Health Concern Act (NEW) (optional)Age ObservationAuthor Participant (NEW)Patient Priority Preference (NEW)Prognosis ObservationProvider Priority Preference (NEW)This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".SEQ Table \* ARABIC434: Problem Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.4.2']entryRelationship0..1MAY9059@typeCode1..1SHALL90602.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL9069trueobservation1..1SHALL15590entryRelationship0..*MAY31063@typeCode1..1SHALL315322.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31064@classCode1..1SHALL90412.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL90422.16.840.1.113883.5.1001 (ActMood) = EVN@negationInd0..1MAY10139templateId1..1SHALL14926@root1..1SHALL149272.16.840.1.113883.10.20.22.4.4.2id1..*SHALL9043code1..1SHALL90452.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)text0..1SHOULD9185reference0..1SHOULD15587@value1..1SHALL15588statusCode1..1SHALL9049@code1..1SHALL191122.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL9050low1..1SHALL15603high0..1MAY15604value1..1SHALLCD90582.16.840.1.113883.3.88.12.3221.7.4 (Problem Value Set)translation0..*MAY16749@code0..1MAY167502.16.840.1.113883.6.90 (ICD10CM)entryRelationship0..1MAY29951@typeCode1..1SHALL315312.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL29952entryRelationship0..*MAY31065@typeCode1..1SHALL315332.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31066author0..*SHOULD31147SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9041).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9042).Use negationInd="true" to indicate that the problem was not observed.MAY contain zero or one [0..1] @negationInd (CONF:10139).SHALL contain exactly one [1..1] templateId (CONF:14926) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4.2" (CONF:14927).SHALL contain at least one [1..*] id (CONF:9043).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:9045).SHOULD contain zero or one [0..1] text (CONF:9185).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15587).The reference, if present, SHALL contain exactly one [1..1] @value (CONF:15588).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15589).SHALL contain exactly one [1..1] statusCode (CONF:9049).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19112).The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolvedSHALL contain exactly one [1..1] effectiveTime (CONF:9050).This effectiveTime SHALL contain exactly one [1..1] low (CONF:15603).This effectiveTime MAY contain zero or one [0..1] high (CONF:15604).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).This value MAY contain zero or more [0..*] translation (CONF:16749).The translation, if present, MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM 2.16.840.1.113883.6.90 STATIC) (CONF:16750).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31147).MAY contain zero or one [0..1] entryRelationship (CONF:9059) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9060).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:9069).SHALL contain exactly one [1..1] Age Observation (templateId:2.16.840.1.113883.10.20.22.4.31) (CONF:15590).MAY contain zero or one [0..1] entryRelationship (CONF:29951) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31531).SHALL contain exactly one [1..1] Prognosis Observation (templateId:2.16.840.1.113883.10.20.22.4.113) (CONF:29952).MAY contain zero or more [0..*] entryRelationship (CONF:31063) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31532).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31064).MAY contain zero or more [0..*] entryRelationship (CONF:31065) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31533).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31066).SEQ Table \* ARABIC435: Problem TypeValue Set: Problem Type 2.16.840.1.113883.3.88.12.3221.7.2CodeCode SystemPrint Name404684003SNOMED CTFinding409586006SNOMED CTComplaint282291009SNOMED CTDiagnosis64572001SNOMED CTCondition248536006SNOMED CTFinding of functional performance and activity418799008SNOMED CTSymptom55607006SNOMED CTProblem373930000SNOMED CTCognitive function findingSEQ Table \* ARABIC436: Problem Value SetValue Set: Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4CodeCode SystemPrint Name50992006SNOMED CT22q partial trisomy syndrome (disorder)237931009SNOMED CT2-Ketoadipic acidemia (disorder)54470008SNOMED CT3 beta-Hydroxysteroid dehydrogenase deficiency (disorder)237950009SNOMED CT3-Methylglutaconic aciduria (disorder)296646009SNOMED CT4-quinolones overdose (disorder)41797007SNOMED CT5 10-Methylenetetrahydrofolate reductase deficiency (disorder)413380004SNOMED CTA pattern strabismus (disorder)425879009SNOMED CTAA amyloid nephropathy (disorder)274945004SNOMED CTAA amyloidosis (disorder)75100008SNOMED CTAbdominal abscess (disorder)43894001SNOMED CTAbdominal actinomycosis (disorder)233985008SNOMED CTAbdominal aortic aneurysm (disorder)253679008SNOMED CTAbdominal aortic coarctation (disorder)116289008SNOMED CTAbdominal bloating (finding)9991008SNOMED CTAbdominal colic (finding)271860004SNOMED CTAbdominal mass (finding)75879005SNOMED CTAbdominal migraine (disorder)21522001SNOMED CTAbdominal pain (finding)82661006SNOMED CTAbdominal pregnancy (disorder)72300008SNOMED CTAbdominal rigidity (finding)...Wound Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.114 (open)]SEQ Table \* ARABIC437: Wound Observation (NEW) ContextsContained By:Contains:Physical Findings of Skin Section (optional)Health Concern Act (NEW) (optional)Physical Exam Section (V2) (optional)Author Participant (NEW)Wound Characteristics (NEW)Wound Measurement Observation (NEW)This template represents acquired or surgical wounds commonly found in the long term care population. It is not intended to encompass all wound types.??The template includes the general type of wound (e.g. pressure ulcers, surgical incisions, deep tissue injury wounds) and can include wound measurements and wound characteristics.??SEQ Table \* ARABIC438: Wound Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.114']templateId1..1SHALL29473@root1..1SHALL294742.16.840.1.113883.10.20.22.4.114code1..1SHALL29476@code1..1SHALL29477ASSERTION@codeSystem1..1SHALL310102.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4value1..1SHALLCD294852.16.840.1.113883.1.11.20.2.6 (Wound Type)targetSiteCode0..1SHOULD294882.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)qualifier0..*MAY29490name1..1SHALL29491@code1..1SHALL29492272741003@codeSystem1..1SHALL315242.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96value1..1SHALL29493@code1..1SHALL294942.16.840.1.113883.11.20.9.37 (TargetSite Qualifiers )entryRelationship0..*SHOULD29495@typeCode1..1SHALL294962.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL29497entryRelationship0..*SHOULD29503@typeCode1..1SHALL29504COMPobservation1..1SHALL29505@classCode1..1SHALL310122.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL310132.16.840.1.113883.5.1001 (ActMood) = EVNauthor0..*SHOULD31542Conforms to Problem Observation (V2) template (2.16.840.1.113883.10.20.22.4.4.2).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31012).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:31013).SHALL contain exactly one [1..1] templateId (CONF:29473) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.114" (CONF:29474).SHALL contain exactly one [1..1] code (CONF:29476).This code SHALL contain exactly one [1..1] @code="ASSERTION" assertion (CONF:29477).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:31010).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Wound Type 2.16.840.1.113883.1.11.20.2.6 DYNAMIC (CONF:29485).SHOULD contain zero or one [0..1] targetSiteCode, which SHOULD be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 (CONF:29488) such that itIf targetSite/qualifierCode name/value pairs are used care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value.??SNOMED-CT body structure codes are often pre-coordinated with laterality.MAY contain zero or more [0..*] qualifier (CONF:29490).The qualifier, if present, SHALL contain exactly one [1..1] name (CONF:29491).This name SHALL contain exactly one [1..1] @code="272741003" laterality (CONF:29492).This name SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31524).The qualifier, if present, SHALL contain exactly one [1..1] value (CONF:29493).This value SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet TargetSite Qualifiers 2.16.840.1.113883.11.20.9.37 STATIC (CONF:29494).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31542).SHOULD contain zero or more [0..*] entryRelationship (CONF:29495) such that itSHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:29496).SHALL contain exactly one [1..1] Wound Measurement Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.133) (CONF:29497).SHOULD contain zero or more [0..*] entryRelationship (CONF:29503) such that itSHALL contain exactly one [1..1] @typeCode="COMP" (CONF:29504).SHALL contain exactly one [1..1] Wound Characteristics (NEW) (templateId:2.16.840.1.113883.10.20.22.4.134) (CONF:29505).SEQ Table \* ARABIC439: Wound TypeValue Set: Wound Type 2.16.840.1.113883.1.11.20.2.6A value set of SNOMED-CT high level wound codes terms commonly used in long term care. Specific URL PendingValueset Source: SystemPrint Name420226006SNOMED CTPressure ulcer46742003SNOMED CTSkin ulcer262557004SNOMED CTDeep wound283396008SNOMED CTIncised wound416886008SNOMED CTClosed wound125643001SNOMED CTOpen wound421076008SNOMED CTPressure ulcer stage 1420324007SNOMED CTPressure Ulcer Stage 2421927004SNOMED CTPressure Ulcer Stage 3420597008SNOMED CTPressure Ulcer Stage 4421594008SNOMED CTNonstageable pressure ulcer425144005SNOMED CTMinor open wound422183001SNOMED CTDiabetic skin ulcer95346009SNOMED CTMucocutaneous ulcer19429009SNOMED CT Chronic ulcer of skinSEQ Table \* ARABIC440: Body Site Value SetValue Set: Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9Body site value set is based upon the concepts descending from the SNOMED CT Anatomical Structure (91723000) hierarchy.CodeCode SystemPrint Name56244007SNOMED CT10 to 19 percent of body surface (body structure)37491003SNOMED CT12 nm filaments (cell structure)78777002SNOMED CT20 to 29 percent of body surface (body structure)12423009SNOMED CT30 to 39 percent of body surface (body structure)36849000SNOMED CT40 to 49 percent of body surface (body structure)305024009SNOMED CT5/6 interchondral joint (body structure)76152003SNOMED CT50 to 59 percent of body surface (body structure)305005006SNOMED CT6/7 interchondral joint (body structure)91551007SNOMED CT60 to 69 percent of body surface (body structure)64700008SNOMED CT7 nm filaments (cell structure)305006007SNOMED CT7/8 interchondral joint (body structure)75324005SNOMED CT70 to 79 percent of body surface (body structure)305007003SNOMED CT8/9 interchondral joint (body structure)19738007SNOMED CT80 to 89 percent of body surface (body structure)19904008SNOMED CT9 nm filaments (cell structure)91035006SNOMED CT90 percent of body surface or more (body structure)51878007SNOMED CTA band (cell structure)416949008SNOMED CTAbdomen and/or pelvis structure (body structure)108350001SNOMED CTAbdomen, excluding retroperitoneal region (body structure)43701009SNOMED CTAbdominal air sac (body structure)...SEQ Table \* ARABIC441: TargetSite Qualifiers Value Set: TargetSite Qualifiers 2.16.840.1.113883.11.20.9.37CodeCode SystemPrint Name255549009SNOMED CTanterior7771000SNOMED CTleft255561001SNOMED CTmedial255551008SNOMED CTposterior24028007SNOMED CTrightFigure SEQ Table \* ARABIC53: Sample<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.114"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <effectiveTime> <low value="20013103"/> </effectiveTime> <value xsi:type="CD" code="425144005" codeSystem="2.16.840.1.113883.6.6" displayName="Minor open wound"/> <targetSiteCode code="182295001" codeSystem="2.16.840.1.113883.6.96" displayName="anterior aspect of knee"> </targetSiteCode> <author> ... </author> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.133"/> ... </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.133"/> ... </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.134"/> ... </entryRelationship> </observation></entry>Problem Status (DEPRECATED)[observation: templateId 2.16.840.1.113883.10.20.22.4.6.2 (open)]SEQ Table \* ARABIC442: Problem Status (DEPRECATED) ContextsContained By:Contains:This template has been deprecated in Consolidated CDA Release 2. Per the explanation in Volume 1, section 3.2 "Determining a Clinical Statement's Status", the status of a problem is determined based on attributes of the Problem ObservationSEQ Table \* ARABIC443: Problem Status (DEPRECATED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.6.2']@classCode1..1SHALL73572.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73582.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7359@root1..1SHALL105182.16.840.1.113883.10.20.22.4.6.2code1..1SHALL19162@code1..1SHALL191632.16.840.1.113883.6.1 (LOINC) = 33999-4statusCode1..1SHALL7364@code1..1SHALL191132.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD73652.16.840.1.113883.3.88.12.80.68 (Problem Status Value Set)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7357).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7358).SHALL contain exactly one [1..1] templateId (CONF:7359) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.6.2" (CONF:10518).SHALL contain exactly one [1..1] code (CONF:19162).This code SHALL contain exactly one [1..1] @code="33999-4" Status (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:19163).SHALL contain exactly one [1..1] statusCode (CONF:7364).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19113).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem Status Value Set 2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:7365).SEQ Table \* ARABIC444: Problem Status Value SetValue Set: Problem Status Value Set 2.16.840.1.113883.3.88.12.80.68CodeCode SystemPrint Name55561003SNOMED CTActive73425007SNOMED CTInactive413322009SNOMED CTResolvedProcedure Activity Act (V2)[act: templateId 2.16.840.1.113883.10.20.22.4.12.2 (open)]SEQ Table \* ARABIC445: Procedure Activity Act (V2) ContextsContained By:Contains:Procedures Section (entries optional) (V2) (optional)Procedures Section (entries required) (V2) (optional)Intervention Act (NEW) (optional)Indication (V2)Instruction (V2)Medication Activity (V2)Service Delivery LocationThis template represents any act that cannot be classified as an observation or procedure according to the HL7 RIM. Examples of these acts are a dressing change, teaching or feeding a patient, or providing comfort measures. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). SEQ Table \* ARABIC446: Procedure Activity Act (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.12.2']entryRelationship0..*MAY8326@typeCode1..1SHALL83272.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL15601entryRelationship0..1MAY8322@typeCode1..1SHALL83232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL8324trueact1..1SHALL31396entryRelationship0..*MAY8329@typeCode1..1SHALL83302.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPsubstanceAdministration1..1SHALL15602@classCode1..1SHALL82892.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL82902.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALL8291@root1..1SHALL105192.16.840.1.113883.10.20.22.4.12.2id1..*SHALL8292code1..1SHALL8293originalText0..1SHOULD19186reference0..1MAY19187@value0..1MAY19188statusCode1..1SHALL82982.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode)effectiveTime0..1SHOULD8299priorityCode0..1MAY83002.16.840.1.113883.1.11.16866 (Act Priority Value Set)performer0..*SHOULD8301assignedEntity1..1SHALL8302id1..*SHALL8303addr1..1SHALL8304telecom1..1SHALL8305representedOrganization0..1SHOULD8306id0..*SHOULD8307name0..*MAY8308telecom1..1SHALL8310addr1..1SHALL8309participant0..*MAY8311@typeCode1..1SHALL83122.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCparticipantRole1..1SHALL15599entryRelationship0..*MAY8314@typeCode1..1SHALL83152.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP@inversionInd1..1SHALL8316trueencounter1..1SHALL8317@classCode1..1SHALL83182.16.840.1.113883.5.6 (HL7ActClass) = ENC@moodCode1..1SHALL83192.16.840.1.113883.5.1001 (ActMood) = EVNid1..1SHALL8320SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8289).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:8290).SHALL contain exactly one [1..1] templateId (CONF:8291) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.12.2" (CONF:10519).SHALL contain at least one [1..*] id (CONF:8292).SHALL contain exactly one [1..1] code (CONF:8293).This code SHOULD contain zero or one [0..1] originalText (CONF:19186).The originalText, if present, MAY contain zero or one [0..1] reference (CONF:19187).The reference, if present, MAY contain zero or one [0..1] @value (CONF:19188).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:19189).This code in a procedure activity act SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:19190).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:8298).SHOULD contain zero or one [0..1] effectiveTime (CONF:8299).MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority Value Set 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:8300).SHOULD contain zero or more [0..*] performer (CONF:8301).The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:8302).This assignedEntity SHALL contain at least one [1..*] id (CONF:8303).This assignedEntity SHALL contain exactly one [1..1] addr (CONF:8304).This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:8305).This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8306).The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:8307).The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:8308).The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:8310).The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:8309).MAY contain zero or more [0..*] participant (CONF:8311) such that itSHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8312).SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:15599).MAY contain zero or more [0..*] entryRelationship (CONF:8314) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8315).SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8316).SHALL contain exactly one [1..1] encounter (CONF:8317).This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8318).This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8319).This encounter SHALL contain exactly one [1..1] id (CONF:8320).Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:16849).MAY contain zero or one [0..1] entryRelationship (CONF:8322) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8323).SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8324).SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31396).MAY contain zero or more [0..*] entryRelationship (CONF:8326) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8327).SHALL contain exactly one [1..1] Indication (V2) (templateId:2.16.840.1.113883.10.20.22.4.19.2) (CONF:15601).MAY contain zero or more [0..*] entryRelationship (CONF:8329) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8330).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:15602).SEQ Table \* ARABIC447: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentSEQ Table \* ARABIC448: ProcedureAct statusCodeValue Set: ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22A ValueSet of HL7 actStatus codes for use with a procedure activityCodeCode SystemPrint NamecompletedActStatusCompletedactiveActStatusActiveabortedActStatusAbortedcancelledActStatusCancelledSEQ Table \* ARABIC449: Act Priority Value SetValue Set: Act Priority Value Set 2.16.840.1.113883.1.11.16866CodeCode SystemPrint NameAActPriorityASAPCRActPriorityCallback resultsCSActPriorityCallback for schedulingCSPActPriorityCallback placer for schedulingCSRActPriorityContact recipient for schedulingELActPriorityElectiveEMActPriorityEmergencyPActPriorityPreoperativePRNActPriorityAs neededRActPriorityRoutineRRActPriorityRush reportingSActPriorityStatTActPriorityTiming criticalUDActPriorityUse as directedURActPriorityUrgentFigure SEQ Table \* ARABIC54: Sample<act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.12.2" /> <id root="1.2.3.4.5.6.7.8" extension="1234567" /> <code code="274025005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonic polypectomy"> <originalText> <reference value="#Proc1" /> </originalText> </code> <statusCode code="completed" /> <effectiveTime value="20110203" /> <priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="Callback results" /> <performer> <assignedEntity> <id root="2.16.840.1.113883.19" extension="1234" /> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="(555)555-555-1234" /> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Community Health and Hospitals</name> <telecom nullFlavor="UNK" /> <addr nullFlavor="UNK" /> </representedOrganization> </assignedEntity> </performer> <participant typeCode="LOC"> <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32" />  ... </participantRole> </participant></act>Procedure Activity Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.13.2 (open)]SEQ Table \* ARABIC450: Procedure Activity Observation (V2) ContextsContained By:Contains:Procedures Section (entries optional) (V2) (optional)Procedures Section (entries required) (V2) (optional)Intervention Act (NEW) (optional)Indication (V2)Instruction (V2)Medication Activity (V2)Service Delivery LocationThe common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs.SEQ Table \* ARABIC451: Procedure Activity Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.13.2']entryRelationship0..*MAY8276@typeCode1..1SHALL82772.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL15906entryRelationship0..1MAY8272@typeCode1..1SHALL82732.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL8274trueact1..1SHALL31394entryRelationship0..*MAY8279@typeCode1..1SHALL82802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPsubstanceAdministration1..1SHALL15907@classCode1..1SHALL82822.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL82372.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALL8238@root1..1SHALL105202.16.840.1.113883.10.20.22.4.13.2id1..*SHALL8239code1..1SHALL19197originalText0..1SHOULD19198reference0..1SHOULD19199@value0..1SHOULD19200statusCode1..1SHALL82452.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode)effectiveTime0..1SHOULD8246priorityCode0..1MAY82472.16.840.1.113883.1.11.16866 (Act Priority Value Set)value1..1SHALL16846methodCode0..1MAYSET<CE>8248targetSiteCode0..*SHOULD8250@code1..1SHALL160712.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)performer0..*SHOULD8251assignedEntity1..1SHALL8252id1..*SHALL8253addr1..1SHALL8254telecom1..1SHALL8255representedOrganization0..1SHOULD8256id0..*SHOULD8257name0..*MAY8258telecom1..1SHALL8260addr1..1SHALL8259participant0..*MAY8261@typeCode1..1SHALL82622.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCparticipantRole1..1SHALL15904entryRelationship0..*MAY8264@typeCode1..1SHALL82652.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP@inversionInd1..1SHALL8266trueencounter1..1SHALL8267@classCode1..1SHALL82682.16.840.1.113883.5.6 (HL7ActClass) = ENC@moodCode1..1SHALL82692.16.840.1.113883.5.1001 (ActMood) = EVNid1..1SHALL8270SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8282).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:8237).SHALL contain exactly one [1..1] templateId (CONF:8238) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13.2" (CONF:10520).SHALL contain at least one [1..*] id (CONF:8239).SHALL contain exactly one [1..1] code (CONF:19197).This code SHOULD contain zero or one [0..1] originalText (CONF:19198).The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:19199).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:19200).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:19201).This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12), ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:19202).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:8245).SHOULD contain zero or one [0..1] effectiveTime (CONF:8246).MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority Value Set 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:8247).SHALL contain exactly one [1..1] value (CONF:16846).MAY contain zero or one [0..1] methodCode (CONF:8248).MethodCode SHALL NOT conflict with the method inherent in Observation / code (CONF:8249).SHOULD contain zero or more [0..*] targetSiteCode (CONF:8250).The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:16071).SHOULD contain zero or more [0..*] performer (CONF:8251).The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:8252).This assignedEntity SHALL contain at least one [1..*] id (CONF:8253).This assignedEntity SHALL contain exactly one [1..1] addr (CONF:8254).This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:8255).This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8256).The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:8257).The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:8258).The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:8260).The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:8259).MAY contain zero or more [0..*] participant (CONF:8261).The participant, if present, SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8262).The participant, if present, SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:15904).MAY contain zero or more [0..*] entryRelationship (CONF:8264).The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8265).The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8266).The entryRelationship, if present, SHALL contain exactly one [1..1] encounter (CONF:8267).This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8268).This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8269).This encounter SHALL contain exactly one [1..1] id (CONF:8270).Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:16847).MAY contain zero or one [0..1] entryRelationship (CONF:8272) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8273).SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8274).SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31394).MAY contain zero or more [0..*] entryRelationship (CONF:8276) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8277).SHALL contain exactly one [1..1] Indication (V2) (templateId:2.16.840.1.113883.10.20.22.4.19.2) (CONF:15906).MAY contain zero or more [0..*] entryRelationship (CONF:8279) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:8280).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:15907).SEQ Table \* ARABIC452: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentSEQ Table \* ARABIC453: ProcedureAct statusCodeValue Set: ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22A ValueSet of HL7 actStatus codes for use with a procedure activityCodeCode SystemPrint NamecompletedActStatusCompletedactiveActStatusActiveabortedActStatusAbortedcancelledActStatusCancelledSEQ Table \* ARABIC454: Act Priority Value SetValue Set: Act Priority Value Set 2.16.840.1.113883.1.11.16866CodeCode SystemPrint NameAActPriorityASAPCRActPriorityCallback resultsCSActPriorityCallback for schedulingCSPActPriorityCallback placer for schedulingCSRActPriorityContact recipient for schedulingELActPriorityElectiveEMActPriorityEmergencyPActPriorityPreoperativePRNActPriorityAs neededRActPriorityRoutineRRActPriorityRush reportingSActPriorityStatTActPriorityTiming criticalUDActPriorityUse as directedURActPriorityUrgentSEQ Table \* ARABIC455: Body Site Value SetValue Set: Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9Body site value set is based upon the concepts descending from the SNOMED CT Anatomical Structure (91723000) hierarchy.CodeCode SystemPrint Name56244007SNOMED CT10 to 19 percent of body surface (body structure)37491003SNOMED CT12 nm filaments (cell structure)78777002SNOMED CT20 to 29 percent of body surface (body structure)12423009SNOMED CT30 to 39 percent of body surface (body structure)36849000SNOMED CT40 to 49 percent of body surface (body structure)305024009SNOMED CT5/6 interchondral joint (body structure)76152003SNOMED CT50 to 59 percent of body surface (body structure)305005006SNOMED CT6/7 interchondral joint (body structure)91551007SNOMED CT60 to 69 percent of body surface (body structure)64700008SNOMED CT7 nm filaments (cell structure)305006007SNOMED CT7/8 interchondral joint (body structure)75324005SNOMED CT70 to 79 percent of body surface (body structure)305007003SNOMED CT8/9 interchondral joint (body structure)19738007SNOMED CT80 to 89 percent of body surface (body structure)19904008SNOMED CT9 nm filaments (cell structure)91035006SNOMED CT90 percent of body surface or more (body structure)51878007SNOMED CTA band (cell structure)416949008SNOMED CTAbdomen and/or pelvis structure (body structure)108350001SNOMED CTAbdomen, excluding retroperitoneal region (body structure)43701009SNOMED CTAbdominal air sac (body structure)...Figure SEQ Table \* ARABIC55: Sample<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.13.2"/>  <id extension="123456789" root="2.16.840.1.113883.19"/> <code code="274025005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonic polypectomy" codeSystemName="SNOMED-CT"> <originalText> <reference value="#Proc1"/> </originalText> </code> <statusCode code="aborted"/> <effectiveTime value="20110203"/> <priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="Callback results"/> <value xsi:type="CD"/> <methodCode nullFlavor="UNK"/> <targetSiteCode code="416949008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Abdomen and pelvis"/> <performer> <assignedEntity> <id root="2.16.840.1.113883.19.5" extension="1234"/> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="(555)555-555-1234"/> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Community Health and Hospitals</name> <telecom nullFlavor="UNK"/> <addr nullFlavor="UNK"/> </representedOrganization> </assignedEntity> </performer> <participant typeCode="LOC"> <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32"/>  ... </participantRole> </participant></observation>Procedure Activity Procedure (V2)[procedure: templateId 2.16.840.1.113883.10.20.22.4.14.2 (open)]SEQ Table \* ARABIC456: Procedure Activity Procedure (V2) ContextsContained By:Contains:Reaction Observation (V2) (optional)Anesthesia Section (V2) (optional)Procedures Section (entries optional) (V2) (optional)Procedures Section (entries required) (V2) (optional)Intervention Act (NEW) (optional)Indication (V2)Instruction (V2)Medication Activity (V2)Product InstanceService Delivery LocationThe common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement and a creation of a gastrostomy.SEQ Table \* ARABIC457: Procedure Activity Procedure (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.14.2']entryRelationship0..*MAY7779@typeCode1..1SHALL77802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL15914entryRelationship0..1MAY7775@typeCode1..1SHALL77762.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL7777trueact1..1SHALL31395entryRelationship0..*MAY7886@typeCode1..1SHALL78872.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPsubstanceAdministration1..1SHALL15915@classCode1..1SHALL76522.16.840.1.113883.5.6 (HL7ActClass) = PROC@moodCode1..1SHALL76532.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALL7654@root1..1SHALL105212.16.840.1.113883.10.20.22.4.14.2id1..*SHALL7655code1..1SHALL7656originalText0..1SHOULD19203reference0..1SHOULD19204@value0..1SHOULD19205statusCode1..1SHALL76612.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode)effectiveTime0..1SHOULD7662priorityCode0..1MAY76682.16.840.1.113883.1.11.16866 (Act Priority Value Set)methodCode0..1MAYSET<CE>7670targetSiteCode0..*SHOULD7683@code1..1SHALL160822.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)specimen0..*MAY7697specimenRole1..1SHALL7704id0..*SHOULD7716performer0..*SHOULD7718assignedEntity1..1SHALL7720id1..*SHALL7722addr1..1SHALL7731telecom1..1SHALL7732representedOrganization0..1SHOULD7733id0..*SHOULD7734name0..*MAY7735telecom1..1SHALL7737addr1..1SHALL7736participant0..*MAY7751@typeCode1..1SHALL77522.16.840.1.113883.5.1002 (HL7ActRelationshipType) = DEVparticipantRole1..1SHALL15911participant0..*MAY7765@typeCode1..1SHALL77662.16.840.1.113883.5.90 (HL7ParticipationType) = LOCparticipantRole1..1SHALL15912entryRelationship0..*MAY7768@typeCode1..1SHALL77692.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP@inversionInd1..1SHALL8009trueencounter1..1SHALL7770@classCode1..1SHALL77712.16.840.1.113883.5.6 (HL7ActClass) = ENC@moodCode1..1SHALL77722.16.840.1.113883.5.1001 (ActMood) = EVNid1..1SHALL7773SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7652).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:7653).SHALL contain exactly one [1..1] templateId (CONF:7654) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14.2" (CONF:10521).SHALL contain at least one [1..*] id (CONF:7655).SHALL contain exactly one [1..1] code (CONF:7656).This code SHOULD contain zero or one [0..1] originalText (CONF:19203).The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:19204).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:19205).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:19206).This code in a procedure activity SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:19207).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:7661).SHOULD contain zero or one [0..1] effectiveTime (CONF:7662).MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority Value Set 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:7668).MAY contain zero or one [0..1] methodCode (CONF:7670).MethodCode SHALL NOT conflict with the method inherent in Procedure / code (CONF:7890).SHOULD contain zero or more [0..*] targetSiteCode (CONF:7683).The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:16082).MAY contain zero or more [0..*] specimen (CONF:7697).The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:7704).This specimenRole SHOULD contain zero or more [0..*] id (CONF:7716).If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id (CONF:29744).This specimen is for representing specimens obtained from a procedure (CONF:16842).SHOULD contain zero or more [0..*] performer (CONF:7718) such that itSHALL contain exactly one [1..1] assignedEntity (CONF:7720).This assignedEntity SHALL contain at least one [1..*] id (CONF:7722).This assignedEntity SHALL contain exactly one [1..1] addr (CONF:7731).This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:7732).This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:7733).The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:7734).The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:7735).The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:7737).The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:7736).MAY contain zero or more [0..*] participant (CONF:7751) such that itSHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7752).SHALL contain exactly one [1..1] Product Instance (templateId:2.16.840.1.113883.10.20.22.4.37) (CONF:15911).MAY contain zero or more [0..*] participant (CONF:7765) such that itSHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:7766).SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:15912).MAY contain zero or more [0..*] entryRelationship (CONF:7768) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7769).SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8009).SHALL contain exactly one [1..1] encounter (CONF:7770).This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7771).This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7772).This encounter SHALL contain exactly one [1..1] id (CONF:7773).Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:16843).MAY contain zero or one [0..1] entryRelationship (CONF:7775) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7776).SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:7777).SHALL contain exactly one [1..1] Instruction (V2) (templateId:2.16.840.1.113883.10.20.22.4.20.2) (CONF:31395).MAY contain zero or more [0..*] entryRelationship (CONF:7779) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7780).SHALL contain exactly one [1..1] Indication (V2) (templateId:2.16.840.1.113883.10.20.22.4.19.2) (CONF:15914).MAY contain zero or more [0..*] entryRelationship (CONF:7886) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7887).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:15915).SEQ Table \* ARABIC458: MoodCodeEvnIntValue Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTCodeCode SystemPrint NameEVNActMoodEventINTActMoodIntentSEQ Table \* ARABIC459: ProcedureAct statusCodeValue Set: ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22A ValueSet of HL7 actStatus codes for use with a procedure activityCodeCode SystemPrint NamecompletedActStatusCompletedactiveActStatusActiveabortedActStatusAbortedcancelledActStatusCancelledSEQ Table \* ARABIC460: Act Priority Value SetValue Set: Act Priority Value Set 2.16.840.1.113883.1.11.16866CodeCode SystemPrint NameAActPriorityASAPCRActPriorityCallback resultsCSActPriorityCallback for schedulingCSPActPriorityCallback placer for schedulingCSRActPriorityContact recipient for schedulingELActPriorityElectiveEMActPriorityEmergencyPActPriorityPreoperativePRNActPriorityAs neededRActPriorityRoutineRRActPriorityRush reportingSActPriorityStatTActPriorityTiming criticalUDActPriorityUse as directedURActPriorityUrgentSEQ Table \* ARABIC461: Body Site Value SetValue Set: Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9Body site value set is based upon the concepts descending from the SNOMED CT Anatomical Structure (91723000) hierarchy.CodeCode SystemPrint Name56244007SNOMED CT10 to 19 percent of body surface (body structure)37491003SNOMED CT12 nm filaments (cell structure)78777002SNOMED CT20 to 29 percent of body surface (body structure)12423009SNOMED CT30 to 39 percent of body surface (body structure)36849000SNOMED CT40 to 49 percent of body surface (body structure)305024009SNOMED CT5/6 interchondral joint (body structure)76152003SNOMED CT50 to 59 percent of body surface (body structure)305005006SNOMED CT6/7 interchondral joint (body structure)91551007SNOMED CT60 to 69 percent of body surface (body structure)64700008SNOMED CT7 nm filaments (cell structure)305006007SNOMED CT7/8 interchondral joint (body structure)75324005SNOMED CT70 to 79 percent of body surface (body structure)305007003SNOMED CT8/9 interchondral joint (body structure)19738007SNOMED CT80 to 89 percent of body surface (body structure)19904008SNOMED CT9 nm filaments (cell structure)91035006SNOMED CT90 percent of body surface or more (body structure)51878007SNOMED CTA band (cell structure)416949008SNOMED CTAbdomen and/or pelvis structure (body structure)108350001SNOMED CTAbdomen, excluding retroperitoneal region (body structure)43701009SNOMED CTAbdominal air sac (body structure)...Figure SEQ Table \* ARABIC56: Sample<procedure classCode="PROC" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.14.2" />  <id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85d" /> <code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscopy"> <originalText> <reference value="#Proc1" /> </originalText> </code> <statusCode code="completed" /> <effectiveTime value="20120512" /> <methodCode nullFlavor="UNK" /> <targetSiteCode code="appropriate_code" displayName="colon" codeSystem="2.16.840.1.113883.3.88.12.3221.8.9" codeSystemName="Body Site Value Set"/> <specimen typeCode="SPC"> <specimenRole classCode="SPEC"> <id root="c2ee9ee9-ae31-4628-a919-fec1cbb58683" /> <specimenPlayingEntity> <code code="309226005" codeSystem="2.16.840.1.113883.6.96" displayName="colonic polyp sample" /> </specimenPlayingEntity> </specimenRole> </specimen> <performer> <assignedEntity> <id root="2.16.840.1.113883.19.5.9999.456" extension="2981823" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="555-555-5000" /> <representedOrganization> <id root="2.16.840.1.113883.19.5.9999.1393" /> <name>Community Health and Hospitals</name> <telecom use="WP" value="555-555-5000" /> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> <participant typeCode="DEV">  <participantRole classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.37" />  ... </participantRole> </participant></procedure><assignedEntity><id root="2.16.840.1.113883.19.5.9999.456" extension="2981823" /><addr><streetAddressLine>1001 Village Avenue</streetAddressLine><city>Portland</city><state>OR</state><postalCode>99123</postalCode><country>US</country></addr><telecom use="WP" value="555-555-5000" /><representedOrganization><id root="2.16.840.1.113883.19.5.9999.1393" /><name>Community Health and Hospitals</name><telecom use="WP" value="555-555-5000" /><addr><streetAddressLine>1001 Village Avenue</streetAddressLine><city>Portland</city><state>OR</state><postalCode>99123</postalCode><country>US</country></addr></representedOrganization></assignedEntity></performer><participant typeCode="DEV"><participantRole classCode="MANU"><templateId root="2.16.840.1.113883.10.20.22.4.37" />...</participantRole></participant></procedure>Medical Device Applied (NEW)[procedure: templateId 2.16.840.1.113883.10.20.22.4.115 (open)]SEQ Table \* ARABIC462: Medical Device Applied (NEW) ContextsContained By:Contains:Medical Equipment Section (V2) (optional)Medical Equipment Organizer (NEW) (required)Non-Medicinal Supply Activity (V2)ReasonNOTES - NOT FOR PRIME TIMEThis template represents:This is NOT a procedure recording to define the device??put in during a procedure - but rather??a list of devices the patient has in/or on his body - butIs probably within a list of historical procedure - but defines more device detailBODY SITE/DATE OF PROCEDURE/(EXPIRATION DATE) IS THERE AN INSTRUCTIONS TEMPLATE IN PROCUDEURE/ LOOK AT THE HEADER PARRTICPANT RGPR IN THE qrda III HEADER (REGULATED PRODUCT)devices applied (aka used on /in the pt)cardiac cathdrains, stents, IV catheter "High risk devices"??(foreign body)SEQ Table \* ARABIC463: Medical Device Applied (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.115']entryRelationship0..1MAY30273@typeCode1..1SHALL30274REFRsupply1..1SHALL30275@moodCode1..1SHALL302502.16.840.1.113883.5.1001 (ActMood)templateId1..1SHALL30251@root1..1SHALL302522.16.840.1.113883.10.20.22.4.115code1..1SHALL30253@code1..1SHALL302542.16.840.1.113883.6.96 (SNOMED CT) = 360030002statusCode1..1SHALL302552.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL30256low1..1SHALL30268high1..1SHALL30269targetSiteCode0..1MAY30257participant1..1SHALL30258@typeCode1..1SHALL302592.16.840.1.113883.5.90 (HL7ParticipationType) = DEVparticipantRole1..1SHALL30260@classCode1..1SHALL302612.16.840.1.113883.5.110 (RoleClass) = MANUplayingDevice1..1SHALL30262@classCode1..1SHALL302632.16.840.1.113883.5.90 (HL7ParticipationType) = DEVcode1..1SHALL30264entryRelationship0..1MAY30265@typeCode1..1SHALL302662.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL30267Conforms to Procedure Activity Procedure (V2) template (2.16.840.1.113883.10.20.22.4.14.2).The moodCode??of “EVN” captures historical and current devices applied to a patient??and a “INT” reflects orders for medical devices.SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001) STATIC (CONF:30250).SHALL contain exactly one [1..1] templateId (CONF:30251) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.115" (CONF:30252).SHALL contain exactly one [1..1] code (CONF:30253).This code SHALL contain exactly one [1..1] @code="360030002" application of device, which SHALL be selected from CodeSystem SNOMED CT (2.16.840.1.113883.6.96) STATIC (CONF:30254).SHALL contain exactly one [1..1] statusCode="completed", which SHALL be selected from CodeSystem ActStatus (2.16.840.1.113883.5.14) STATIC (CONF:30255).The effectiveTime represents the start and stop dates of device usageSHALL contain exactly one [1..1] effectiveTime (CONF:30256) such that itSHALL contain exactly one [1..1] low (CONF:30268).SHALL contain exactly one [1..1] high (CONF:30269).MAY contain zero or one [0..1] targetSiteCode (CONF:30257).The participant represents the device applied or intended to be applied.SHALL contain exactly one [1..1] participant (CONF:30258) such that itSHALL contain exactly one [1..1] @typeCode="DEV" device, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90) STATIC (CONF:30259).SHALL contain exactly one [1..1] participantRole (CONF:30260).This participantRole SHALL contain exactly one [1..1] @classCode="MANU" manufactured product, which SHALL be selected from CodeSystem RoleClass (2.16.840.1.113883.5.110) STATIC (CONF:30261).This participantRole SHALL contain exactly one [1..1] playingDevice (CONF:30262).This playingDevice SHALL contain exactly one [1..1] @classCode="DEV" device, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90) STATIC (CONF:30263).This playingDevice SHALL contain exactly one [1..1] code (CONF:30264).MAY contain zero or one [0..1] entryRelationship (CONF:30265) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002) STATIC (CONF:30266).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:30267).Any associated supply order represented using a ‘Non- medicinal supply Activity’ with a moodCode ‘RQO’. Previously supplied devices represented with a moodCode ‘EVN’. MAY contain zero or one [0..1] entryRelationship (CONF:30273) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CONF:30274).SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.50.2) (CONF:30275).Figure SEQ Table \* ARABIC57: Sample<?xml version="1.0" encoding="UTF-8"?><procedure classCode="PROC" moodCode="EVN" >  <templateId root="2.16.840.1.113883.10.20.22.4.115"/>  <templateId root="2.16.840.1.113883.10.20.22.4.14"/> <id root="F3D6FD73-B2C0-4274-BFD2-A485957734DB"/> <code code="360030002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="application of device"/> <text>Device, Applied</text> <statusCode code="completed"/> <effectiveTime xsi:type="IVL_TS"> <low value="20070103"/> <high value="20120515"/> </effectiveTime> <targetSiteCode code="181216001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="181216001"/> <participant typeCode="DEV"> <participantRole classCode="MANU"> <playingDevice classCode="DEV"> <code > <originalText>Suctioning</originalText> </code> </playingDevice> </participantRole> </participant>  <entryRelationship typeCode="RSON"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.19"/> <id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/> ... </observation> </entryRelationship>  <entryRelationship typeCode="REFR"> <supply classCode="SPLY" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.50.2"/>  <id root="2413773c-2372-4299-bbe6-5b0f60664446"/> ... </supply> </entryRelationship></procedure>Procedure Context[act: templateId 2.16.840.1.113883.10.20.6.2.5 (open)]SEQ Table \* ARABIC464: Procedure Context ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)The ServiceEvent Procedure Context of the document header may be overridden in the CDA structured body if there is a need to refer to multiple imaging procedures or acts. The selection of the Procedure or Act entry from the clinical statement choice box depends on the nature of the imaging service that has been performed. The Procedure entry shall be used for image-guided interventions and minimal invasive imaging services, whereas the Act entry shall be used for diagnostic imaging services.SEQ Table \* ARABIC465: Procedure Context Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.6.2.5']templateId1..1SHALL9200@root1..1SHALL105302.16.840.1.113883.10.20.6.2.5code1..1SHALL9201effectiveTime0..1SHOULDTS9203@value1..1SHALL17173@classCode1..1SHALL264522.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL264532.16.840.1.113883.5.1001 (ActMood) = EVNSHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:26452).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:26453).SHALL contain exactly one [1..1] templateId (CONF:9200) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.5" (CONF:10530).SHALL contain exactly one [1..1] code (CONF:9201).SHOULD contain zero or one [0..1] effectiveTime (CONF:9203).The effectiveTime, if present, SHALL contain exactly one [1..1] @value (CONF:17173).Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:9199).Figure SEQ Table \* ARABIC58: Sample<act moodCode="EVN" classCode="ACT"> <templateId root="2.16.840.1.113883.10.20.6.2.5" />  <code code="70548" displayName="Magnetic resonance angiography, head; with contrast
material(s)" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4" />  <effectiveTime value="20060823222400" /></act>Procedure Plan (V2)[procedure: templateId 2.16.840.1.113883.10.20.22.4.41.2 (open)]SEQ Table \* ARABIC466: Procedure Plan (V2) ContextsContained By:Contains:Plan of Treatment Section (V2) (optional)Goal Observation (NEW) (optional)Intervention Act (NEW) (optional)Planned Procedure Section (V2) (optional)Patient Priority Preference (NEW)Provider Priority Preference (NEW)The Plan Activity Procedure represents planned alterations of the physical condition. Examples of such procedures are tracheostomy, knee replacements, and??craniectomy. The priority of the procedure to the patient and provider is communicated through Patient Priority Preference and Provider Priority Preference. The effective time indicates the time when the procedure is intended to take place.SEQ Table \* ARABIC467: Procedure Plan (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.41.2']entryRelationship0..*MAY31079@typeCode1..1SHALL310802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31081@classCode1..1SHALL85682.16.840.1.113883.5.6 (HL7ActClass) = PROC@moodCode1..1SHALL85692.16.840.1.113883.11.20.9.23 (Plan of Care moodCode (Act/Encounter/Procedure))templateId1..1SHALL30444@root1..1SHALL304452.16.840.1.113883.10.20.22.4.41.2id1..*SHALL8571statusCode1..1SHALL30446effectiveTime1..1SHALL30447performer0..*MAY30449participant0..*MAY30450entryRelationship0..*MAY31082@typeCode1..1SHALL310832.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31084SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8568).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Plan of Care moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:8569).SHALL contain exactly one [1..1] templateId (CONF:30444) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.41.2" (CONF:30445).SHALL contain at least one [1..*] id (CONF:8571).SHALL contain exactly one [1..1] statusCode (CONF:30446).SHALL contain exactly one [1..1] effectiveTime (CONF:30447).Performers represent clinicians who are responsible for assessing and treating the patient.MAY contain zero or more [0..*] performer (CONF:30449).Participants represent those in supporting roles such as caregiver, who participate in the patient's care.MAY contain zero or more [0..*] participant (CONF:30450).This entryRelationship represents the priority that a patient places on the procedure.MAY contain zero or more [0..*] entryRelationship (CONF:31079) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31080).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31081).This entryRelationship represents the priority that a provider places on the procedure.MAY contain zero or more [0..*] entryRelationship (CONF:31082) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31083).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31084).SEQ Table \* ARABIC468: Plan of Care moodCode (Act/Encounter/Procedure)Value Set: Plan of Care moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23CodeCode SystemPrint NameINTActMoodIntentARQActMoodAppointment RequestPRMSActMoodPromisePRPActMoodProposalRQOActMoodRequestFigure SEQ Table \* ARABIC59: Sample<entry> <procedure moodCode="RQO" classCode="PROC"> <templateId root="2.16.840.1.113883.10.20.22.4.41.2"/>  <id root="9a6d1bac-17d3-4195-89c4-1121bc809b5a"/> <code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscopy"/> <statusCode code="new"/> <effectiveTime> <center value="20130613"/> </effectiveTime> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.142"/> ... </observation> </entryRelationship> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.143"/> ... </entryRelationship> </procedure></entry>Nutrition Recommendations (NEW)[procedure: templateId 2.16.840.1.113883.10.20.22.4.130 (open)]SEQ Table \* ARABIC469: Nutrition Recommendations (NEW) ContextsContained By:Contains:Nutrition Section (NEW) (optional)Intervention Act (NEW) (optional)This template represents nutrition regimens (e.g. fluid restrictions, calorie minimum), interventions (e.g. NPO, nutritional supplements), and procedures (e.g. G-Tube by bolus, TPN by central line). It may also depict the need for nutrition education.SEQ Table \* ARABIC470: Nutrition Recommendations (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.130']templateId1..1SHALL30340@root1..1SHALL303412.16.840.1.113883.10.20.22.4.130code1..1SHALL303422.16.840.1.113883.1.11.20.2.9 (Nutrition Recommendations)@classCode1..1SHALL303852.16.840.1.113883.5.6 (HL7ActClass) = PROC@moodCode1..1SHALL303862.16.840.1.113883.5.1001 (ActMood) = RQOConforms to Procedure Plan (V2) template (2.16.840.1.113883.10.20.22.4.41.2).SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30385).SHALL contain exactly one [1..1] @moodCode="RQO" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:30386).SHALL contain exactly one [1..1] templateId (CONF:30340) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.130" (CONF:30341).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Nutrition Recommendations 2.16.840.1.113883.1.11.20.2.9 DYNAMIC (CONF:30342).SEQ Table \* ARABIC471: Nutrition RecommendationsValue Set: Nutrition Recommendations 2.16.840.1.113883.1.11.20.2.9Types of nutritional regimes, therapies or interventions.CodeCode SystemPrint Name61310001SNOMED CTnutrition education (procedure)386373004SNOMED CTnutrition therapy (regime/therapy)418995006SNOMED CTfeeding regime (regime/therapy)413315001SNOMED CTnutrition / feeding management (regime/therapy)182922004SNOMED CTdietary regime (regime/therapy)229912004SNOMED CTenteral feeding (regime/therapy)373453009SNOMED CTnutritional supplement (substance)225372007SNOMED CTtotal parenteral nutrition (regime/therapy)2897151011SNOMED CToral nutrition support (regime/therapy)Figure SEQ Table \* ARABIC60: Sample<entry> <procedure moodCode="RQO" classCode="PROC">  <templateId root="2.16.840.1.113883.10.20.22.4.41.2"/>  <templateId root="2.16.840.1.113883.10.20.22.4.130"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/> <code xsi:type="CD" code="229917005" displayName="gastrostomy feeding (regime/therapy)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <text>GT feeding</text> <statusCode code="active"/> <effectiveTime value="20130512"/> </procedure></entry>Product Instance[participantRole: templateId 2.16.840.1.113883.10.20.22.4.37 (open)]SEQ Table \* ARABIC472: Product Instance ContextsContained By:Contains:Non-Medicinal Supply Activity (optional)Procedure Activity Procedure (V2) (optional)Non-Medicinal Supply Activity (V2) (optional)This clinical statement represents a particular device that was placed in or used as part of a procedure or other act. This provides a record of the identifier and other details about the given product that was used. For example, it is important to have a record that indicates not just that a hip prostheses was placed in a patient but that it was a particular hip prostheses number with a unique identifier.The FDA Amendments Act specifies the creation of a Unique Device Identification (UDI) System that requires the label of devices to bear a unique identifier that will standardize device identification and identify the device through distribution and use.??The UDI should be sent in the participantRole/id.SEQ Table \* ARABIC473: Product Instance Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueparticipantRole[templateId/@root = '2.16.840.1.113883.10.20.22.4.37']@classCode1..1SHALL79002.16.840.1.113883.5.110 (RoleClass) = MANUtemplateId1..1SHALL7901@root1..1SHALL105222.16.840.1.113883.10.20.22.4.37id1..*SHALL7902playingDevice1..1SHALL7903code0..1SHOULD16837scopingEntity1..1SHALL7905id1..*SHALL7908SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:7900).SHALL contain exactly one [1..1] templateId (CONF:7901) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.37" (CONF:10522).SHALL contain at least one [1..*] id (CONF:7902).SHALL contain exactly one [1..1] playingDevice (CONF:7903).This playingDevice SHOULD contain zero or one [0..1] code (CONF:16837).SHALL contain exactly one [1..1] scopingEntity (CONF:7905).This scopingEntity SHALL contain at least one [1..*] id (CONF:7908).Prognosis Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.113 (open)]SEQ Table \* ARABIC474: Prognosis Observation ContextsContained By:Contains:Problem Observation (V2) (optional)Health Concern Act (NEW) (optional)This template represents the patient’s prognosis. Prognosis is associated with a problem or concern. It may serve as an alert to scope intervention plans. The effectiveTime represents the clinically relevant time of the observation. The observation/value is not constrained and can represent the expected life duration in PQ, an anticipated course of the disease in text, or coded term.SEQ Table \* ARABIC475: Prognosis Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.113']@classCode1..1SHALL290352.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL290362.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL29037@root1..1SHALL290382.16.840.1.113883.10.20.22.4.113code1..1SHALL29039@code1..1SHALL29468170967006@codeSystem1..1SHALL313492.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96value1..1SHALL29469effectiveTime1..1SHALL31123statusCode1..1SHALL31350@code1..1SHALL313512.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:29035).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:29036).SHALL contain exactly one [1..1] templateId (CONF:29037) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.113" (CONF:29038).SHALL contain exactly one [1..1] code (CONF:29039).This code SHALL contain exactly one [1..1] @code="170967006" prognosis/outlook (CONF:29468).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31349).SHALL contain exactly one [1..1] statusCode (CONF:31350).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:31351).SHALL contain exactly one [1..1] effectiveTime (CONF:31123).SHALL contain exactly one [1..1] value (CONF:29469).Figure SEQ Table \* ARABIC61: Prognosis, free text example<observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.113"/> <id root="2097c709-291b-4a0f-bef9-ad9b23b3bb43"/> <code code="170967006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="prognosis/outlook"/> <text> Presence of a life limiting condition(>50% possibility of death within 2 year) </text> <statusCode code="completed"/> <effectiveTime value="20130606"/> <value xsi:type="ST">Presence of a life limiting condition(>50% possibility of death within 2 year</value></observation>Figure SEQ Table \* ARABIC62: Prognosis, coded example<entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.113"/> <id root="2097c709-291b-4a0f-bef9-ad9b23b3bb43"/> <code code="170967006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="prognosis/outlook"/> <statusCode code="completed"/> <effectiveTime> <low value="20130301"/> </effectiveTime> <value xsi:type="CD" code="67334001" codeSystem="2.16.840.1.113883.6.96" displayName="guarded prognosis" codeSystemName="SNOMED CT"/> </observation></entryRelationship>>Progress Toward Goal Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.110 (open)]SEQ Table \* ARABIC476: Progress Toward Goal Observation ContextsContained By:Contains:Outcome Observation (NEW) (optional)This template represents progress toward a goal.TODO* Need better description.SEQ Table \* ARABIC477: Progress Toward Goal Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.110']@classCode1..1SHALL314182.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL314192.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL31420@root1..1SHALL314212.16.840.1.113883.10.20.22.4.110id1..1SHALL31422code1..1SHALL31423@code1..1SHALL31424ASSERTION@codeSystem1..1SHALL314252.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4value1..1SHALLCD314262.16.840.1.113883.11.20.9.55 (Goal Achievement)SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31418).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:31419).SHALL contain exactly one [1..1] templateId (CONF:31420) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.110" (CONF:31421).SHALL contain exactly one [1..1] id (CONF:31422).SHALL contain exactly one [1..1] code (CONF:31423).This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:31424).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:31425).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Goal Achievement 2.16.840.1.113883.11.20.9.55 (CONF:31426).SEQ Table \* ARABIC478: Goal AchievementValue Set: Goal Achievement 2.16.840.1.113883.11.20.9.55CodeCode SystemPrint Name390802008SNOMED CTGoal achieved390801001SNOMED CTGoal not achievedCODE_TO_BE_DETERMINEDSNOMED CTGoal not achieved - no discernible changeCODE_TO_BE_DETERMINEDSNOMED CTGoal not achieved - progressing toward goalCODE_TO_BE_DETERMINEDSNOMED CTGoal not achieved - declining from goalProvider Preference[observation: templateId 2.16.840.1.113883.10.20.24.3.84 (open)]SEQ Table \* ARABIC479: Provider Preference ContextsContained By:Contains:Communication from Provider to Provider (optional)Provider preferences are choices made by care providers relative to options for care or treatment (including scheduling, care experience, and meeting of personal health goals).SEQ Table \* ARABIC480: Provider Preference Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.84']@classCode1..1SHALL111262.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL111272.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11128@root1..1SHALL111292.16.840.1.113883.10.20.24.3.84code1..1SHALL11131@code1..1SHALL111322.16.840.1.113883.6.96 (SNOMED CT) = 103323008value1..1SHALLCD11323id1..1SHALL11356SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:11126).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:11127).SHALL contain exactly one [1..1] templateId (CONF:11128).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.84" (CONF:11129).SHALL contain exactly one [1..1] id (CONF:11356).SHALL contain exactly one [1..1] code (CONF:11131).This code SHALL contain exactly one [1..1] @code="103323008" provider preference (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:11132).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11323).Provider Priority Preference (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.143 (open)]SEQ Table \* ARABIC481: Provider Priority Preference (NEW) ContextsContained By:Contains:Problem Observation (V2) (optional)Goal Observation (NEW) (optional)Act Plan (V2) (optional)Encounter Plan (V2) (optional)Procedure Plan (V2) (optional)Observation Plan (V2) (optional)Supply Plan (V2) (optional)Substance Administration Plan (V2) (optional)Health Concern Act (NEW) (optional)This template represents provider preferences.Provider preferences are choices made by care providers relative to options for care or treatment (including scheduling, care experience, and meeting of personal health goals).SEQ Table \* ARABIC482: Provider Priority Preference (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.143']@classCode1..1SHALL309492.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL309502.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId0..*SHALL30951@root1..1SHALL309522.16.840.1.113883.10.20.22.4.143id1..1SHALL30953code1..1SHALL30954@code1..1SHALL30955103323008@codeSystem1..1SHALL309562.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96value1..1SHALLCD309572.16.840.1.113883.11.20.9.60 (Priority Level)author0..*SHOULD30958priorityCode0..1SHOULD309702.16.840.1.113883.11.20.9.57 (Priority Order)SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30949).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:30950).SHALL contain zero or more [0..*] templateId (CONF:30951) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.143" (CONF:30952).SHALL contain exactly one [1..1] id (CONF:30953).SHALL contain exactly one [1..1] code (CONF:30954).This code SHALL contain exactly one [1..1] @code="103323008" Provider preference (CONF:30955).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:30956).SHOULD contain zero or one [0..1] priorityCode, which SHOULD be selected from ValueSet Priority Order 2.16.840.1.113883.11.20.9.57 (CONF:30970).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Priority Level 2.16.840.1.113883.11.20.9.60 (CONF:30957).SHOULD contain zero or more [0..*] author (CONF:30958).SEQ Table \* ARABIC483: Priority LevelValue Set: Priority Level 2.16.840.1.113883.11.20.9.60CodeCode SystemPrint Name394849002SNOMED CTHigh priority394848005SNOMED CTNormal priority441808003SNOMED CTDelayed prioritySEQ Table \* ARABIC484: Priority OrderValue Set: Priority Order 2.16.840.1.113883.11.20.9.57CodeCode SystemPrint Name255216001SNOMED CTFirst81170007SNOMED CTSecond70905002SNOMED CTThird29970001SNOMED CTFourth32088001SNOMED CTFifth53046009SNOMED CTSixth86777004SNOMED CTSeventh51601003SNOMED CTEighth58584009SNOMED CTNinth28226006SNOMED CTTenthPurpose of Reference Observation[observation: templateId 2.16.840.1.113883.10.20.6.2.9 (open)]SEQ Table \* ARABIC485: Purpose of Reference Observation ContextsContained By:Contains:SOP Instance Observation (optional)A Purpose of Reference Observation describes the purpose of the DICOM composite object reference. Appropriate codes, such as externally defined DICOM codes, may be used to specify the semantics of the purpose of reference. When this observation is absent, it implies that the reason for the reference is unknown.SEQ Table \* ARABIC486: Purpose of Reference Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.6.2.9']@classCode1..1SHALL92642.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL92652.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL9266@root1..1SHALL105312.16.840.1.113883.10.20.6.2.9code1..1SHALL9267@code0..1SHOULD192082.16.840.1.113883.5.4 (ActCode) = ASSERTIONvalue0..1SHOULDCD92732.16.840.1.113883.11.20.9.28 (DICOMPurposeOfReference)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9264).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9265).SHALL contain exactly one [1..1] templateId (CONF:9266) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.9" (CONF:10531).SHALL contain exactly one [1..1] code (CONF:9267).This code SHOULD contain zero or one [0..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:19208).For backwards compatibility with the DICOM CMET, the code MAY be drawn from ValueSet 2.16.840.1.113883.11.20.9.28 DICOMPurposeOfReference DYNAMIC (CONF:19209).The value element is a SHOULD to allow backwards compatibility with the DICOM CMET.??Note that the use of ASSERTION for the code differs from the DICOM CMET. This is intentional. The DICOM CMET was created before the Term Info guidelines describing the use of the assertion pattern were released. It was determined that this IG should follow the latest Term Info guidelines. Implementers using both this IG and the DICOM CMET should be aware of this difference and apply appropriate transformations.SHOULD contain zero or one [0..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet DICOMPurposeOfReference 2.16.840.1.113883.11.20.9.28 DYNAMIC (CONF:9273).SEQ Table \* ARABIC487: DICOMPurposeOfReferenceValue Set: DICOMPurposeOfReference 2.16.840.1.113883.11.20.9.28CodeCode SystemPrint Name121079DCMBaseline121080DCMBest illustration of finding121112DCMSource of MeasurementFigure SEQ Table \* ARABIC63: Sample<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.6.2.9"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/><value xsi:type="CD" code="121112"codeSystem="1.2.840.10008.2.16.4"codeSystemName="DCM"displayName="Source of Measurement"/></observation>Quantity Measurement Observation[observation: templateId 2.16.840.1.113883.10.20.6.2.14 (open)]SEQ Table \* ARABIC488: Quantity Measurement Observation ContextsContained By:Contains:Text Observation (optional)Code Observations (optional)Diagnostic Imaging Report (V2) (optional)SOP Instance ObservationA Quantity Measurement Observation records quantity measurements based on image data such as linear, area, volume, and numeric measurements. The codes in DIRQuantityMeasurementTypeCodes (ValueSet: 2.16.840.1.113883.11.20.9.29) are from the qualifier hierarchy of SNOMED CT and are not valid for observation/code according to the Term Info guidelines. These codes can be used for backwards compatibility, but going forward, codes from the observable entity hierarchy will be requested and used.SEQ Table \* ARABIC489: Quantity Measurement Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.6.2.14']@classCode1..1SHALL93172.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL93182.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL9319@root1..1SHALL105322.16.840.1.113883.10.20.6.2.14code1..1SHALL9320@code0..1SHOULD192102.16.840.1.113883.11.20.9.29 (DIRQuantityMeasurementTypeCodes)value1..1SHALLPQ9324effectiveTime0..1SHOULD9326entryRelationship0..*MAY9327@typeCode1..1SHALL93282.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SPRTobservation1..1SHALL15916SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9317).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9318).SHALL contain exactly one [1..1] templateId (CONF:9319) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.14" (CONF:10532).The value set of the observation/code includes numeric measurement types for linear dimensions, areas, volumes, and other numeric measurements. This value set is extensible and comprises the union of SNOMED codes for observable entities as reproduced in DIRQuantityMeasurementTypeCodes (ValueSet: 2.16.840.1.113883.11.20.9.29) and DICOM Codes in DICOMQuantityMeasurementTypeCodes (ValueSet: 2.16.840.1.113883.11.20.9.30).SHALL contain exactly one [1..1] code (CONF:9320).This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet DIRQuantityMeasurementTypeCodes 2.16.840.1.113883.11.20.9.29 DYNAMIC (CONF:19210).SHOULD contain zero or one [0..1] effectiveTime (CONF:9326).SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:9324).MAY contain zero or more [0..*] entryRelationship (CONF:9327) such that itSHALL contain exactly one [1..1] @typeCode="SPRT" Has Support (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9328).SHALL contain exactly one [1..1] SOP Instance Observation (templateId:2.16.840.1.113883.10.20.6.2.8) (CONF:15916).SEQ Table \* ARABIC490: DIRQuantityMeasurementTypeCodesValue Set: DIRQuantityMeasurementTypeCodes 2.16.840.1.113883.11.20.9.29These codes are used for the DIR quantity measurement observation. They are from SNOMED CT ()Valueset Source: SystemPrint Name439932008SNOMED CTLength of structure440357003SNOMED CTWidth of structure439934009SNOMED CTDepth of structure439984002SNOMED CTDiameter of structure439933003SNOMED CTLong axis length of structure439428006SNOMED CTShort axis length of structure439982003SNOMED CTMajor axis length of structure439983008SNOMED CTMinor axis length of structure440356007SNOMED CTPerpendicular axis length of structure439429003SNOMED CTRadius of structure440433004SNOMED CTPerimeter of non-circular structure439747008SNOMED CTCircumference of circular structure439748003SNOMED CTDiameter of circular structure439746004SNOMED CTArea of structure439985001SNOMED CTArea of body region439749006SNOMED CTVolume of structure...Figure SEQ Table \* ARABIC64: Sample<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/> <code code="439984002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNM3" displayName="Diameter of structure"> <originalText> <reference value="#Diam2"/> </originalText> </code> <statusCode code="completed"/> <effectiveTime value="20060823223912"/> <value xsi:type="PQ" value="45" unit="mm"> codeSystemVersion="1.5"/> </value> </observation>Reaction Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.9.2 (open)]SEQ Table \* ARABIC491: Reaction Observation (V2) ContextsContained By:Contains:Medication Activity (V2) (optional)Allergy - Intolerance Observation (V2) (optional)Substance or Device Allergy - Intolerance Observation (V2) (optional)Immunization Activity (V2) (optional)Health Concern Act (NEW) (optional)Medication Activity (V2)Procedure Activity Procedure (V2)Severity Observation (V2)This clinical statement represents an undesired symptom, finding, etc., due to an administered or exposed substance. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions.SEQ Table \* ARABIC492: Reaction Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.9.2']entryRelationship0..*MAY7340@typeCode1..1SHALL73412.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSON@inversionInd1..1SHALL7344truesubstanceAdministration1..1SHALL15921entryRelationship0..*MAY7337@typeCode1..1SHALL73382.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSON@inversionInd1..1SHALL7343trueprocedure1..1SHALL15920@classCode1..1SHALL73252.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73262.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7323@root1..1SHALL105232.16.840.1.113883.10.20.22.4.9.2id1..1SHALL7329code1..1SHALL16851@code1..1SHALL311242.16.840.1.113883.5.4 (ActCode) = ASSERTIONtext0..1SHOULD7330reference0..1SHOULD15917@value0..1SHOULD15918statusCode1..1SHALL7328@code1..1SHALL191142.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime0..1SHOULD7332low0..1SHOULD7333high0..1SHOULD7334value1..1SHALLCD73352.16.840.1.113883.3.88.12.3221.7.4 (Problem Value Set)entryRelationship0..1MAY7580@typeCode1..1SHALL75812.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL10375trueobservation1..1SHALL15922SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7325).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7326).SHALL contain exactly one [1..1] templateId (CONF:7323) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.9.2" (CONF:10523).SHALL contain exactly one [1..1] id (CONF:7329).SHALL contain exactly one [1..1] code (CONF:16851).This code SHALL contain exactly one [1..1] @code="ASSERTION" (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:31124).SHOULD contain zero or one [0..1] text (CONF:7330).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15917).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15918).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15919).SHALL contain exactly one [1..1] statusCode (CONF:7328).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19114).SHOULD contain zero or one [0..1] effectiveTime (CONF:7332).The effectiveTime, if present, SHOULD contain zero or one [0..1] low (CONF:7333).The effectiveTime, if present, SHOULD contain zero or one [0..1] high (CONF:7334).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:7335).MAY contain zero or more [0..*] entryRelationship (CONF:7337) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7338).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7343).SHALL contain exactly one [1..1] Procedure Activity Procedure (V2) (templateId:2.16.840.1.113883.10.20.22.4.14.2) (CONF:15920).This procedure activity is intended to contain information about procedures that were performed in response to an allergy reaction (CONF:16853).MAY contain zero or more [0..*] entryRelationship (CONF:7340) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7341).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7344).SHALL contain exactly one [1..1] Medication Activity (V2) (templateId:2.16.840.1.113883.10.20.22.4.16.2) (CONF:15921).This medication activity is intended to contain information about medications that were administered in response to an allergy reaction (CONF:16840).MAY contain zero or one [0..1] entryRelationship (CONF:7580) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7581).SHALL contain exactly one [1..1] @inversionInd="true" TRUE (CONF:10375).SHALL contain exactly one [1..1] Severity Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.8.2) (CONF:15922).SEQ Table \* ARABIC493: Problem Value SetValue Set: Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4CodeCode SystemPrint Name50992006SNOMED CT22q partial trisomy syndrome (disorder)237931009SNOMED CT2-Ketoadipic acidemia (disorder)54470008SNOMED CT3 beta-Hydroxysteroid dehydrogenase deficiency (disorder)237950009SNOMED CT3-Methylglutaconic aciduria (disorder)296646009SNOMED CT4-quinolones overdose (disorder)41797007SNOMED CT5 10-Methylenetetrahydrofolate reductase deficiency (disorder)413380004SNOMED CTA pattern strabismus (disorder)425879009SNOMED CTAA amyloid nephropathy (disorder)274945004SNOMED CTAA amyloidosis (disorder)75100008SNOMED CTAbdominal abscess (disorder)43894001SNOMED CTAbdominal actinomycosis (disorder)233985008SNOMED CTAbdominal aortic aneurysm (disorder)253679008SNOMED CTAbdominal aortic coarctation (disorder)116289008SNOMED CTAbdominal bloating (finding)9991008SNOMED CTAbdominal colic (finding)271860004SNOMED CTAbdominal mass (finding)75879005SNOMED CTAbdominal migraine (disorder)21522001SNOMED CTAbdominal pain (finding)82661006SNOMED CTAbdominal pregnancy (disorder)72300008SNOMED CTAbdominal rigidity (finding)...Figure SEQ Table \* ARABIC65: Sample<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.9.2"/><id root="4adc1020-7b14-11db-9fe1-0800200c9a64"/><code code="ASSERTION" displayName="Assertion"codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode "/><text><reference value="#reaction1"/></text><statusCode code="completed"/><effectiveTime><low value="20070501"/> <high value="20090227130000+0500"/></effectiveTime><value xsi:type="CD" code="422587007" codeSystem="2.16.840.1.113883.6.96"displayName="Nausea"/> <entryRelationship typeCode="SUBJ" inversionInd="true"><observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.8"/> .... </observation> </entryRelationship></observation>Reason[observation: templateId 2.16.840.1.113883.10.20.24.3.88 (open)]SEQ Table \* ARABIC494: Reason ContextsContained By:Contains:Medical Device Applied (NEW) (optional)This template describes the thought process or justification for an action or for not performing an action. Examples include patient, system, or medical-related reasons for declining to perform specific actions. Note that the parent template that calls this template can be asserted to have occurred or to not have occurred. Therefore, this template simply tacks on a reason to some other (possibly negated) act. As such, there is nothing in this template that says whether the parent act did or did not occur. SEQ Table \* ARABIC495: Reason Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.88']@classCode1..1SHALL113572.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL113582.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11359@root1..1SHALL113602.16.840.1.113883.10.20.24.3.88code1..1SHALL11361@code1..1SHALL113622.16.840.1.113883.6.96 (SNOMED CT) = 410666004statusCode1..1SHALL11364@code1..1SHALL113652.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11366value1..1SHALLCD11367SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:11357).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:11358).SHALL contain exactly one [1..1] templateId (CONF:11359).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.88" (CONF:11360).SHALL contain exactly one [1..1] code (CONF:11361).This code SHALL contain exactly one [1..1] @code="410666004" reason (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:11362).SHALL contain exactly one [1..1] statusCode (CONF:11364).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:11365).SHALL contain exactly one [1..1] effectiveTime (CONF:11366).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11367).Referenced Frames Observation[observation: templateId 2.16.840.1.113883.10.20.6.2.10 (open)]SEQ Table \* ARABIC496: Referenced Frames Observation ContextsContained By:Contains:SOP Instance Observation (optional)Boundary ObservationA Referenced Frames Observation is used if the referenced DICOM SOP instance is a multiframe image and the reference does not apply to all frames. The list of integer values for the referenced frames of a DICOM multiframe image SOP instance is contained in a Boundary Observation nested inside this class.SEQ Table \* ARABIC497: Referenced Frames Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.6.2.10']entryRelationship1..1SHALL9279@typeCode1..1SHALL92802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL15923@classCode1..1SHALL92762.16.840.1.113883.5.6 (HL7ActClass) = ROIBND@moodCode1..1SHALL92772.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALL19164@code0..1MAY191651.2.840.10008.2.16.4 (DCM) = 121190SHALL contain exactly one [1..1] @classCode="ROIBND" Bounded Region of Interest (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9276).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9277).SHALL contain exactly one [1..1] code (CONF:19164).This code MAY contain zero or one [0..1] @code="121190" Referenced Frames (CodeSystem: DCM 1.2.840.10008.2.16.4 STATIC) (CONF:19165).SHALL contain exactly one [1..1] entryRelationship (CONF:9279).This entryRelationship SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9280).This entryRelationship SHALL contain exactly one [1..1] Boundary Observation (templateId:2.16.840.1.113883.10.20.6.2.11) (CONF:15923).Figure SEQ Table \* ARABIC66: Sample<observation classCode="ROIBND" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.6.2.10"/><code code="121190" codeSystem="1.2.840.10008.2.16.4"displayName="Referenced Frames"/><entryRelationship typeCode="COMP"><observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.6.2.11"/><code code="113036" codeSystem="1.2.840.10008.2.16.4"displayName="Frames for Display"/><value xsi:type="INT" value="1"/></observation></entryRelationship></observation>Result Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.2.2 (open)]SEQ Table \* ARABIC498: Result Observation (V2) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Result Organizer (V2) (required)Results Section (entries required) (V2) (required)Author Participant (NEW)This clinical statement represents details of a lab, radiology, or other study performed on a patient.The result observation includes a statusCode to allow recording the status of an observation. If a Result Observation is not completed, the Result Organizer must include corresponding statusCode. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus.SEQ Table \* ARABIC499: Result Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.2.2']@classCode1..1SHALL71302.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL71312.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7136@root1..1SHALL91382.16.840.1.113883.10.20.22.4.2.2id1..*SHALL7137code1..1SHALL7133text0..1SHOULD7138reference0..1SHOULD15924@value0..1SHOULD15925statusCode1..1SHALL7134@code1..1SHALL148492.16.840.1.113883.11.20.9.39 (Result Status)effectiveTime1..1SHALL7140value1..1SHALL7143interpretationCode0..*SHOULD7147methodCode0..1MAYSET<CE>7148targetSiteCode0..1MAYSET<CD>7153author0..*SHOULD7149referenceRange0..*SHOULD7150observationRange1..1SHALL7151code0..0SHALL NOT7152SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7130).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7131).SHALL contain exactly one [1..1] templateId (CONF:7136) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2.2" (CONF:9138).SHALL contain at least one [1..*] id (CONF:7137).SHALL contain exactly one [1..1] code (CONF:7133).SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:19211).Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency. Local and/or regional codes for laboratory results are allowed. The Local and/or regional codes SHOULD be sent in the translation element. See the Local code example figure (CONF:19212).SHOULD contain zero or one [0..1] text (CONF:7138).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15924).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15925).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15926).SHALL contain exactly one [1..1] statusCode (CONF:7134).This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC (CONF:14849).SHALL contain exactly one [1..1] effectiveTime (CONF:7140).Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) (CONF:16838).SHALL contain exactly one [1..1] value (CONF:7143).If Observation/value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression (CONF:31484).SHOULD contain zero or more [0..*] interpretationCode (CONF:7147).MAY contain zero or one [0..1] methodCode (CONF:7148).MAY contain zero or one [0..1] targetSiteCode (CONF:7153).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:7149).SHOULD contain zero or more [0..*] referenceRange (CONF:7150).The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:7151).This observationRange SHALL NOT contain [0..0] code (CONF:7152).SEQ Table \* ARABIC500: Result StatusValue Set: Result Status 2.16.840.1.113883.11.20.9.39CodeCode SystemPrint NameabortedActStatusabortedactiveActStatusactivecancelledActStatuscancelledcompletedActStatuscompletedheldActStatusheldsuspendedActStatussuspendedFigure SEQ Table \* ARABIC67: Result Observation<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.2.2"/> <id root="107c2dc0-67a5-11db-bd13-0800200c9a66"/> <code code="30313-1" displayName="HGB"codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result1"/> </text> <statusCode code="completed"/> <effectiveTime value="200803190830-0800"/> <value xsi:type="PQ" value="13.2" unit="g/dl"> <originalText> <reference value="#resultvalue1"/> </originalText> </value> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="IVL_PQ"> <low value="12.0" unit="g/dL"/> <high value="15.5" unit="g/dL"/> <originalText> <reference value="#referencerange1">Normal hemoglobin range females 18+yo</reference> </originalText> </value> </observationRange> </referenceRange></observation>Outcome Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.144 (open)]SEQ Table \* ARABIC501: Outcome Observation (NEW) ContextsContained By:Contains:Health Status Evaluations/Outcomes Section (NEW) (required)Goal Observation (NEW) (optional)Goal Observation (NEW)Progress Toward Goal ObservationEvaluates a goal.TODO*SEQ Table \* ARABIC502: Outcome Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.144']entryRelationship1..*SHALL31224@typeCode1..1SHALL312252.16.840.1.113883.5.1002 (HL7ActRelationshipType) = GEVLobservation1..1SHALL31226entryRelationship0..1SHOULDEntryRelationship31427@typeCode1..1SHALL314282.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SPRT@inversionInd1..1SHALL31429trueobservation1..1SHALL31430@classCode1..1SHALL312192.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL312202.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL31221@root1..1SHALL312222.16.840.1.113883.10.20.22.4.144id1..1SHALL31223Conforms to Result Observation (V2) template (2.16.840.1.113883.10.20.22.4.2.2).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31219).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:31220).SHALL contain exactly one [1..1] templateId (CONF:31221) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.144" (CONF:31222).SHALL contain exactly one [1..1] id (CONF:31223).This entryRelationship represents the relationship between an Outcome Observation and an Goal Observation (Outcome Observation EVALUATES Goal Observation).SHALL contain at least one [1..*] entryRelationship (CONF:31224).Such entryRelationships SHALL contain exactly one [1..1] @typeCode="GEVL" Evaluates goal (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31225).Such entryRelationships SHALL contain exactly one [1..1] Goal Observation (NEW) (templateId:2.16.840.1.113883.10.20.22.4.121) (CONF:31226).This entryRelationship represents the relationship between an Outcome Observation and an Outcome Assessment Observation (Outcome Observation SUPPORTS Outcome Assessment Observation).SHOULD contain zero or one [0..1] entryRelationship (CONF:31427).The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31428).The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" (CONF:31429).The entryRelationship, if present, SHALL contain exactly one [1..1] Progress Toward Goal Observation (templateId:2.16.840.1.113883.10.20.22.4.110) (CONF:31430).Result Organizer (V2)[organizer: templateId 2.16.840.1.113883.10.20.22.4.1.2 (open)]SEQ Table \* ARABIC503: Result Organizer (V2) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Results Section (entries optional) (V2) (optional)Results Section (entries required) (V2) (required)Author Participant (NEW)Result Observation (V2)This clinical statement identifies set of result observations. It contains information applicable to all of the contained result observations. Result type codes categorize a result into one of several commonly accepted values (e.g., “Hematology”, “Chemistry”, “Nuclear Medicine”). These values are often implicit in the Organizer/code (e.g., an Organizer/code of “complete blood count” implies a ResultTypeCode of “Hematology”). This template requires Organizer/code to include a ResultTypeCode either directly or as a translation of a code from some other code system.An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown.If any Result Observation within the organizer has a statusCode of ‘active’, the Result Organizer must also have as statusCode of ‘active.SEQ Table \* ARABIC504: Result Organizer (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.1.2']component1..*SHALL7124observation1..1SHALL14850@classCode1..1SHALL71212.16.840.1.113883.5.6 (HL7ActClass)@moodCode1..1SHALL71222.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7126@root1..1SHALL91342.16.840.1.113883.10.20.22.4.1.2id1..*SHALL7127code1..1SHALL7128statusCode1..1SHALL7123@code1..1SHALL148482.16.840.1.113883.11.20.9.39 (Result Status)author0..*SHOULD31149SHALL contain exactly one [1..1] @classCode (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7121).SHOULD contain zero or one 0..1] @classCode="CLUSTER" Cluster (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) OR SHOULD contain zero or one 0..1] @classCode="BATTERY" Battery (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7165).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7122).SHALL contain exactly one [1..1] templateId (CONF:7126) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.1.2" (CONF:9134).SHALL contain at least one [1..*] id (CONF:7127).SHALL contain exactly one [1..1] code (CONF:7128).SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12) (CONF:19218).Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency.??Local and/or regional codes for laboratory results SHOULD also be allowed (CONF:19219).SHALL contain exactly one [1..1] statusCode (CONF:7123).This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC (CONF:14848).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31149).SHALL contain at least one [1..*] component (CONF:7124) such that itSHALL contain exactly one [1..1] Result Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.2.2) (CONF:14850).SEQ Table \* ARABIC505: Result StatusValue Set: Result Status 2.16.840.1.113883.11.20.9.39CodeCode SystemPrint NameabortedActStatusabortedactiveActStatusactivecancelledActStatuscancelledcompletedActStatuscompletedheldActStatusheldsuspendedActStatussuspendedSelf-Care Activities (ADL and IADL) (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.128 (open)]SEQ Table \* ARABIC506: Self-Care Activities (ADL and IADL) (NEW) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Functional Status Section (V2) (optional)Functional Status Organizer (V2) (required)This template represents the adult patient's daily self-care ability. These activities are called activities of daily living (ADL) and instrumental activities of daily living (IADL).??ADLs involve caring for and moving the body (e.g. dressing, bathing, eating). IADLs support an independent life style (e.g. cooking, managing medications, driving, shopping). SEQ Table \* ARABIC507: Self-Care Activities (ADL and IADL) (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.128']value1..1SHALLCD280422.16.840.1.113883.11.20.9.46 (Ability Value Set)code1..1SHALL281532.16.840.1.113883.11.20.9.47 (ADL Result Type)templateId1..1SHALL28190@root1..1SHALL284572.16.840.1.113883.10.20.22.4.128@classCode1..1SHALL313892.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL313902.16.840.1.113883.5.1001 (ActMood) = EVNSHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31389).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:31390).SHALL contain exactly one [1..1] templateId (CONF:28190) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.128" (CONF:28457).SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ADL Result Type 2.16.840.1.113883.11.20.9.47 DYNAMIC (CONF:28153).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Ability Value Set 2.16.840.1.113883.11.20.9.46 STATIC (CONF:28042).SEQ Table \* ARABIC508: Ability Value SetValue Set: Ability Value Set 2.16.840.1.113883.11.20.9.46A value set containing SNOMED-CT codes for dependency.CodeCode SystemPrint Name371153006SNOMED CTIndependent371154000SNOMED CTDependent371152001SNOMED CTAssistedSEQ Table \* ARABIC509: ADL Result TypeValue Set: ADL Result Type 2.16.840.1.113883.11.20.9.47This value set includes Basic ADL and IADL activities.CodeCode SystemPrint Name46008-9?LOINCBathing28409-1?LOINCDressing?28408-3LOINCToileting46484-2LOINCFeeding or Eating46482-6?LOINCTransferring28413-3LOINCAmbulation45618-6LOINCBowel continence?45619-4LOINCBladder continenceFigure SEQ Table \* ARABIC68: Sample<observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.128"/> <id root="c6b5a04b-2bf4-49d1-8336-636a3813df0a"/> <code code="46482-6" displayName="Transferring" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <statusCode code="completed"/> <effectiveTime value="200130311"/> <value xsi:type="CD" code="371153006" displayName="Independent" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <author> ... </author></observation>Sensory and Speech Status (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.127 (open)]SEQ Table \* ARABIC510: Sensory and Speech Status (NEW) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Functional Status Section (V2) (optional)Assessment Scale ObservationThis template represents a patient’s sensory or speech ability. It may contain an Assessment Scale related to the sensory or speech ability.SEQ Table \* ARABIC511: Sensory and Speech Status (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.127']entryRelationship0..*MAY27984@typeCode1..1SHALL279852.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL27986templateId1..1SHALL27959@root1..1SHALL279602.16.840.1.113883.10.20.22.4.127code1..1SHALL279622.16.840.1.113883.11.20.9.50 (Sensory and Speech Problem Type)value1..1SHALLCD279742.16.840.1.113883.11.20.9.44 (Mental and Functional Status Response Value Set)@classCode1..1SHALL310172.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL310182.16.840.1.113883.5.1001 (ActMood) = EVNstatusCode1..1SHALL31437@code1..1SHALL314382.16.840.1.113883.5.14 (ActStatus) = completedauthor0..1SHOULD31439time1..1SHALL31440effectiveTime1..1SHALL31441SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31017).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:31018).SHALL contain exactly one [1..1] templateId (CONF:27959) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.127" (CONF:27960).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Sensory and Speech Problem Type 2.16.840.1.113883.11.20.9.50 DYNAMIC (CONF:27962).SHALL contain exactly one [1..1] statusCode (CONF:31437).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:31438).SHALL contain exactly one [1..1] effectiveTime (CONF:31441).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Mental and Functional Status Response Value Set 2.16.840.1.113883.11.20.9.44 DYNAMIC (CONF:27974).SHOULD contain zero or one [0..1] author (CONF:31439).The author, if present, SHALL contain exactly one [1..1] time (CONF:31440).MAY contain zero or more [0..*] entryRelationship (CONF:27984) such that itSHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:27985).SHALL contain exactly one [1..1] Assessment Scale Observation (templateId:2.16.840.1.113883.10.20.22.4.69) (CONF:27986).SEQ Table \* ARABIC512: Sensory and Speech Problem TypeValue Set: Sensory and Speech Problem Type 2.16.840.1.113883.11.20.9.50A value set of SNOMED-CT observable codes to identify sensory and speech problems.CodeCode SystemPrint Name47078008SNOMED CTHearing405183003SNOMED CTSensory function status: vision373713005SNOMED CTSensory perception397627001SNOMED CTTaste, function397686008SNOMED CTSense of smell, functionSEQ Table \* ARABIC513: Mental and Functional Status Response Value SetValue Set: Mental and Functional Status Response Value Set 2.16.840.1.113883.11.20.9.44A value set containing 2 SNOMED-CT qualifier codes that are common responses to mental and functional ability queries.CodeCode SystemPrint Name11163003SNOMED CTIntact260379002SNOMED CTImpairedFigure SEQ Table \* ARABIC69: Sample<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.127"/> <id root="c6b5a04b-2bf4-49d1-8336-636a3813df0a"/> <code code="47078008" displayName="Hearing" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> <statusCode code="completed"/> <effectiveTime value="200130311"/> <value xsi:type="CD" code="260379002" displayName="Impaired" codeSystemName="SNOMED CT"/> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.69"/> <id root="c6b5a04b-2bf4-49d1-8336-636a3813df0b"/> ... </observation> </entryRelationship> </observation></entry>Series Act[act: templateId 2.16.840.1.113883.10.20.22.4.63 (open)]SEQ Table \* ARABIC514: Series Act ContextsContained By:Contains:Study Act (required)SOP Instance ObservationA Series Act contains the DICOM series information for referenced DICOM composite objects. The series information defines the attributes that are used to group composite instances into distinct logical sets. Each series is associated with exactly one study. Series Act clinical statements are only instantiated in the DICOM Object Catalog section inside a Study Act, and thus do not require a separate templateId; in other sections, the SOP Instance Observation is included directly.SEQ Table \* ARABIC515: Series Act Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.63']@classCode1..1SHALL92222.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL92232.16.840.1.113883.5.1001 (ActMood) = EVNid1..*SHALL9224@root1..1SHALL9225@extension0..0SHALL NOT9226text0..1MAY9233effectiveTime0..1SHOULD9235entryRelationship1..*SHALL9237@typeCode1..1SHALL92382.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL15927templateId1..1SHALL10918@root1..1SHALL109192.16.840.1.113883.10.20.22.4.63code1..1SHALL19166@code1..1SHALL19167113015@codeSystem0..1MAY264611.2.840.10008.2.16.4 (DCM) = 1.2.840.10008.2.16.4qualifier1..1SHALL26462name1..1SHALL26463@code1..1SHALL26464121139@codeSystem1..1SHALL264651.2.840.10008.2.16.4 (DCM) = 1.2.840.10008.2.16.4value1..1SHALL26466SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9222).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9223).SHALL contain exactly one [1..1] templateId (CONF:10918) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.63" (CONF:10919).SHALL contain at least one [1..*] id (CONF:9224).The @root contains the OID of the study instance UID since DICOM study ids consist only of an OIDSuch ids SHALL contain exactly one [1..1] @root (CONF:9225).Such ids SHALL NOT contain [0..0] @extension (CONF:9226).SHALL contain exactly one [1..1] code (CONF:19166).This code SHALL contain exactly one [1..1] @code="113015" (CONF:19167).This code MAY contain zero or one [0..1] @codeSystem="1.2.840.10008.2.16.4" (CodeSystem: DCM 1.2.840.10008.2.16.4) (CONF:26461).This code SHALL contain exactly one [1..1] qualifier (CONF:26462).This qualifier SHALL contain exactly one [1..1] name (CONF:26463).This name SHALL contain exactly one [1..1] @code="121139" Modality (CONF:26464).This name SHALL contain exactly one [1..1] @codeSystem="1.2.840.10008.2.16.4" (CodeSystem: DCM 1.2.840.10008.2.16.4) (CONF:26465).This qualifier SHALL contain exactly one [1..1] value (CONF:26466).If present, the text element contains the description of the seriesMAY contain zero or one [0..1] text (CONF:9233).If present, the effectiveTime contains the time the series was startedSHOULD contain zero or one [0..1] effectiveTime (CONF:9235).SHALL contain at least one [1..*] entryRelationship (CONF:9237) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9238).SHALL contain exactly one [1..1] SOP Instance Observation (templateId:2.16.840.1.113883.10.20.6.2.8) (CONF:15927).Figure SEQ Table \* ARABIC70: Sample<act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.63" /> <id root="1.2.840.113619.2.62.994044785528.20060823223142485051" /> <code code="113015" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Series"> <qualifier> <name code="121139" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Modality" /> <value code="CR" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Computed Radiography" /> </qualifier> </code>  <entryRelationship typeCode="COMP"> <observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8" />...</observation> </entryRelationship></act>Service Delivery Location[participantRole: templateId 2.16.840.1.113883.10.20.22.4.32 (open)]SEQ Table \* ARABIC516: Service Delivery Location ContextsContained By:Contains:Procedure Activity Act (V2) (optional)Procedure Activity Procedure (V2) (optional)Procedure Activity Observation (V2) (optional)Encounter Activity (V2) (optional)This clinical statement represents the location of a service event where an act, observation or procedure took place.SEQ Table \* ARABIC517: Service Delivery Location Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueparticipantRole[templateId/@root = '2.16.840.1.113883.10.20.22.4.32']templateId1..1SHALL7635@root1..1SHALL105242.16.840.1.113883.10.20.22.4.32@classCode1..1SHALL77582.16.840.1.113883.5.111 (RoleCode) = SDLOCaddr0..*SHOULD7760telecom0..*SHOULD7761playingEntity0..1MAY7762@classCode1..1SHALL77632.16.840.1.113883.5.41 (EntityClass) = PLCname0..1MAY16037code1..1SHALL168502.16.840.1.113883.1.11.20275 (HealthcareServiceLocation)SHALL contain exactly one [1..1] @classCode="SDLOC" (CodeSystem: RoleCode 2.16.840.1.113883.5.111 STATIC) (CONF:7758).SHALL contain exactly one [1..1] templateId (CONF:7635) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.32" (CONF:10524).SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet HealthcareServiceLocation 2.16.840.1.113883.1.11.20275 STATIC (CONF:16850).SHOULD contain zero or more [0..*] addr (CONF:7760).SHOULD contain zero or more [0..*] telecom (CONF:7761).MAY contain zero or one [0..1] playingEntity (CONF:7762).The playingEntity, if present, SHALL contain exactly one [1..1] @classCode="PLC" (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) (CONF:7763).The playingEntity, if present, MAY contain zero or one [0..1] name (CONF:16037).SEQ Table \* ARABIC518: HealthcareServiceLocationValue Set: HealthcareServiceLocation 2.16.840.1.113883.1.11.20275CodeCode SystemPrint Name1162-7HL7 HealthcareServiceLocation24-Hour observation area1184-1HL7 HealthcareServiceLocationAdministrative area1210-4HL7 HealthcareServiceLocationAdult Mixed Acuity Unit1099-1HL7 HealthcareServiceLocationAdult step down unit [post-critical care]1110-6HL7 HealthcareServiceLocationAllergy clinic1166-8HL7 HealthcareServiceLocationAmbulatory surgical setting1212-0HL7 HealthcareServiceLocationAny Age Mixed Acuity Unit1106-4HL7 HealthcareServiceLocationAssisted living area1145-2HL7 HealthcareServiceLocationBehavioral health clinic1185-8HL7 HealthcareServiceLocationBlood bank1195-7HL7 HealthcareServiceLocationBlood collection [Blood drive campaign]1147-8HL7 HealthcareServiceLocationBlood collection center1022-3HL7 HealthcareServiceLocationBone marrow transplant unit1026-4HL7 HealthcareServiceLocationBurn critical care unit1005-8HL7 HealthcareServiceLocationCardiac catheterization lab1112-2HL7 HealthcareServiceLocationCardiac rehabilitation center1113-0HL7 HealthcareServiceLocationCardiology clinic1186-6HL7 HealthcareServiceLocationCentral sterile supply1187-4HL7 HealthcareServiceLocationCentral trash area1095-9HL7 HealthcareServiceLocationCesarean section room/suite...Severity Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.8.2 (open)]SEQ Table \* ARABIC519: Severity Observation (V2) ContextsContained By:Contains:Reaction Observation (V2) (optional)Allergy - Intolerance Observation (V2) (optional)Substance or Device Allergy - Intolerance Observation (V2) (optional)This clinical statement represents the gravity of the problem, such as allergy or reaction, in terms of its actual or potential impact on the patient. The Severity Observation can be associated with an Allergy - Intolerance Observation, Substance or Device Allergy - Intolerance Observation, Reaction Observation or all. When the Severity Observation is associated directly with an allergy it characterizes the allergy. When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. A person may manifest many symptoms in a reaction to a single substance, and each reaction to the substance can be represented. However, each reaction observation can have only one severity observation associated with it. For example, someone may have a rash reaction observation as well as an itching reaction observation, but each can have only one level of severity.SEQ Table \* ARABIC520: Severity Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.8.2']@classCode1..1SHALL73452.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73462.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7347@root1..1SHALL105252.16.840.1.113883.10.20.22.4.8.2code1..1SHALL19168@code1..1SHALL191692.16.840.1.113883.5.4 (ActCode) = SEVtext0..1SHOULD7350reference0..1SHOULD15928@value0..1SHOULD15929statusCode1..1SHALL7352@code1..1SHALL191152.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD73562.16.840.1.113883.3.88.12.3221.6.8 (Problem Severity)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7345).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7346).SHALL contain exactly one [1..1] templateId (CONF:7347) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.8.2" (CONF:10525).SHALL contain exactly one [1..1] code (CONF:19168).This code SHALL contain exactly one [1..1] @code="SEV" (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:19169).SHOULD contain zero or one [0..1] text (CONF:7350).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15928).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15929).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15930).SHALL contain exactly one [1..1] statusCode (CONF:7352).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19115).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC (CONF:7356).SEQ Table \* ARABIC521: Problem SeverityValue Set: Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8CodeCode SystemPrint Name255604002SNOMED CTMild (qualifier value)371923003SNOMED CTMild to moderate (qualifier value)6736007SNOMED CTModerate (severity modifier) (qualifier value)371924009SNOMED CTModerate to severe (qualifier value)24484000SNOMED CTSevere (severity modifier) (qualifier value)399166001SNOMED CTFatal (qualifier value)Social History Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.38.2 (open)]SEQ Table \* ARABIC522: Social History Observation (V2) ContextsContained By:Contains:Social History Section (V2) (optional)Health Concern Act (NEW) (optional)This template represents a patient's occupations, lifestyle, and environmental health risk factors. Demographic data (e.g. marital status, race, ethnicity, religious affiliation) is captured in the header.SEQ Table \* ARABIC523: Social History Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.38.2']@classCode1..1SHALL85482.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL85492.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL8550@root1..1SHALL105262.16.840.1.113883.10.20.22.4.38.2id1..*SHALL8551code1..1SHALL85582.16.840.1.113883.3.88.12.80.60.2 (Social History Type Set Definition (V2))originalText0..1SHOULD19221reference0..1SHOULD19222@value0..1SHOULD19223statusCode1..1SHALL8553@code1..1SHALL191172.16.840.1.113883.5.14 (ActStatus) = completedvalue0..1SHOULD8559SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8548).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:8549).SHALL contain exactly one [1..1] templateId (CONF:8550) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.38.2" (CONF:10526).SHALL contain at least one [1..*] id (CONF:8551).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Social History Type Set Definition (V2) 2.16.840.1.113883.3.88.12.80.60.2 DYNAMIC (CONF:8558).This code SHOULD contain zero or one [0..1] originalText (CONF:19221).The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:19222).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:19223).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:19224).SHALL contain exactly one [1..1] statusCode (CONF:8553).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19117).SHOULD contain zero or one [0..1] value (CONF:8559).If Observation/value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression (CONF:8555).SEQ Table \* ARABIC524: Social History Type Set Definition (V2)Value Set: Social History Type Set Definition (V2) 2.16.840.1.113883.3.88.12.80.60.2Personal and social history observation typesCodeCode SystemPrint Name229819007SNOMED CTTobacco use and exposure (observable entity)256235009SNOMED CTExercise (observable entity)160573003SNOMED CTAlcohol intake (observable entity)364393001SNOMED CTNutritional observable (observable entity)364703007SNOMED CTEmployment detail (observable entity)425400000SNOMED CTToxic exposure status (observable entity)363908000SNOMED CTDetails of drug misuse behavior (observable entity)228272008SNOMED CTHealth-related behavior (observable entity)105421008SNOMED CTEducational Achievement(observable entity)423514004SNOMED CTCommunity resource details (observable entity)302160007SNOMED CTHousehold, family and support network detail (observable entity)102487004SNOMED CTenvironmental risk factor (observable entity)424483007SNOMED CTtransportation details (observable entity)442133001SNOMED CThousing history (observable entity)224209007SNOMED CTResidence and accommodation circumstances (observable entity)446996006SNOMED CTDosage of radiation exposure (observable entity)Figure SEQ Table \* ARABIC71: Sample<entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.38.2"/> <id root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1" /> <code code="160573003" codeSystem="2.16.840.1.113883.6.96" displayName="Alcohol Intake"> </code> <statusCode code="completed" /> <effectiveTime value="20130312"/> <value xsi:type="ST">2 drinks per week</value> </observation></entry>SOP Instance Observation[observation: templateId 2.16.840.1.113883.10.20.6.2.8 (open)]SEQ Table \* ARABIC525: SOP Instance Observation ContextsContained By:Contains:Series Act (required)Text Observation (optional)Code Observations (optional)Quantity Measurement Observation (optional)Diagnostic Imaging Report (V2) (optional)Purpose of Reference ObservationReferenced Frames ObservationA SOP Instance Observation contains the DICOM Service Object Pair (SOP) Instance information for referenced DICOM composite objects. The SOP Instance act class is used to reference both image and non-image DICOM instances. The text attribute contains the DICOM WADO reference.SEQ Table \* ARABIC526: SOP Instance Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.6.2.8']entryRelationship0..*MAY9257@typeCode1..1SHALL92582.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL15935entryRelationship0..*MAY9260@typeCode1..1SHALL92612.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPobservation1..1SHALL15936@classCode1..1SHALL92402.16.840.1.113883.5.6 (HL7ActClass) = DGIMG@moodCode1..1SHALL92412.16.840.1.113883.5.1001 (ActMood) = EVNid1..*SHALL9242code1..1SHALL9244@code1..1SHALL19225@codeSystem1..1SHALL192271.2.840.10008.2.6.1text0..1SHOULD9246@mediaType1..1SHALL9247application/dicomreference1..1SHALL9248effectiveTime0..1SHOULD9250@value1..1SHALL9251low0..0SHALL NOT9252high0..0SHALL NOT9253entryRelationship0..*MAY9254@typeCode1..1SHALL92552.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJSHALL contain exactly one [1..1] @classCode="DGIMG" Diagnostic Image (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9240).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9241).The @root contains an OID representing the DICOM SOP Instance UIDSHALL contain at least one [1..*] id (CONF:9242).SHALL contain exactly one [1..1] code (CONF:9244).This code SHALL contain exactly one [1..1] @code (CONF:19225).@code is an OID for a valid SOP class name UID (CONF:19226).This code SHALL contain exactly one [1..1] @codeSystem="1.2.840.10008.2.6.1" DCMUID (CONF:19227).SHOULD contain zero or one [0..1] text (CONF:9246).The text, if present, SHALL contain exactly one [1..1] @mediaType="application/dicom" (CONF:9247).The text, if present, SHALL contain exactly one [1..1] reference (CONF:9248).SHALL contain a @value that contains a WADO reference as a URI (CONF:9249).SHOULD contain zero or one [0..1] effectiveTime (CONF:9250).The effectiveTime, if present, SHALL contain exactly one [1..1] @value (CONF:9251).The effectiveTime, if present, SHALL NOT contain [0..0] low (CONF:9252).The effectiveTime, if present, SHALL NOT contain [0..0] high (CONF:9253).MAY contain zero or more [0..*] entryRelationship (CONF:9254) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9255).MAY contain zero or more [0..*] entryRelationship (CONF:9257) such that itSHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9258).SHALL contain exactly one [1..1] Purpose of Reference Observation (templateId:2.16.840.1.113883.10.20.6.2.9) (CONF:15935).MAY contain zero or more [0..*] entryRelationship (CONF:9260) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9261).SHALL contain exactly one [1..1] Referenced Frames Observation (templateId:2.16.840.1.113883.10.20.6.2.10) (CONF:15936).This entryRelationship SHALL be present if the referenced DICOM object is a multiframe object and the reference does not apply to all frames (CONF:9263).Figure SEQ Table \* ARABIC72: Sample<observation classCode="DGIMG" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.8" /> <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3" /> <code code="1.2.840.10008.5.1.4.1.1.1" codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID" displayName="Computed Radiography Image Storage"> </code> <text mediaType="application/dicom"> <reference value="" />  </text> <effectiveTime value="20060823223232" /></observation>Study Act[act: templateId 2.16.840.1.113883.10.20.6.2.6 (open)]SEQ Table \* ARABIC527: Study Act ContextsContained By:Contains:DICOM Object Catalog Section - DCM 121181 (required)Series ActA Study Act contains the DICOM study information that defines the characteristics of a referenced medical study performed on a patient. A study is a collection of one or more series of medical images, presentation states, SR documents, overlays, and/or curves that are logically related for the purpose of diagnosing a patient. Each study is associated with exactly one patient. A study may include composite instances that are created by a single modality, multiple modalities, or by multiple devices of the same modality. The study information is modality-independent. Study Act clinical statements are only instantiated in the DICOM Object Catalog section; in other sections, the SOP Instance Observation is included directly.SEQ Table \* ARABIC528: Study Act Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.6.2.6']entryRelationship1..*SHALL9219@typeCode1..1SHALL92202.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPact1..1SHALL15937@classCode1..1SHALL92072.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL92082.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL9209@root1..1SHALL105332.16.840.1.113883.10.20.6.2.6id1..*SHALL9210@root1..1SHALL9213@extension0..0SHALL NOT9211text0..1MAY9215reference0..1SHOULD15995@value0..1SHOULD15996effectiveTime0..1SHOULD9216code1..1SHALL19172@code1..1SHALL191731.2.840.10008.2.16.4 (DCM) = 113014SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:9207).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9208).SHALL contain exactly one [1..1] templateId (CONF:9209) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.6" (CONF:10533).SHALL contain at least one [1..*] id (CONF:9210).The @root contains the OID of the study instance UID since DICOM study ids consist only of an OIDSuch ids SHALL contain exactly one [1..1] @root (CONF:9213).Such ids SHALL NOT contain [0..0] @extension (CONF:9211).SHALL contain exactly one [1..1] code (CONF:19172).This code SHALL contain exactly one [1..1] @code="113014" (CodeSystem: DCM 1.2.840.10008.2.16.4 STATIC) (CONF:19173).If present, the text element contains the description of the study.MAY contain zero or one [0..1] text (CONF:9215).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15995).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15996).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15997).If present, the effectiveTime contains the time the study was startedSHOULD contain zero or one [0..1] effectiveTime (CONF:9216).SHALL contain at least one [1..*] entryRelationship (CONF:9219) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9220).SHALL contain exactly one [1..1] Series Act (templateId:2.16.840.1.113883.10.20.22.4.63) (CONF:15937).Figure SEQ Table \* ARABIC73: Sample<act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.6" /> <id root="1.2.840.113619.2.62.994044785528.114289542805" /> <code code="113014" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Study" />  <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN">...</act> </entryRelationship></act>Substance Administered Act (NEW)[act: templateId 2.16.840.1.113883.10.20.22.4.118 (open)]SEQ Table \* ARABIC529: Substance Administered Act (NEW) ContextsContained By:Contains:Medication Activity (V2) (optional)Immunization Activity (V2) (optional)This template, like the Medication Administered template in QRDA, is used where there is a need to group a number of administrations into a larger act (e.g. to group all of the immunizations that are part of a series). The relationship between this template and component substance administrations can include a sequenceNumber, to indicate the component administration's ordering in the series. SEQ Table \* ARABIC530: Substance Administered Act (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.118']@classCode1..1SHALL315002.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL315012.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL31502@root1..1SHALL315032.16.840.1.113883.10.20.22.4.118id1..*SHALL31504statusCode1..1SHALL315052.16.840.1.113883.5.14 (ActStatus) = completedcode1..1SHALL31506@code1..1SHALL315072.16.840.1.113883.6.96 (SNOMED CT) = 416118004@codeSystem1..1SHALL315082.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96effectiveTime0..1MAY31509SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:31500).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:31501).SHALL contain exactly one [1..1] templateId (CONF:31502) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.118" (CONF:31503).SHALL contain at least one [1..*] id (CONF:31504).SHALL contain exactly one [1..1] code (CONF:31506).This code SHALL contain exactly one [1..1] @code="416118004" Administration (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31507).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31508).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:31505).MAY contain zero or one [0..1] effectiveTime (CONF:31509).Substance Administration Plan (V2)[substanceAdministration: templateId 2.16.840.1.113883.10.20.22.4.42.2 (open)]SEQ Table \* ARABIC531: Substance Administration Plan (V2) ContextsContained By:Contains:Plan of Treatment Section (V2) (optional)Goal Observation (NEW) (optional)Intervention Act (NEW) (optional)Patient Priority Preference (NEW)Provider Priority Preference (NEW)The Plan Activity Substance Administration describes substance administrations that will occur. The priority of the??substance administration activity to the patient and provider is communicated through Patient Priority Preference and Provider Priority Preference. The effective time indicates the time when the substance is intended to be administered.SEQ Table \* ARABIC532: Substance Administration Plan (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValuesubstanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.22.4.42.2']entryRelationship0..*MAY31104@typeCode1..1SHALL311052.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31106entryRelationship0..*MAY31107@typeCode1..1SHALL311082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31109@classCode1..1SHALL85722.16.840.1.113883.5.6 (HL7ActClass) = SBADM@moodCode1..1SHALL85732.16.840.1.113883.11.20.9.24 (Plan of Care moodCode (SubstanceAdministration/Supply))templateId1..1SHALL30465@root1..1SHALL304662.16.840.1.113883.10.20.22.4.42.2id1..*SHALL8575statusCode1..1SHALL30467effectiveTime1..1SHALL30468performer0..*MAY30470participant0..*MAY30471SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8572).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Plan of Care moodCode (SubstanceAdministration/Supply) 2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:8573).SHALL contain exactly one [1..1] templateId (CONF:30465) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.42.2" (CONF:30466).SHALL contain at least one [1..*] id (CONF:8575).SHALL contain exactly one [1..1] statusCode (CONF:30467).SHALL contain exactly one [1..1] effectiveTime (CONF:30468).Performers represent clinicians who are responsible for assessing and treating the patient.MAY contain zero or more [0..*] performer (CONF:30470).Participants represent those in supporting roles such as caregiver, who participate in the patient's care.MAY contain zero or more [0..*] participant (CONF:30471).This entryRelationship represents the priority that a patient places on the substance administration.MAY contain zero or more [0..*] entryRelationship (CONF:31104) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31105).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31106).This entryRelationship represents the priority that a provider places on the substance administration.MAY contain zero or more [0..*] entryRelationship (CONF:31107) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31108).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31109).SEQ Table \* ARABIC533: Plan of Care moodCode (SubstanceAdministration/Supply)Value Set: Plan of Care moodCode (SubstanceAdministration/Supply) 2.16.840.1.113883.11.20.9.24CodeCode SystemPrint NameINTActMoodIntentPRMSActMoodPromisePRPActMoodProposalRQOActMoodRequestFigure SEQ Table \* ARABIC74: Sample<entry> <substanceAdministration moodCode="RQO" classCode="SBADM"> <templateId root="2.16.840.1.113883.10.20.22.4.42.2"/>  <id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/> <text>Heparin 0.25 ml Prefilled Syringe</text> <statusCode code="completed"/> <effectiveTime xsi:type="IVL_TS"> <low value="20130615"/> </effectiveTime> <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A"> <period value="4" unit="h"/> </effectiveTime> <consumable> ... </consumable> <participant typeCode="IND"> <participantRole classCode="CAREGIVER"> <code code="MTH" codeSystem="2.16.840.1.113883.5.111" displayName="Mother"/> </participantRole> </participant> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.142"/> <id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/> ... </observation> </entryRelationship> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.143"/> ... </observation> </entryRelationship> </substanceAdministration></entry> <participant typeCode="IND"> ...> </participant> </substanceAdministration></entry>Drug Monitoring Act (NEW)[act: templateId 2.16.840.1.113883.10.20.22.4.123 (open)]SEQ Table \* ARABIC534: Drug Monitoring Act (NEW) ContextsContained By:Contains:Medication Activity (V2) (optional)This clinical statement represents a drug monitoring therapy including but not limited to ‘anticoagulant therapy’, 'chemotherapy', ‘insulin therapy’ and ‘Narcotics therapy’. The moodCode "INT"??reflect what a clinician intends a patient to be taking.This clinical statement contains the person responsible for monitoring the medication. The participant is null if no clinician is assigned to monitor the drug. The prescriber of the medication is not necessarily the same person who is designated to monitor the drug.??SEQ Table \* ARABIC535: Drug Monitoring Act (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.123']@moodCode1..1SHALL28656INTtemplateId1..1SHALL28657@root1..1SHALL286582.16.840.1.113883.10.20.22.4.123code1..1SHALL28660@code1..1SHALL30818395170001@codeSystem0..1MAY308192.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96participant1..*SHALL28661@typeCode1..1SHALL28663RESPparticipantRole1..1SHALL28662@classCode1..1SHALL28664ASSIGNEDid1..*SHALL28665@nullFlavor0..1MAY28666playingEntity1..1SHALL28667@nullFlavor0..1MAY28673@classCode1..1SHALL28668PSNname1..1SHALL28669@classCode1..1SHALL308232.16.840.1.113883.5.6 (HL7ActClass) = SBADMConforms to Substance Administration Plan (V2) template (2.16.840.1.113883.10.20.22.4.42.2).SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:30823).SHALL contain exactly one [1..1] @moodCode="INT" (CONF:28656).SHALL contain exactly one [1..1] templateId (CONF:28657) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.123" (CONF:28658).SHALL contain exactly one [1..1] code (CONF:28660).This code SHALL contain exactly one [1..1] @code="395170001" medication monitoring (regime/therapy) (CONF:30818).This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:30819).SHALL contain at least one [1..*] participant (CONF:28661).Such participants SHALL contain exactly one [1..1] @typeCode="RESP" (CONF:28663).Such participants SHALL contain exactly one [1..1] participantRole (CONF:28662).This participantRole SHALL contain exactly one [1..1] @classCode="ASSIGNED" (CONF:28664).This participantRole SHALL contain at least one [1..*] id (CONF:28665).Such ids MAY contain zero or one [0..1] @nullFlavor (CONF:28666).Note: SHALL contain nullFlavor if playingEntity/name is null.This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:28667).This playingEntity MAY contain zero or one [0..1] @nullFlavor (CONF:28673).This playingEntity SHALL contain exactly one [1..1] @classCode="PSN" (CONF:28668).This playingEntity SHALL contain exactly one [1..1] name (CONF:28669).The content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1) (CONF:29181).Figure SEQ Table \* ARABIC75: Sample --> <templateId root="2.16.840.1.113883.10.20.24.3.47.2"/>  <templateId root="2.16.840.1.113883.10.20.22.4.123"/> <id root="e09f8bea-dd8d-11e2-a834-f23c91aec05e"/> <code code="395170001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="medication monitoring (regime/therapy)" /> <statusCode code="new"/>  <effectiveTime xsi:type="IVL_TS"> <low value="20130715"/> <high value="20130815"/> </effectiveTime> <consumable> <manufacturedProduct classCode="MANU" nullFlavor="NI">  <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <id root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/> <manufacturedMaterial> <code code="313735" codeSystem="2.16.840.1.113883.6.88" displayName="Warfarin"> </code> </manufacturedMaterial> <entryRelationship typeCode="COMP" inversionInd="true"> <substanceAdministration classCode="SBADM" moodCode="INT">  <templateId root="2.16.840.1.113883.10.20.24.3.47.2"/>  <templateId root="2.16.840.1.113883.10.20.22.4.123"/> <id root="e09f8bea-dd8d-11e2-a834-f23c91aec05e"/> <code code="395170001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="medication monitoring (regime/therapy)" /> <statusCode code="new"/>  <effectiveTime xsi:type="IVL_TS"> <low value="20130715"/> <high value="20130815"/> </effectiveTime> <consumable> <manufacturedProduct classCode="MANU" nullFlavor="NI">  <templateId root="2.16.840.1.113883.10.20.22.4.23"/> ... </consumable>  <participant typeCode="RESP"> <participantRole classCode="ASSIGNED"> <id root="b90adecc-0aa7-4307-822a-b44ac5b1dd03"/> <playingEntity classCode="PSN"> <name> <given>Alistair</given> <family>Jones</family> <prefix>DR</prefix> </name> </playingEntity> </participantRole> </participant> </substanceAdministration></entryRelationship>Substance or Device Allergy - Intolerance Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.24.3.90.2 (open)]SEQ Table \* ARABIC536: Substance or Device Allergy - Intolerance Observation (V2) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Allergy Status Observation (DEPRECATED)Author Participant (NEW)Reaction Observation (V2)Severity Observation (V2)This template reflects a discrete observation about a patient's allergy or intolerance to a substance or device. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago. The effectiveTime of the Substance or Device Allergy - Intolerance Observation is the definitive indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".SEQ Table \* ARABIC537: Substance or Device Allergy - Intolerance Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.90.2']entryRelationship0..1MAY16333@typeCode1..1SHALL163352.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL16334trueobservation1..1SHALL16336entryRelationship0..*SHOULD16337@typeCode1..1SHALL163392.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL16338trueobservation1..1SHALL16340entryRelationship0..1MAY16341@typeCode1..1SHALL163422.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL16343trueobservation1..1SHALL16344@classCode1..1SHALL163032.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL163042.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16305@root1..1SHALL163062.16.840.1.113883.10.20.24.3.90.2id1..*SHALL16307code1..1SHALL16345@code1..1SHALL163462.16.840.1.113883.5.4 (ActCode) = ASSERTIONstatusCode1..1SHALL16308@code1..1SHALL263542.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL16309low1..1SHALL31536high0..1MAY31537value1..1SHALLCD16312@code1..1SHALLCS163172.16.840.1.113883.3.88.12.3221.6.2 (Allergy/Adverse Event Type Value Set)participant0..*SHOULD16318@typeCode1..1SHALL163192.16.840.1.113883.5.90 (HL7ParticipationType) = CSMparticipantRole1..1SHALL16320@classCode1..1SHALL163212.16.840.1.113883.5.110 (RoleClass) = MANUplayingEntity1..1SHALL16322@classCode1..1SHALL163232.16.840.1.113883.5.41 (EntityClass) = MMATcode1..1SHALL16324Temp-ValueSet-substanceReactantForIntolerance (Substance / Reactant for Intolerance)author0..*SHOULD31144SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:16303).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:16304).SHALL contain exactly one [1..1] templateId (CONF:16305) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.90.2" (CONF:16306).SHALL contain at least one [1..*] id (CONF:16307).SHALL contain exactly one [1..1] code (CONF:16345).This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:16346).SHALL contain exactly one [1..1] statusCode (CONF:16308).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:26354).The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within an allergy/intolerance does indicate that the allergy/intolerance has been resolvedSHALL contain exactly one [1..1] effectiveTime (CONF:16309).This effectiveTime SHALL contain exactly one [1..1] low (CONF:31536).This effectiveTime MAY contain zero or one [0..1] high (CONF:31537).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:16312).The consumable participant points to the precise allergen or substance of intolerance. Because the consumable and the reaction are more clinically relevant than a categorization of the allergy/adverse event type, many systems will simply assign a fixed value here (e.g. "allergy to substance"). This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Allergy/Adverse Event Type Value Set 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC (CONF:16317).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31144).SHOULD contain zero or more [0..*] participant (CONF:16318).The participant, if present, SHALL contain exactly one [1..1] @typeCode="CSM" Consumable (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:16319).The participant, if present, SHALL contain exactly one [1..1] participantRole (CONF:16320).This participantRole SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:16321).This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:16322).This playingEntity SHALL contain exactly one [1..1] @classCode="MMAT" Manufactured Material (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) (CONF:16323).This playingEntity SHALL contain exactly one [1..1] code, which MAY be selected from ValueSet Substance / Reactant for Intolerance Temp-ValueSet-substanceReactantForIntolerance DYNAMIC (CONF:16324).MAY contain zero or one [0..1] entryRelationship (CONF:16333) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:16335).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:16334).SHALL contain exactly one [1..1] Allergy Status Observation (DEPRECATED) (templateId:2.16.840.1.113883.10.20.22.4.28.2) (CONF:16336).SHOULD contain zero or more [0..*] entryRelationship (CONF:16337) such that itSHALL contain exactly one [1..1] @typeCode="MFST" Is Manifestation of (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:16339).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:16338).SHALL contain exactly one [1..1] Reaction Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.9.2) (CONF:16340).MAY contain zero or one [0..1] entryRelationship (CONF:16341) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:16342).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:16343).SHALL contain exactly one [1..1] Severity Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.8.2) (CONF:16344).SEQ Table \* ARABIC538: Allergy/Adverse Event Type Value SetValue Set: Allergy/Adverse Event Type Value Set 2.16.840.1.113883.3.88.12.3221.6.2This describes the type of product and intolerance suffered by the patientCodeCode SystemPrint Name419199007SNOMED CTAllergy to substance (disorder)416098002SNOMED CTDrug allergy (disorder)59037007SNOMED CTDrug intolerance (disorder)414285001SNOMED CTFood allergy (disorder)235719002SNOMED CTFood intolerance (disorder)420134006SNOMED CTPropensity to adverse reactions (disorder)419511003SNOMED CTPropensity to adverse reactions to drug (disorder)418471000SNOMED CTPropensity to adverse reactions to food (disorder)418038007SNOMED CTPropensity to adverse reactions to substance (disorder)232347008SNOMED CTDander (animal) allergy426232007SNOMED CTEnvironmental allergySEQ Table \* ARABIC539: Substance / Reactant for IntoleranceValue Set: Substance / Reactant for Intolerance Temp-ValueSet-substanceReactantForIntoleranceA grouping value set consisting of the following value sets derived from NDFRT, RXNORM, UNII, SNOMED CT. The intention is that instance content will be determined from the concepts in this grouping value set but values will be determined by searching through the grouped value sets in priority order, and when a concept matching the intension (by preferred name or any synonym), only that particular concept identifier will be included, and not any additional similar or matching identifiers. In this way overlaps in concept representation will be resolved. NDFRT value set will only have drug class identifiers to be defined by work of PCVSC that is expected to include concepts that are commonly associated with intolerances. This will not be a full list of all drug classes. Until this is completed, the existing value set is included. At some point the UNII value set , which is intended to represent mostly non-active drug ingredients, may be restricted to only identifiers that do not have exact maps in RXNORM. Priority order for concept determination is: NDFRT, RXNORM, UNII, SNOMED CT. (Final VSAC URL pending)Valueset Source: SystemPrint Name18867RxNormbenazepril196500RxNormCoversyl83515RxNormeprosartan237057RxNormlepirudin...Allergy - Intolerance Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.7.2 (open)]SEQ Table \* ARABIC540: Allergy - Intolerance Observation (V2) ContextsContained By:Contains:Allergy Problem Act (V2) (required)Health Concern Act (NEW) (optional)Author Participant (NEW)Reaction Observation (V2)Severity Observation (V2)This template reflects a discrete observation about a patient's allergy or intolerance. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago. The effectiveTime of the Allergy - Intolerance Observation is the definitive indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".NOTE: The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent.SEQ Table \* ARABIC541: Allergy - Intolerance Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.7.2']entryRelationship0..*SHOULD7447@typeCode1..1SHALL79072.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL7449trueobservation1..1SHALL15955entryRelationship0..1MAY9961@typeCode1..1SHALL99622.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL9964trueobservation1..1SHALL15956@classCode1..1SHALL73792.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73802.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7381@root1..1SHALL104882.16.840.1.113883.10.20.22.4.7.2id1..*SHALL7382code1..1SHALL15947@code1..1SHALL159482.16.840.1.113883.5.4 (ActCode) = ASSERTIONstatusCode1..1SHALL19084@code1..1SHALL190852.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL7387low1..1SHALL31538high0..1MAY31539value1..1SHALLCD73902.16.840.1.113883.3.88.12.3221.6.2 (Allergy/Adverse Event Type Value Set)participant1..1SHALL7402@typeCode1..1SHALL74032.16.840.1.113883.5.90 (HL7ParticipationType) = CSMparticipantRole1..1SHALL7404@classCode1..1SHALL74052.16.840.1.113883.5.110 (RoleClass) = MANUplayingEntity1..1SHALL7406@classCode1..1SHALL74072.16.840.1.113883.5.41 (EntityClass) = MMATcode1..1SHALL7419Temp-ValueSet-substanceReactantForIntolerance (Substance / Reactant for Intolerance)author0..*SHOULD31143@negationInd0..1MAY31526text0..1SHOULD31527reference0..1SHOULD31528@value1..1SHALL31529Conforms to Substance or Device Allergy - Intolerance Observation (V2) template (2.16.840.1.113883.10.20.24.3.90.2).SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7379).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7380).Use negationInd="true" to indicate that the allergy was not observed.MAY contain zero or one [0..1] @negationInd (CONF:31526).SHALL contain exactly one [1..1] templateId (CONF:7381) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.7.2" (CONF:10488).SHALL contain at least one [1..*] id (CONF:7382).SHALL contain exactly one [1..1] code (CONF:15947).This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:15948).SHOULD contain zero or one [0..1] text (CONF:31527).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:31528).The reference, if present, SHALL contain exactly one [1..1] @value (CONF:31529).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:31530).SHALL contain exactly one [1..1] statusCode (CONF:19084).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19085).The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved.If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within an allergy/intolerance does indicate that the allergy/intolerance has been resolvedSHALL contain exactly one [1..1] effectiveTime (CONF:7387).This effectiveTime SHALL contain exactly one [1..1] low (CONF:31538).This effectiveTime MAY contain zero or one [0..1] high (CONF:31539).The consumable participant points to the precise allergen or substance of intolerance. Because the consumable and the reaction are more clinically relevant than a categorization of the allergy/adverse event type, many systems will simply assign a fixed value here (e.g. "allergy to substance"). SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Allergy/Adverse Event Type Value Set 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC (CONF:7390).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31143).SHALL contain exactly one [1..1] participant (CONF:7402) such that itSHALL contain exactly one [1..1] @typeCode="CSM" Consumable (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:7403).SHALL contain exactly one [1..1] participantRole (CONF:7404).This participantRole SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:7405).This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:7406).This playingEntity SHALL contain exactly one [1..1] @classCode="MMAT" Manufactured Material (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) (CONF:7407).This playingEntity SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Substance / Reactant for Intolerance Temp-ValueSet-substanceReactantForIntolerance DYNAMIC (CONF:7419).SHOULD contain zero or more [0..*] entryRelationship (CONF:7447) such that itSHALL contain exactly one [1..1] @typeCode="MFST" Is Manifestation of (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:7907).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7449).SHALL contain exactly one [1..1] Reaction Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.9.2) (CONF:15955).MAY contain zero or one [0..1] entryRelationship (CONF:9961) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9962).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:9964).SHALL contain exactly one [1..1] Severity Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.8.2) (CONF:15956).SEQ Table \* ARABIC542: Allergy/Adverse Event Type Value SetValue Set: Allergy/Adverse Event Type Value Set 2.16.840.1.113883.3.88.12.3221.6.2This describes the type of product and intolerance suffered by the patientCodeCode SystemPrint Name419199007SNOMED CTAllergy to substance (disorder)416098002SNOMED CTDrug allergy (disorder)59037007SNOMED CTDrug intolerance (disorder)414285001SNOMED CTFood allergy (disorder)235719002SNOMED CTFood intolerance (disorder)420134006SNOMED CTPropensity to adverse reactions (disorder)419511003SNOMED CTPropensity to adverse reactions to drug (disorder)418471000SNOMED CTPropensity to adverse reactions to food (disorder)418038007SNOMED CTPropensity to adverse reactions to substance (disorder)232347008SNOMED CTDander (animal) allergy426232007SNOMED CTEnvironmental allergySEQ Table \* ARABIC543: Substance / Reactant for IntoleranceValue Set: Substance / Reactant for Intolerance Temp-ValueSet-substanceReactantForIntoleranceA grouping value set consisting of the following value sets derived from NDFRT, RXNORM, UNII, SNOMED CT. The intention is that instance content will be determined from the concepts in this grouping value set but values will be determined by searching through the grouped value sets in priority order, and when a concept matching the intension (by preferred name or any synonym), only that particular concept identifier will be included, and not any additional similar or matching identifiers. In this way overlaps in concept representation will be resolved. NDFRT value set will only have drug class identifiers to be defined by work of PCVSC that is expected to include concepts that are commonly associated with intolerances. This will not be a full list of all drug classes. Until this is completed, the existing value set is included. At some point the UNII value set , which is intended to represent mostly non-active drug ingredients, may be restricted to only identifiers that do not have exact maps in RXNORM. Priority order for concept determination is: NDFRT, RXNORM, UNII, SNOMED CT. (Final VSAC URL pending)Valueset Source: SystemPrint Name18867RxNormbenazepril196500RxNormCoversyl83515RxNormeprosartan237057RxNormlepirudin...Figure SEQ Table \* ARABIC76: Sample<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.7.2" /> <id root="4adc1020-7b14-11db-9fe1-0800200c9a66" /> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed" /> <effectiveTime>  <low value="20070501" />  </effectiveTime> <value xsi:type="CD" code="419511003" displayName="Propensity to adverse reactions to drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText>  <reference value="#reaction1" /> </originalText> </value> <participant typeCode="CSM"> <participantRole classCode="MANU"> <playingEntity classCode="MMAT"> <code code="314422" displayName="ALLERGENIC EXTRACT, PENICILLIN" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> <reference value="#reaction1" /> </originalText> </code> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation> <templateId root="2.16.840.1.113883.10.20.22.4.28" />  ... </observation> </entryRelationship> <entryRelationship typeCode="MFST" inversionInd="true"> <observation> <templateId root="2.16.840.1.113883.10.20.22.4.9.2" />  ... </observation> </entryRelationship> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation> <templateId root="2.16.840.1.113883.10.20.22.4.8" />  ... </observation> </entryRelationship></observation>Supply Plan (V2)[supply: templateId 2.16.840.1.113883.10.20.22.4.43.2 (open)]SEQ Table \* ARABIC544: Supply Plan (V2) ContextsContained By:Contains:Plan of Treatment Section (V2) (optional)Goal Observation (NEW) (optional)Intervention Act (NEW) (optional)Patient Priority Preference (NEW)Provider Priority Preference (NEW)This template represents both medicinal and non-medicinal supplies ordered, requested or intended for the patient. The importance of the supply order or request to the patient and provider may be indicated in the Patient Priority Preference and Provider Priority Preference. The author/time indicates the time when the supply plan was documented.SEQ Table \* ARABIC545: Supply Plan (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.43.2']entryRelationship0..*MAY31110@typeCode1..1SHALL311112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31112entryRelationship0..*MAY31113@typeCode1..1SHALL311142.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL31115@classCode1..1SHALL85772.16.840.1.113883.5.6 (HL7ActClass) = SPLY@moodCode1..1SHALL85782.16.840.1.113883.11.20.9.24 (Plan of Care moodCode (SubstanceAdministration/Supply))templateId1..1SHALL30463@root1..1SHALL304642.16.840.1.113883.10.20.22.4.43.2id1..*SHALL8580statusCode1..1SHALL30458effectiveTime0..1SHOULD30459author0..1SHOULD31129time1..1SHALL31130SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8577).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Plan of Care moodCode (SubstanceAdministration/Supply) 2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:8578).SHALL contain exactly one [1..1] templateId (CONF:30463) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.43.2" (CONF:30464).SHALL contain at least one [1..*] id (CONF:8580).SHALL contain exactly one [1..1] statusCode (CONF:30458).SHOULD contain zero or one [0..1] effectiveTime (CONF:30459).Note: effectiveTime in a plan template indicates the time frame around which an event should occur.If the author of a Supply Plan is different then the author of the document, or if there is more than one document author, the supplyAct author must be stated. SHOULD contain zero or one [0..1] author (CONF:31129).The author, if present, SHALL contain exactly one [1..1] time (CONF:31130).Note: The author/time indicates the time when the supply plan was documented.This entryRelationship represents the priority that a patient places on the supply.MAY contain zero or more [0..*] entryRelationship (CONF:31110) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31111).SHALL contain exactly one [1..1] Patient Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.142) (CONF:31112).This entryRelationship represents the priority that a provider places on the supply.MAY contain zero or more [0..*] entryRelationship (CONF:31113) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:31114).SHALL contain exactly one [1..1] Provider Priority Preference (NEW) (templateId:2.16.840.1.113883.10.20.22.4.143) (CONF:31115).SEQ Table \* ARABIC546: Plan of Care moodCode (SubstanceAdministration/Supply)Value Set: Plan of Care moodCode (SubstanceAdministration/Supply) 2.16.840.1.113883.11.20.9.24CodeCode SystemPrint NameINTActMoodIntentPRMSActMoodPromisePRPActMoodProposalRQOActMoodRequestFigure SEQ Table \* ARABIC77: Sample<entry> <supply moodCode="INT" classCode="SPLY"> <templateId root="2.16.840.1.113883.10.20.22.4.43.2" />  <id root="9a6d1bac-17d3-4195-89c4-1121bc809b5d" /> <statusCode code="completed" /> <effectiveTime value="20130615" /> <repeatNumber value="1" /> <quantity value="3" /> <product> <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23" /> <id root="2a620155-9d11-439e-92b3-5d9815ff4ee8" /> <manufacturedMaterial> <code code="573621" codeSystem="2.16.840.1.113883.6.88" displayName="Proventil 0.09 MG/ACTUAT inhalant solution"> <originalText> <reference value="#MedSec_1" /> </originalText> <translation code="573621" displayName="Proventil 0.09 MG/ACTUAT inhalant solution" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" /> </code> </manufacturedMaterial> <manufacturerOrganization> <name>Medication Factory Inc.</name> </manufacturerOrganization> </manufacturedProduct> </product> <performer> .... </performer> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.142" /> .... </observation> </entryRelationship> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.143" /> .... </observation> </entryRelationship> </supply></entry>Text Observation[observation: templateId 2.16.840.1.113883.10.20.6.2.12 (open)]SEQ Table \* ARABIC547: Text Observation ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)Quantity Measurement ObservationSOP Instance ObservationDICOM Template 2000 specifies that Imaging Report Elements of Value Type Text are contained in sections. The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations that consist of image references and measurements (linear, area, volume, and numeric). Text DICOM Imaging Report Elements in this context are mapped to CDA text observations that are section components and are related to the SOP Instance Observations (templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT (Support) act relationship.A Text Observation is required if the findings in the section text are represented as inferred from SOP Instance Observations.SEQ Table \* ARABIC548: Text Observation Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.6.2.12']entryRelationship0..*MAY9301@typeCode1..1SHALL93022.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SPRTobservation1..1SHALL15942entryRelationship0..*MAY9298@typeCode1..1SHALL92992.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SPRTobservation1..1SHALL15941@classCode1..1SHALL92882.16.840.1.113883.5.4 (ActCode) = OBS@moodCode1..1SHALL92892.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL9290@root1..1SHALL105342.16.840.1.113883.10.20.6.2.12code1..1SHALL9291value1..1SHALLED9292effectiveTime0..1SHOULD9294text0..1MAY9295reference0..1SHOULD15938@value0..1SHOULD15939SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:9288).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:9289).SHALL contain exactly one [1..1] templateId (CONF:9290) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.12" (CONF:10534).SHALL contain exactly one [1..1] code (CONF:9291).MAY contain zero or one [0..1] text (CONF:9295).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15938).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15939).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15940).SHOULD contain zero or one [0..1] effectiveTime (CONF:9294).SHALL contain exactly one [1..1] value with @xsi:type="ED" (CONF:9292).MAY contain zero or more [0..*] entryRelationship (CONF:9298) such that itSHALL contain exactly one [1..1] @typeCode="SPRT" Has Support (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9299).SHALL contain exactly one [1..1] SOP Instance Observation (templateId:2.16.840.1.113883.10.20.6.2.8) (CONF:15941).MAY contain zero or more [0..*] entryRelationship (CONF:9301) such that itSHALL contain exactly one [1..1] @typeCode="SPRT" Has Support (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:9302).SHALL contain exactly one [1..1] Quantity Measurement Observation (templateId:2.16.840.1.113883.10.20.6.2.14) (CONF:15942).Figure SEQ Table \* ARABIC78: Sample<text> <paragraph> <caption>Finding</caption> <content ID="Fndng2">The cardiomediastinum is within normal limits. The trachea is midline. The previously described opacity at the medial right lung base has cleared. There are no new infiltrates. There is a new round density at the left hilus, superiorly (diameter about 45mm). A CT scan is recommended for further evaluation. The pleural spaces are clear. The visualized musculoskeletal structures and the upper abdomen are stable and unremarkable.</content> </paragraph> ...</text><entry> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.6.2.12"/> <code code="121071" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Finding"/> <value xsi:type="ED"><reference value="#Fndng2"/></value> ...  </observation></entry>Tobacco Use (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.85.2 (open)]SEQ Table \* ARABIC549: Tobacco Use (V2) ContextsContained By:Contains:Social History Section (V2) (optional)Health Concern Act (NEW) (optional)Author Participant (NEW)This clinical statement represents a patient’s tobacco use. All types of tobacco use are represented using the codes from the tobacco use and exposure - finding hierarchy in SNOMED CT as well as codes required for recording smoking status in Meaningful Use Stage 2. The effectiveTime element is used to describe dates associated with the patient's tobacco use (e.g., patient was a moderate smoker 10-19/day from 2009-2011)SEQ Table \* ARABIC550: Tobacco Use (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.85.2']@classCode1..1SHALL165582.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL165592.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL16566@root1..1SHALL165672.16.840.1.113883.10.20.22.4.85.2code1..1SHALL19174@code1..1SHALL191752.16.840.1.113883.6.96 (SNOMED CT) = 229819007statusCode1..1SHALL16561@code1..1SHALL191182.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL16564low1..1SHALL16565high0..1MAY31431value1..1SHALLCD16562@code1..1SHALL165632.16.840.1.113883.11.20.9.41 (Tobacco Use)author0..*SHOULD31152SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:16558).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:16559).SHALL contain exactly one [1..1] templateId (CONF:16566) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.85.2" (CONF:16567).SHALL contain exactly one [1..1] code (CONF:19174).This code SHALL contain exactly one [1..1] @code="229819007" Tobacco use and exposure (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:19175).SHALL contain exactly one [1..1] statusCode (CONF:16561).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19118).SHALL contain exactly one [1..1] effectiveTime (CONF:16564).This effectiveTime SHALL contain exactly one [1..1] low (CONF:16565).Note: The low value represents when the tobacco use or exposure began.This effectiveTime MAY contain zero or one [0..1] high (CONF:31431).Note: The high value represents when the tobacco use or exposure ended.SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:16562).This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Tobacco Use 2.16.840.1.113883.11.20.9.41 DYNAMIC (CONF:16563).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31152).SEQ Table \* ARABIC551: Tobacco UseValue Set: Tobacco Use 2.16.840.1.113883.11.20.9.41CodeCode SystemPrint Name81703003SNOMED CTChews tobacco228494002SNOMED CTSnuff user59978006SNOMED CTCigar smoker43381005SNOMED CTPassive smoker449868002SNOMED CTCurrent every day smoker230059006SNOMED CTCurrent some day smoker8517006SNOMED CTFormer smoker266919005SNOMED CTNever smoker77176002SNOMED CTSmoker, current status unknown266927001SNOMED CTUnknown if ever smoked428071000124103SNOMED CTHeavy tobacco smoker428061000124105SNOMED CTLight tobacco smokerFigure SEQ Table \* ARABIC79: Sample<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.85.2"/><id root="45efb604-7049-4a2e-ad33-d38556c9636c"/><code code="229819007" codeSystem="2.16.840.1.113883.6.96"displayName="Tobacco use and exposure"></code><text><reference value="#soc2"/></text><statusCode code="completed"/><effectiveTime><low value="20090214"/><high value="20110215"/></effectiveTime><value xsi:type="CD" code="160604004" displayName="Moderate cigarette smoker, 10-19/day" codeSystem="2.16.840.1.113883.6.96"/></observation>Current Smoking Status (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.78.2 (open)]SEQ Table \* ARABIC552: Current Smoking Status (V2) ContextsContained By:Contains:Social History Section (V2) (optional)Health Concern Act (NEW) (optional)Author Participant (NEW)This clinical statement represents a patient’s current smoking status. The vocabulary selected for this clinical statement consist of the SNOMED CT codes specified in Meaningful Use (MU) Stage 2.??The effectiveTime element reflects the date/time when the patient's current smoking status was observed. Details regarding the time period when the patient is/was smoking would be recorded in the Tobacco Use template.If the patient's current smoking status is unknown, the value element must be populated with SNOMED CT code '266927001' to communicate 'Unknown if ever smoked' from the Current Smoking Status Value Set. SEQ Table \* ARABIC553: Current Smoking Status (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.78.2']@classCode1..1SHALL148062.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL148072.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL14815@root1..1SHALL148162.16.840.1.113883.10.20.22.4.78.2code1..1SHALL19170@code1..1SHALL310392.16.840.1.113883.6.96 (SNOMED CT) = 229819007statusCode1..1SHALL14809@code1..1SHALL191162.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL14814value1..1SHALLCD14810@code1..1SHALL148172.16.840.1.113883.11.20.9.38.2 (Current Smoking Status)author0..*SHOULD31148Conforms to Tobacco Use (V2) template (2.16.840.1.113883.10.20.22.4.85.2).SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:14806).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:14807).SHALL contain exactly one [1..1] templateId (CONF:14815) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.78.2" (CONF:14816).SHALL contain exactly one [1..1] code (CONF:19170).This code SHALL contain exactly one [1..1] @code="229819007" Tobacco use and exposure (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:31039).SHALL contain exactly one [1..1] statusCode (CONF:14809).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19116).SHALL contain exactly one [1..1] effectiveTime (CONF:14814).Note: The value for effectiveTime reflects when the patient's current smoking status was observed.SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:14810).This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Current Smoking Status 2.16.840.1.113883.11.20.9.38.2 DYNAMIC 2013-07-25 (CONF:14817).If the patient's current smoking status is unknown, @code SHALL contain '266927001' (Unknown if ever smoked) from Current Smoking Status Value Set (2.16.840.1.113883.10.22.4.78.2) (CONF:31019).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31148).SEQ Table \* ARABIC554: Current Smoking StatusValue Set: Current Smoking Status 2.16.840.1.113883.11.20.9.38.2This value set indicates the current smoking status of a patient using codes specified for Meaningful Use Stage 2. CodeCode SystemPrint Name449868002SNOMED CTCurrent every day smoker428041000124106SNOMED CTCurrent some day smoker8517006SNOMED CTFormer smoker77176002SNOMED CTSmoker, current status unknown266927001SNOMED CTUnknown if ever smoked428071000124103SNOMED CTHeavy tobacco smoker428061000124105SNOMED CTLight tobacco smokerFigure SEQ Table \* ARABIC80: Sample<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.78.2"/><code code="229819007" codeSystem="2.16.840.1.113883.6.96"displayName="Tobacco use and exposure"></code><text><reference value="#soc1"/></text><statusCode code="completed"/><effectiveTime value="20130801"/><value xsi:type="CD" code="8517006" displayName="Former smoker"codeSystem="2.16.840.1.113883.6.96"/></observation>Vital Sign Observation (V2)[observation: templateId 2.16.840.1.113883.10.20.22.4.27.2 (open)]SEQ Table \* ARABIC555: Vital Sign Observation (V2) ContextsContained By:Contains:Health Concern Act (NEW) (optional)Vital Signs Organizer (V2) (required)Author Participant (NEW)Vital signs are represented as are other results, with additional vocabulary constraints.SEQ Table \* ARABIC556: Vital Sign Observation (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.27.2']@classCode1..1SHALL72972.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL72982.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7299@root1..1SHALL105272.16.840.1.113883.10.20.22.4.27.2id1..*SHALL7300code1..1SHALL73012.16.840.1.113883.3.88.12.80.62 (Vital Sign Result Value Set)text0..1SHOULD7302reference0..1SHOULD15943@value0..1SHOULD15944statusCode1..1SHALL7303@code1..1SHALL191192.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL7304value1..1SHALLPQ7305interpretationCode0..1MAY7307methodCode0..1MAYSET<CE>7308targetSiteCode0..1MAYSET<CD>7309author0..*SHOULD7310SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7297).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7298).SHALL contain exactly one [1..1] templateId (CONF:7299) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.27.2" (CONF:10527).SHALL contain at least one [1..*] id (CONF:7300).SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Vital Sign Result Value Set 2.16.840.1.113883.3.88.12.80.62 DYNAMIC (CONF:7301).SHOULD contain zero or one [0..1] text (CONF:7302).The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15943).The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15944).This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15945).SHALL contain exactly one [1..1] statusCode (CONF:7303).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19119).SHALL contain exactly one [1..1] effectiveTime (CONF:7304).SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7305).MAY contain zero or one [0..1] interpretationCode (CONF:7307).MAY contain zero or one [0..1] methodCode (CONF:7308).MAY contain zero or one [0..1] targetSiteCode (CONF:7309).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:7310).SEQ Table \* ARABIC557: Vital Sign Result Value SetValue Set: Vital Sign Result Value Set 2.16.840.1.113883.3.88.12.80.62This identifies the vital sign result typeCodeCode SystemPrint Name8310-5LOINCBody Temperature8462-4LOINCBP Diastolic8480-6LOINCBP Systolic8287-5LOINCHead Circumference8867-4LOINCHeart Rate8302-2LOINCHeight8306-3LOINCHeight (Lying)2710-2LOINCO2 % BldC Oximetry9279-1LOINCRespiratory Rate3141-9LOINCWeight Measured39156-5LOINCBMI (Body Mass Index)3140-1LOINCBSA (Body Surface Area)Vital Signs Organizer (V2)[organizer: templateId 2.16.840.1.113883.10.20.22.4.26.2 (open)]SEQ Table \* ARABIC558: Vital Signs Organizer (V2) ContextsContained By:Contains:Vital Signs Section (entries optional) (V2) (optional)Vital Signs Section (entries required) (V2) (required)Author Participant (NEW)Vital Sign Observation (V2)The Vital Signs Organizer groups vital signs, which is similar to the Result Organizer, but with further constraints. An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown.SEQ Table \* ARABIC559: Vital Signs Organizer (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.22.4.26.2']component1..*SHALL7285observation1..1SHALL15946@classCode1..1SHALL72792.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALL72802.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL7281@root1..1SHALL105282.16.840.1.113883.10.20.22.4.26.2id1..*SHALL7282code1..1SHALL19176@code1..1SHALL191772.16.840.1.113883.6.96 (SNOMED CT) = 46680005@codeSystem1..1SHALL309012.16.840.1.113883.6.96statusCode1..1SHALL7284@code1..1SHALL191202.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL7288author0..*SHOULD31153SHALL contain exactly one [1..1] @classCode="CLUSTER" CLUSTER (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:7279).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:7280).SHALL contain exactly one [1..1] templateId (CONF:7281) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.26.2" (CONF:10528).SHALL contain at least one [1..*] id (CONF:7282).SHALL contain exactly one [1..1] code (CONF:19176).This code SHALL contain exactly one [1..1] @code="46680005" Vital signs (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:19177).This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CONF:30901).SHALL contain exactly one [1..1] statusCode (CONF:7284).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:19120).The effectiveTime represents clinically effective time of the measurement, which is most likely when the measurement was performed (e.g., a BP measurement).SHALL contain exactly one [1..1] effectiveTime (CONF:7288).SHOULD contain zero or more [0..*] Author Participant (NEW) (templateId:2.16.840.1.113883.10.20.22.4.119) (CONF:31153).SHALL contain at least one [1..*] component (CONF:7285) such that itSHALL contain exactly one [1..1] Vital Sign Observation (V2) (templateId:2.16.840.1.113883.10.20.22.4.27.2) (CONF:15946).Figure SEQ Table \* ARABIC81: Sample<organizer classCode="CLUSTER" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.26" /> <id root="24f6ad18-c512-40fc-82bd-1e131aa9e52b" /> <code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED -CT" displayName="Vital signs" /> <statusCode code="completed" /> <effectiveTime value="20110901" /> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> ...</observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> ...</observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> ...</observation> </component></organizer>Wound Characteristics (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.134 (open)]SEQ Table \* ARABIC560: Wound Characteristics (NEW) ContextsContained By:Contains:Wound Observation (NEW) (optional)This template represents characteristics of a wound (e.g. integrity of suture line, odor, erythema) SEQ Table \* ARABIC561: Wound Characteristics (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.134']@classCode1..1SHALL299382.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL299392.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL29940@root1..1SHALL299412.16.840.1.113883.10.20.22.4.134id1..*SHALL29942code1..1SHALL29943@code1..1SHALL31540ASSERTION@codeSystem0..1MAY315412.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4statusCode1..1SHALL299442.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL29946value1..1SHALLCD299472.16.840.1.113883.11.20.9.58 (Wound Charactersitic)SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:29938).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:29939).SHALL contain exactly one [1..1] templateId (CONF:29940) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.134" (CONF:29941).SHALL contain at least one [1..*] id (CONF:29942).SHALL contain exactly one [1..1] code (CONF:29943).This code SHALL contain exactly one [1..1] @code="ASSERTION" assertion (CONF:31540).This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:31541).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:29944).SHALL contain exactly one [1..1] effectiveTime (CONF:29946).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Wound Charactersitic 2.16.840.1.113883.11.20.9.58 DYNAMIC (CONF:29947).SEQ Table \* ARABIC562: Wound CharactersiticValue Set: Wound Charactersitic 2.16.840.1.113883.11.20.9.58A value set of SNOMED-CT codes primarily selected from codes descending from 225552003 "Wound finding". Specific URL PendingValueset Source: SystemPrint Name239165001SNOMED CTWound granuloma239163008SNOMED CTWound erythema409590008SNOMED CTSkin eschar449746002SNOMED CTWound slough445916002SNOMED CTWound odor239164002SNOMED CTWound discharge447547000SNOMED CTOffensive wound odor271618001SNOMED CTImpaired wound healing449744004SNOMED CTInduration of wound298008006SNOMED CTWound moist225917003SNOMED CTsuture line intact298006005SNOMED CTWound healedFigure SEQ Table \* ARABIC82: Sample<entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.134"/> <id root="763428a0-eb35-11e2-91e2-0700200c9a66"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <effectiveTime value="20013103"/> <value xsi:type="CD" code="447547000" displayName="Offensive wound odor" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> </observation></entryRelationship>Wound Measurement Observation (NEW)[observation: templateId 2.16.840.1.113883.10.20.22.4.133 (open)]SEQ Table \* ARABIC563: Wound Measurement Observation (NEW) ContextsContained By:Contains:Wound Observation (NEW) (optional)This template represents the Wound Measurement Observations of wound width, depth and length. SEQ Table \* ARABIC564: Wound Measurement Observation (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.133']@classCode1..1SHALL299262.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL299272.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL29928@root1..1SHALL299292.16.840.1.113883.10.20.22.4.133id1..*SHALL29930code1..1SHALL299312.16.840.1.113883.1.11.20.2.5 (Wound Measurements)statusCode1..1SHALL29933@code1..1SHALL299342.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL29935value1..1SHALLPQ29936SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:29926).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:29927).SHALL contain exactly one [1..1] templateId (CONF:29928) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.133" (CONF:29929).SHALL contain at least one [1..*] id (CONF:29930).SHALL contain exactly one [1..1] code (ValueSet: Wound Measurements 2.16.840.1.113883.1.11.20.2.5 DYNAMIC) (CONF:29931).SHALL contain exactly one [1..1] statusCode (CONF:29933).This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:29934).SHALL contain exactly one [1..1] effectiveTime (CONF:29935).SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:29936).SEQ Table \* ARABIC565: Wound MeasurementsValue Set: Wound Measurements 2.16.840.1.113883.1.11.20.2.5CodeCode SystemPrint Name401239006SNOMED CTwidth of wound (observable entity)401238003SNOMED CTlength of wound (observable entity)425094009SNOMED CTdepth of wound (observable entity)Figure SEQ Table \* ARABIC83: Sample<entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.22.4.133"/> <id root="d2b46280-eb34-11e2-91e2-0800200c9a66"/> <code code=" 401238003" codeSystem="2.16.840.1.113883.6.96" displayName="Length of Wound"/> <statusCode code="completed"/> <effectiveTime value="20013103"/> <value xsi:type="PQ" value="2" unit="[in_i]"/> </observation></entryRelationship>Participant and Other TemplatesThe participant and other templates chapter contains templates for CDA participants (e.g. author, performer), and other fielded items (e.g. address, name) that cannot stand on their own without being nested in another template .Author Participant (NEW)[author: templateId 2.16.840.1.113883.10.20.22.4.119 (open)]SEQ Table \* ARABIC566: Author Participant (NEW) ContextsContained By:Contains:Medication Activity (V2) (optional)Mental Status Observation (NEW) (optional)Wound Observation (NEW) (optional)Problem Observation (V2) (optional)Problem Concern Act (Condition) (V2) (optional)Allergy - Intolerance Observation (V2) (optional)Substance or Device Allergy - Intolerance Observation (V2) (optional)Immunization Activity (V2) (optional)Allergy Problem Act (V2) (optional)Cognitive Status Observation (V2) (optional)Functional Status Observation (V2) (optional)Current Smoking Status (V2) (optional)Vital Sign Observation (V2) (optional)Result Observation (V2) (optional)Vital Signs Organizer (V2) (optional)Patient Priority Preference (NEW) (optional)Result Organizer (V2) (optional)Tobacco Use (V2) (optional)Provenance is primarily addressed via the Author Participant (including the author timestamp). CDA R2 requires that Author and Author timestamp be asserted in the document header. From there, authorship propagates to contained sections and contained entries, unless explicitly overridden.SEQ Table \* ARABIC567: Author Participant (NEW) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueauthor[templateId/@root = '2.16.840.1.113883.10.20.22.4.119']@typeCode1..1SHALL31468AUTtime1..1SHALL31471assignedAuthor1..1SHALL31472id1..*SHALL31473assignedPerson0..1MAY31474name0..*MAY31475representedOrganization0..1MAY31476@classCode1..1SHALL31477ORGid0..*MAY31478name0..*MAY31479telecom0..*MAY31480addr0..*MAY31481functionCode0..1MAY315212.16.840.1.113883.1.11.10267 (ParticipationFunction)SHALL contain exactly one [1..1] @typeCode="AUT" (CONF:31468).MAY contain zero or one [0..1] functionCode, which MAY be selected from ValueSet ParticipationFunction 2.16.840.1.113883.1.11.10267 (CONF:31521).SHALL contain exactly one [1..1] time (CONF:31471).SHALL contain exactly one [1..1] assignedAuthor (CONF:31472).This id may be set equal to (a pointer to) an id on a participant elsewhere in the document (header or entries) or a new author participant can be described here. If the id is pointing to a participant already described elsewhere in the document, assignedAuthor/id is sufficient to identify this participant and none of the remaining details of assignedAuthor are required to be set.This assignedAuthor SHALL contain at least one [1..*] id (CONF:31473).This assignedAuthor MAY contain zero or one [0..1] assignedPerson (CONF:31474).The assignedPerson, if present, MAY contain zero or more [0..*] name (CONF:31475).This assignedAuthor MAY contain zero or one [0..1] representedOrganization (CONF:31476).The representedOrganization, if present, SHALL contain exactly one [1..1] @classCode="ORG" (CONF:31477).The representedOrganization, if present, MAY contain zero or more [0..*] id (CONF:31478).The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:31479).The representedOrganization, if present, MAY contain zero or more [0..*] telecom (CONF:31480).The representedOrganization, if present, MAY contain zero or more [0..*] addr (CONF:31481).SEQ Table \* ARABIC568: ParticipationFunctionValue Set: ParticipationFunction 2.16.840.1.113883.1.11.10267This HL7-defined value set can be used to specify the exact function an actor had in a service in all necessary detail. - URL pending -Valueset Source: SystemPrint NameSNRSparticipationFunctionScrub nurse SASST participationFunctionSecond assistant surgeon...Figure SEQ Table \* ARABIC84: Full author example<author> <time value="20130801" /> <assignedAuthor> <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" /> <code code="163W00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Registered nurse" /> <assignedPerson> <name> <given>Nurse</given> <family>Nightingale</family> <suffix>RN</suffix> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Good Health Hospital</name> </representedOrganization> </assignedAuthor></author>Figure SEQ Table \* ARABIC85: Author pointer example<author> <time value="20130801" /> <assignedAuthor>  <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" /> </assignedAuthor></author>Physician Reading Study Performer (V2)[performer: templateId 2.16.840.1.113883.10.20.6.2.1.2 (open)]SEQ Table \* ARABIC569: Physician Reading Study Performer (V2) ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)This participant is the Physician Reading Study Performer defined in documentationOf/serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition)SEQ Table \* ARABIC570: Physician Reading Study Performer (V2) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueperformer[templateId/@root = '2.16.840.1.113883.10.20.6.2.1.2']@typeCode1..1SHALL84242.16.840.1.113883.5.6 (HL7ActClass) = PRFtime0..1MAY8425assignedEntity1..1SHALL8426id1..*SHALL10033@root1..1SHALL312022.16.840.1.113883.4.6code1..1SHALL8427templateId1..1SHALL30773@root1..1SHALL307742.16.840.1.113883.10.20.6.2.1.2SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:8424).SHALL contain exactly one [1..1] templateId (CONF:30773).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.1.2" (CONF:30774).MAY contain zero or one [0..1] time (CONF:8425).The content of time SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:10134).SHALL contain exactly one [1..1] assignedEntity (CONF:8426).This assignedEntity SHALL contain at least one [1..*] id (CONF:10033).MISSING NARRATIVE FOR PRIMITIVE??(CONF:31201).SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:31202).This assignedEntity SHALL contain exactly one [1..1] code (CONF:8427).SHALL contain a valid DICOM personal identification code sequence (@codeSystem is 1.2.840.10008.2.16.4) or an appropriate national health care provider coding system (e.g., NUCC in the U.S., where @codeSystem is 2.16.840.1.113883.6.101) (CONF:8428).Every assignedEntity element SHALL have at least one assignedPerson or representedOrganization (CONF:8429).Figure SEQ Table \* ARABIC86: Sample<performer typeCode="PRF"> <templateId root="2.16.840.1.113883.10.20.6.2.1.2" /> <assignedEntity> <id extension="111111111" root="2.16.840.1.113883.4.6" /> <code code="2085R0202X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Diagnostic Radiology" /> <addr nullFlavor="NI" /> <telecom nullFlavor="NI" /> <assignedPerson> <name> <given>Christine</given> <family>Cure</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity></performer>US Realm Address (AD.US.FIELDED)[addr: templateId 2.16.840.1.113883.10.20.22.5.2 (open)]SEQ Table \* ARABIC571: US Realm Address (AD.US.FIELDED) ContextsContained By:Contains:Reusable address template, for use in US Realm CDA Header.SEQ Table \* ARABIC572: US Realm Address (AD.US.FIELDED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valueaddr[templateId/@root = '2.16.840.1.113883.10.20.22.5.2']@use0..1SHOULD72902.16.840.1.113883.1.11.10637 (PostalAddressUse)streetAddressLine1..4SHALLST7291city1..1SHALLST7292state0..1SHOULDST72932.16.840.1.113883.3.88.12.80.1 (StateValueSet)postalCode0..1SHOULD72942.16.840.1.113883.3.88.12.80.2 (PostalCodeValueSet)country0..1SHOULD72952.16.840.1.113883.3.88.12.80.63 (CountryValueSet)SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 (CONF:7290).SHOULD contain zero or one [0..1] country, which SHALL be selected from ValueSet CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:7295).SHOULD contain zero or one [0..1] state (ValueSet: StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC) (CONF:7293).State is required if the country is US. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:10024).SHALL contain exactly one [1..1] city (CONF:7292).SHOULD contain zero or one [0..1] postalCode, which SHOULD be selected from ValueSet PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMIC (CONF:7294).PostalCode is required if the country is US. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:10025).SHALL contain at least one and not more than 4 streetAddressLine (CONF:7291).SHALL NOT have mixed content except for white space (CONF:7296).SEQ Table \* ARABIC573: PostalAddressUseValue Set: PostalAddressUse 2.16.840.1.113883.1.11.10637CodeCode SystemPrint NameBADAddressUsebad addressCONFAddressUseconfidentialDIRAddressUsedirectHAddressUsehome addressHPAddressUseprimary homeHVAddressUsevacation homePHYSAddressUsephysical visit addressPSTAddressUsepostal addressPUBAddressUsepublicTMPAddressUsetemporaryWPAddressUsework placeSEQ Table \* ARABIC574: StateValueSetValue Set: StateValueSet 2.16.840.1.113883.3.88.12.80.1Identifies addresses within the United States are recorded using the FIPS 5-2 two-letter alphabetic codes for the State, District of Columbia, or an outlying area of the United States or associated areaCodeCode SystemPrint NameSEQ Table \* ARABIC575: PostalCodeValueSetValue Set: PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2This identifies the postal (ZIP) Code of an address in the United StatesCodeCode SystemPrint NameSEQ Table \* ARABIC576: CountryValueSetValue Set: CountryValueSet 2.16.840.1.113883.3.88.12.80.63This identifies the codes for the representation of names of countries, territories and areas of geographical interest.CodeCode SystemPrint NameUS Realm Date and Time (DT.US.FIELDED) (obsolete)[IVL_TS: templateId 2.16.840.1.113883.10.20.22.5.3.obsolete (open)]SEQ Table \* ARABIC577: US Realm Date and Time (DT.US.FIELDED) (obsolete) ContextsContained By:Contains:This template is obsolete and will be deleted completely in the future. It is a duplicate. Use 2.16.840.1.113883.10.20.22.5.4 instead.SEQ Table \* ARABIC578: US Realm Date and Time (DT.US.FIELDED) (obsolete) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueIVL_TS[templateId/@root = '2.16.840.1.113883.10.20.22.5.3.obsolete']US Realm Date and Time (DTM.US.FIELDED)[effectiveTime: templateId 2.16.840.1.113883.10.20.22.5.4 (open)]SEQ Table \* ARABIC579: US Realm Date and Time (DTM.US.FIELDED) ContextsContained By:Contains:The US Realm Clinical Document Date and Time datatype flavor records date and time information. If no time zone offset is provided, you can make no assumption about time, unless you have made a local exchange agreement.SEQ Table \* ARABIC580: US Realm Date and Time (DTM.US.FIELDED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed ValueeffectiveTime[templateId/@root = '2.16.840.1.113883.10.20.22.5.4']SHALL be precise to the day (CONF:10127).SHOULD be precise to the minute (CONF:10128).MAY be precise to the second (CONF:10129).If more precise than day, SHOULD include time-zone offset (CONF:10130).US Realm Patient Name (PTN.US.FIELDED)[name: templateId 2.16.840.1.113883.10.20.22.5.1 (open)]SEQ Table \* ARABIC581: US Realm Patient Name (PTN.US.FIELDED) ContextsContained By:Contains:The US Realm Patient Name datatype flavor is a set of reusable constraints that can be used for the patient or any other person. It requires a first (given) and last (family) name. If a patient or person has only one name part (e.g., patient with first name only) place the name part in the field required by the organization. Use the appropriate nullFlavor, ""Not Applicable"" (NA), in the other field.For information on mixed content see the Extensible Markup Language reference ().SEQ Table \* ARABIC582: US Realm Patient Name (PTN.US.FIELDED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuename[templateId/@root = '2.16.840.1.113883.10.20.22.5.1']@use0..1MAY71542.16.840.1.113883.1.11.15913 (EntityNameUse)prefix0..*MAYST7155@qualifier0..1MAY71562.16.840.1.113883.11.20.9.26 (EntityPersonNamePartQualifier)given1..*SHALLST7157@qualifier0..1MAY71582.16.840.1.113883.11.20.9.26 (EntityPersonNamePartQualifier)family1..1SHALLST7159@qualifier0..1MAY71602.16.840.1.113883.11.20.9.26 (EntityPersonNamePartQualifier)suffix0..1MAYST7161@qualifier0..1MAY71622.16.840.1.113883.11.20.9.26 (EntityPersonNamePartQualifier)MAY contain zero or one [0..1] @use, which SHALL be selected from ValueSet EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01 (CONF:7154).SHALL contain exactly one [1..1] family (CONF:7159).This family MAY contain zero or one [0..1] @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7160).SHALL contain at least one [1..*] given (CONF:7157).Such givens MAY contain zero or one [0..1] @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7158).The second occurrence of given (given2]) if provided, SHALL include middle name or middle initial (CONF:7163).MAY contain zero or more [0..*] prefix (CONF:7155).The prefix, if present, MAY contain zero or one [0..1] @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7156).MAY contain zero or one [0..1] suffix (CONF:7161).The suffix, if present, MAY contain zero or one [0..1] @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7162).SHALL NOT have mixed content except for white space (CONF:7278).SEQ Table \* ARABIC583: EntityNameUseValue Set: EntityNameUse 2.16.840.1.113883.1.11.15913CodeCode SystemPrint NameAEntityNameUseArtist/StageABCEntityNameUseAlphabeticASGNEntityNameUseAssignedCEntityNameUseLicenseIEntityNameUseIndigenous/TribalIDEEntityNameUseIdeographicLEntityNameUseLegalPEntityNameUsePseudonymPHONEntityNameUsePhoneticREntityNameUseReligiousSNDXEntityNameUseSoundexSRCHEntityNameUseSearchSYLEntityNameUseSyllabicSEQ Table \* ARABIC584: EntityPersonNamePartQualifierValue Set: EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26CodeCode SystemPrint NameACEntityNamePartQualifieracademicADEntityNamePartQualifieradoptedBREntityNamePartQualifierbirthCLEntityNamePartQualifiercallmeINEntityNamePartQualifierinitialNBEntityNamePartQualifiernobilityPREntityNamePartQualifierprofessionalSPEntityNamePartQualifierspouseTITLEEntityNamePartQualifiertitleVVEntityNamePartQualifiervoorvoegselUS Realm Person Name (PN.US.FIELDED)[name: templateId 2.16.840.1.113883.10.20.22.5.1.1 (open)]SEQ Table \* ARABIC585: US Realm Person Name (PN.US.FIELDED) ContextsContained By:Contains:Diagnostic Imaging Report (V2) (optional)Physician of Record Participant (V2) (optional)The US Realm Clinical Document Person Name datatype flavor is a set of reusable constraints that can be used for Persons.SEQ Table \* ARABIC586: US Realm Person Name (PN.US.FIELDED) Constraints OverviewXPathCard.VerbData TypeCONF#Fixed Valuename[templateId/@root = '2.16.840.1.113883.10.20.22.5.1.1']name1..1SHALL9368SHALL contain exactly one [1..1] name (CONF:9368).The content of name SHALL be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:9371).The string SHALL NOT contain name parts (CONF:9372).Template Ids in This GuideSEQ Table \* ARABIC587: Template ListTemplate TitleTemplate TypetemplateIdCare Plan (NEW)document2.16.840.1.113883.10.20.22.1.15Consultation Note (V2)document2.16.840.1.113883.10.20.22.1.4.2Continuity of Care Document (CCD) (V2)document2.16.840.1.113883.10.20.22.1.2.2Diagnostic Imaging Report (V2)document2.16.840.1.113883.10.20.22.1.5.2Discharge Summary (V2)document2.16.840.1.113883.10.20.22.1.8.2History and Physical (V2)document2.16.840.1.113883.10.20.22.1.3.2Operative Note (V2)document2.16.840.1.113883.10.20.22.1.7.2Procedure Note (V2)document2.16.840.1.113883.10.20.22.1.6.2Progress Note (V2)document2.16.840.1.113883.10.20.22.1.9.2Referral Note (NEW)document2.16.840.1.113883.10.20.22.1.14Transfer Summary (NEW)document2.16.840.1.113883.10.20.22.1.13Unstructured Document (V2)document2.16.840.1.113883.10.20.22.1.10.2US Realm Header - Patient Generated Document (NEW)document2.16.840.1.113883.10.20.29.1US Realm Header (V2)document2.16.840.1.113883.10.20.22.1.1.2Advance Directives Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.21.2Advance Directives Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.21.1.2Allergies Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.6.2Allergies Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.6.1.2Anesthesia Section (V2)section2.16.840.1.113883.10.20.22.2.25.2Assessment and Plan Section (V2)section2.16.840.1.113883.10.20.22.2.9.2Assessment Sectionsection2.16.840.1.113883.10.20.22.2.8Chief Complaint and Reason for Visit Sectionsection2.16.840.1.113883.10.20.22.2.13Chief Complaint Sectionsection1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Complications (OpNote) (obsolete)section2.16.840.1.113883.10.20.22.2.32.obsoleteComplications Section (V2)section2.16.840.1.113883.10.20.22.2.37.2DICOM Object Catalog Section - DCM 121181section2.16.840.1.113883.10.20.6.1.1Discharge Diet Section (deprecated)section1.3.6.1.4.1.19376.1.5.3.1.3.33.2Encounters Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.22.2Encounters Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.22.1.2Family History Sectionsection2.16.840.1.113883.10.20.22.2.15Fetus Subject Contextsection2.16.840.1.113883.10.20.6.2.3Findings Section (DIR)section2.16.840.1.113883.10.20.6.1.2Functional Status Section (V2)section2.16.840.1.113883.10.20.22.2.14.2General Status Sectionsection2.16.840.1.113883.10.20.2.5Goals Section (NEW)section2.16.840.1.113883.10.20.22.2.60Health Concerns Section (NEW)section2.16.840.1.113883.10.20.22.2.58Health Status Evaluations/Outcomes Section (NEW)section2.16.840.1.113883.10.20.22.2.61History of Past Illness Section (V2)section2.16.840.1.113883.10.20.22.2.20.2History of Present Illness Sectionsection1.3.6.1.4.1.19376.1.5.3.1.3.4Hospital Admission Diagnosis Section (V2)section2.16.840.1.113883.10.20.22.2.43.2Hospital Admission Medications Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.44.2Hospital Consultations Sectionsection2.16.840.1.113883.10.20.22.2.42Hospital Course Sectionsection1.3.6.1.4.1.19376.1.5.3.1.3.5Hospital Discharge Diagnosis Section (V2)section2.16.840.1.113883.10.20.22.2.24.2Hospital Discharge Instructions Sectionsection2.16.840.1.113883.10.20.22.2.41Hospital Discharge Medications Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.11.2Hospital Discharge Medications Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.11.1.2Hospital Discharge Physical Sectionsection1.3.6.1.4.1.19376.1.5.3.1.3.26Hospital Discharge Studies Summary Sectionsection2.16.840.1.113883.10.20.22.2.16Immunizations Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.2.2Immunizations Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.2.1.2Implants Sectionsection2.16.840.1.113883.10.20.22.2.33Instructions Section (V2)section2.16.840.1.113883.10.20.22.2.45.2Interventions Section (V2)section2.16.840.1.113883.10.20.21.2.3.2Medical (General) History Section (V2)section2.16.840.1.113883.10.20.22.2.39.2Medical Equipment Section (V2)section2.16.840.1.113883.10.20.22.2.23.2Medications Administered Section (V2)section2.16.840.1.113883.10.20.22.2.38.2Medications Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.1.2Medications Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.1.1.2Mental Status Section (NEW)section2.16.840.1.113883.10.20.22.2.56Nutrition Section (NEW)section2.16.840.1.113883.10.20.22.2.57Objective Sectionsection2.16.840.1.113883.10.20.21.2.1Observer Contextsection2.16.840.1.113883.10.20.6.2.4Operative Note Fluids Sectionsection2.16.840.1.113883.10.20.7.12Operative Note Surgical Procedure Sectionsection2.16.840.1.113883.10.20.7.14Payers Section (V2)section2.16.840.1.113883.10.20.22.2.18.2Physical Exam Section (V2)section2.16.840.1.113883.10.20.2.10.2Physical Findings of Skin Sectionsection2.16.840.1.113883.10.20.22.2.62Plan of Treatment Section (V2)section2.16.840.1.113883.10.20.22.2.10.2Planned Procedure Section (V2)section2.16.840.1.113883.10.20.22.2.30.2Postoperative Diagnosis Sectionsection2.16.840.1.113883.10.20.22.2.35Postprocedure Diagnosis Section (V2)section2.16.840.1.113883.10.20.22.2.36.2Preoperative Diagnosis Section (V2)section2.16.840.1.113883.10.20.22.2.34.2Problem Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.5.2Problem Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.5.1.2Procedure Description Sectionsection2.16.840.1.113883.10.20.22.2.27Procedure Disposition Sectionsection2.16.840.1.113883.10.20.18.2.12Procedure Estimated Blood Loss Sectionsection2.16.840.1.113883.10.20.18.2.9Procedure Findings Section (V2)section2.16.840.1.113883.10.20.22.2.28.2Procedure Implants Sectionsection2.16.840.1.113883.10.20.22.2.40Procedure Indications Section (V2)section2.16.840.1.113883.10.20.22.2.29.2Procedure Specimens Taken Sectionsection2.16.840.1.113883.10.20.22.2.31Procedures Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.7.2Procedures Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.7.1.2Reason for Referral Section (V2)section1.3.6.1.4.1.19376.1.5.3.1.3.1.2Reason for Visit Sectionsection2.16.840.1.113883.10.20.22.2.12Results Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.3.2Results Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.3.1.2Review of Systems Sectionsection1.3.6.1.4.1.19376.1.5.3.1.3.18Social History Section (V2)section2.16.840.1.113883.10.20.22.2.17.2Subjective Sectionsection2.16.840.1.113883.10.20.21.2.2Surgery Description Sectionsection2.16.840.1.113883.10.20.22.2.26Surgical Drains Sectionsection2.16.840.1.113883.10.20.7.13Vital Signs Section (entries optional) (V2)section2.16.840.1.113883.10.20.22.2.4.2Vital Signs Section (entries required) (V2)section2.16.840.1.113883.10.20.22.2.4.1.2Act Plan (V2)entry2.16.840.1.113883.10.20.22.4.39.2Act Reference (NEW)entry2.16.840.1.113883.10.20.22.4.122Admission Medication (V2)entry2.16.840.1.113883.10.20.22.4.36.2Advance Directive Observation (V2)entry2.16.840.1.113883.10.20.22.4.48.2Advance Directive Organizerentry2.16.840.1.113883.10.20.22.4.108Age Observationentry2.16.840.1.113883.10.20.22.4.31Allergy - Intolerance Observation (V2)entry2.16.840.1.113883.10.20.22.4.7.2Allergy Problem Act (V2)entry2.16.840.1.113883.10.20.22.4.30.2Allergy Status Observation (DEPRECATED)entry2.16.840.1.113883.10.20.22.4.28.2Assessment Scale Observationentry2.16.840.1.113883.10.20.22.4.69Assessment Scale Supporting Observationentry2.16.840.1.113883.10.20.22.4.86Authorization Activityentry2.16.840.1.113883.10.20.1.19Boundary Observationentry2.16.840.1.113883.10.20.6.2.11Caregiver Characteristicsentry2.16.840.1.113883.10.20.22.4.72Characteristics of Home Environment (NEW)entry2.16.840.1.113883.10.20.22.4.109Clinical Statement Referenceentry2.16.840.1.113883.10.20.22.4.112Code Observationsentry2.16.840.1.113883.10.20.6.2.13Cognitive Abilities Observation (NEW)entry2.16.840.1.113883.10.20.22.4.126Cognitive Status Observation (V2)entry2.16.840.1.113883.10.20.22.4.74.2Cognitive Status Organizer (V2)entry2.16.840.1.113883.10.20.22.4.75.2Cognitive Status Problem Observation (DEPRECATED)entry2.16.840.1.113883.10.20.22.4.73.2Comment Activityentry2.16.840.1.113883.10.20.22.4.64Communication from Provider to Providerentry2.16.840.1.113883.10.20.24.3.4Coverage Activity (V2)entry2.16.840.1.113883.10.20.22.4.60.2Cultural and Religious Observation (NEW)entry2.16.840.1.113883.10.20.22.4.111Current Smoking Status (V2)entry2.16.840.1.113883.10.20.22.4.78.2Deceased Observation (V2)entry2.16.840.1.113883.10.20.22.4.79.2Diet (NEW)entry2.16.840.1.113883.10.20.22.4.138Discharge Medication (V2)entry2.16.840.1.113883.10.20.22.4.35.2Drug Monitoring Act (NEW)entry2.16.840.1.113883.10.20.22.4.123Drug Vehicleentry2.16.840.1.113883.10.20.22.4.24Encounter Activity (V2)entry2.16.840.1.113883.10.20.22.4.49.2Encounter Diagnosis (V2)entry2.16.840.1.113883.10.20.22.4.80.2Encounter Plan (V2)entry2.16.840.1.113883.10.20.22.4.40.2Entry Authorentryentry_authorEstimated Date of Deliveryentry2.16.840.1.113883.10.20.15.3.1Family History Death Observationentry2.16.840.1.113883.10.20.22.4.47Family History Observationentry2.16.840.1.113883.10.20.22.4.46Family History Organizerentry2.16.840.1.113883.10.20.22.4.45Functional Status Observation (V2)entry2.16.840.1.113883.10.20.22.4.67.2Functional Status Organizer (V2)entry2.16.840.1.113883.10.20.22.4.66.2Functional Status Problem Observation (DEPRECATED)entry2.16.840.1.113883.10.20.22.4.68.2Goal Observation (NEW)entry2.16.840.1.113883.10.20.22.4.121Handoff Communication (NEW)entry2.16.840.1.113883.10.20.22.4.141Health Concern Act (NEW)entry2.16.840.1.113883.10.20.22.4.132Health Status Observation (V2)entry2.16.840.1.113883.10.20.22.4.5.2Highest Pressure Ulcer Stageentry2.16.840.1.113883.10.20.22.4.77Hospital Admission Diagnosis (V2)entry2.16.840.1.113883.10.20.22.4.34.2Hospital Discharge Diagnosis (V2)entry2.16.840.1.113883.10.20.22.4.33.2Immunization Activity (V2)entry2.16.840.1.113883.10.20.22.4.52.2Immunization Medication Informationentry2.16.840.1.113883.10.20.22.4.54Immunization Medication Information (V2)entry2.16.840.1.113883.10.20.22.4.54.2Immunization Refusal Reasonentry2.16.840.1.113883.10.20.22.4.53Indication (V2)entry2.16.840.1.113883.10.20.22.4.19.2Instruction (V2)entry2.16.840.1.113883.10.20.22.4.20.2Intervention Act (NEW)entry2.16.840.1.113883.10.20.22.4.131Medical Device Applied (NEW)entry2.16.840.1.113883.10.20.22.4.115Medical Equipment Organizer (NEW)entry2.16.840.1.113883.10.20.22.4.135Medication Activity (V2)entry2.16.840.1.113883.10.20.22.4.16.2Medication Dispense (V2)entry2.16.840.1.113883.10.20.22.4.18.2Medication Information (V2)entry2.16.840.1.113883.10.20.22.4.23.2Medication Supply Order (V2)entry2.16.840.1.113883.10.20.22.4.17.2Medication Use - None Known (obsolete)entry2.16.840.1.113883.10.20.22.4.29.obsoleteMental Status Observation (NEW)entry2.16.840.1.113883.10.20.22.4.125Non-Medicinal Supply Activityentry2.16.840.1.113883.10.20.22.4.50Non-Medicinal Supply Activity (V2)entry2.16.840.1.113883.10.20.22.4.50.2Number of Pressure Ulcers Observationentry2.16.840.1.113883.10.20.22.4.76Nutrition Recommendations (NEW)entry2.16.840.1.113883.10.20.22.4.130Nutritional Status Observation (NEW)entry2.16.840.1.113883.10.20.22.4.124Observation Plan (V2)entry2.16.840.1.113883.10.20.22.4.44.2Outcome Observation (NEW)entry2.16.840.1.113883.10.20.22.4.144Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Patient Priority Preference (NEW)entry2.16.840.1.113883.10.20.22.4.142Patient Referral Activity Observation (NEW)entry2.16.840.1.113883.10.20.22.4.140Physician of Record Participant (V2)entry2.16.840.1.113883.10.20.6.2.2.2Policy Activity (V2)entry2.16.840.1.113883.10.20.22.4.61.2Postprocedure Diagnosis (V2)entry2.16.840.1.113883.10.20.22.4.51.2Precondition for Substance Administrationentry2.16.840.1.113883.10.20.22.4.25Pregnancy Observationentry2.16.840.1.113883.10.20.15.3.8Preoperative Diagnosis (V2)entry2.16.840.1.113883.10.20.22.4.65.2Pressure Ulcer Observation (DEPRECATED)entry2.16.840.1.113883.10.20.22.4.70.2Problem Concern Act (Condition) (V2)entry2.16.840.1.113883.10.20.22.4.3.2Problem Observation (V2)entry2.16.840.1.113883.10.20.22.4.4.2Problem Status (DEPRECATED)entry2.16.840.1.113883.10.20.22.4.6.2Procedure Activity Act (V2)entry2.16.840.1.113883.10.20.22.4.12.2Procedure Activity Observation (V2)entry2.16.840.1.113883.10.20.22.4.13.2Procedure Activity Procedure (V2)entry2.16.840.1.113883.10.20.22.4.14.2Procedure Contextentry2.16.840.1.113883.10.20.6.2.5Procedure Plan (V2)entry2.16.840.1.113883.10.20.22.4.41.2Product Instanceentry2.16.840.1.113883.10.20.22.4.37Prognosis Observationentry2.16.840.1.113883.10.20.22.4.113Progress Toward Goal Observationentry2.16.840.1.113883.10.20.22.4.110Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Provider Priority Preference (NEW)entry2.16.840.1.113883.10.20.22.4.143Purpose of Reference Observationentry2.16.840.1.113883.10.20.6.2.9Quantity Measurement Observationentry2.16.840.1.113883.10.20.6.2.14Reaction Observation (V2)entry2.16.840.1.113883.10.20.22.4.9.2Reasonentry2.16.840.1.113883.10.20.24.3.88Referenced Frames Observationentry2.16.840.1.113883.10.20.6.2.10Result Observation (V2)entry2.16.840.1.113883.10.20.22.4.2.2Result Organizer (V2)entry2.16.840.1.113883.10.20.22.4.1.2Self-Care Activities (ADL and IADL) (NEW)entry2.16.840.1.113883.10.20.22.4.128Sensory and Speech Status (NEW)entry2.16.840.1.113883.10.20.22.4.127Series Actentry2.16.840.1.113883.10.20.22.4.63Service Delivery Locationentry2.16.840.1.113883.10.20.22.4.32Severity Observation (V2)entry2.16.840.1.113883.10.20.22.4.8.2Social History Observation (V2)entry2.16.840.1.113883.10.20.22.4.38.2SOP Instance Observationentry2.16.840.1.113883.10.20.6.2.8Study Actentry2.16.840.1.113883.10.20.6.2.6Substance Administered Act (NEW)entry2.16.840.1.113883.10.20.22.4.118Substance Administration Plan (V2)entry2.16.840.1.113883.10.20.22.4.42.2Substance or Device Allergy - Intolerance Observation (V2)entry2.16.840.1.113883.10.20.24.3.90.2Supply Plan (V2)entry2.16.840.1.113883.10.20.22.4.43.2Text Observationentry2.16.840.1.113883.10.20.6.2.12Tobacco Use (V2)entry2.16.840.1.113883.10.20.22.4.85.2Vital Sign Observation (V2)entry2.16.840.1.113883.10.20.22.4.27.2Vital Signs Organizer (V2)entry2.16.840.1.113883.10.20.22.4.26.2Wound Characteristics (NEW)entry2.16.840.1.113883.10.20.22.4.134Wound Measurement Observation (NEW)entry2.16.840.1.113883.10.20.22.4.133Wound Observation (NEW)entry2.16.840.1.113883.10.20.22.4.114Author Participant (NEW)unspecified2.16.840.1.113883.10.20.22.4.119Physician Reading Study Performer (V2)unspecified2.16.840.1.113883.10.20.6.2.1.2US Realm Address (AD.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.2US Realm Date and Time (DT.US.FIELDED) (obsolete)unspecified2.16.840.1.113883.10.20.22.5.3.obsoleteUS Realm Date and Time (DTM.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.4US Realm Patient Name (PTN.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.1US Realm Person Name (PN.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.1.1Value Sets In This GuideSEQ Table \* ARABIC588: Valueset ListNameOIDAbility Value Set2.16.840.1.113883.11.20.9.46Act Priority Value Set2.16.840.1.113883.1.11.16866Act Priority Value Set2.16.840.1.113883.1.11.16866Act Priority Value Set2.16.840.1.113883.1.11.16866ActStatus2.16.840.1.113883.1.11.159331ActStatus2.16.840.1.113883.1.11.159331ADL Result Type2.16.840.1.113883.11.20.9.47Administrative Gender (HL7 V3)2.16.840.1.113883.1.11.1Administrative Gender (HL7 V3)2.16.840.1.113883.1.11.1AdvanceDirectiveTypeCode (V2)2.16.840.1.113883.1.11.20.2.2AgePQ_UCUM2.16.840.1.113883.11.20.9.21Allergy/Adverse Event Type Value Set2.16.840.1.113883.3.88.12.3221.6.2Allergy/Adverse Event Type Value Set2.16.840.1.113883.3.88.12.3221.6.2Body Site Value Set2.16.840.1.113883.3.88.12.3221.8.9Body Site Value Set2.16.840.1.113883.3.88.12.3221.8.9Body Site Value Set2.16.840.1.113883.3.88.12.3221.8.9Body Site Value Set2.16.840.1.113883.3.88.12.3221.8.9Body Site Value Set2.16.840.1.113883.3.88.12.3221.8.9Cognitive Abilities Value Set2.16.840.1.113883.11.20.9.48ConsultDocumentType2.16.840.1.113883.11.20.9.31CountryValueSet2.16.840.1.113883.3.88.12.80.63CountryValueSet2.16.840.1.113883.3.88.12.80.63Coverage Role Type Value Set2.16.840.1.113883.1.11.18877Current Smoking Status2.16.840.1.113883.11.20.9.38.2DICOMPurposeOfReference2.16.840.1.113883.11.20.9.28DIRDocumentTypeCodes2.16.840.1.113883.11.20.9.32DIRQuantityMeasurementTypeCodes2.16.840.1.113883.11.20.9.29DIRSectionTypeCodes2.16.840.1.113883.11.20.9.59DischargeSummaryDocumentTypeCode2.16.840.1.113883.11.20.4.1EncounterTypeCode2.16.840.1.113883.3.88.12.80.32EntityNameUse2.16.840.1.113883.1.11.15913EntityPersonNamePartQualifier2.16.840.1.113883.11.20.9.26EthnicityGroup2.16.840.1.114222.4.11.837Family Member Value Set2.16.840.1.113883.1.11.19579Goal Achievement2.16.840.1.113883.11.20.9.55Health Insurance Type Value Set2.16.840.1.113883.3.88.12.3221.5.2Healthcare Agent Qualifier Value Set2.16.840.1.113883.11.20.9.51Healthcare Provider Taxonomy (HIPAA)2.16.840.1.114222.4.11.1066Healthcare Provider Taxonomy (HIPAA)2.16.840.1.114222.4.11.1066HealthcareServiceLocation2.16.840.1.113883.1.11.20275HealthStatus (V2)2.16.840.1.113883.1.11.20.12.2HL7 BasicConfidentialityKind2.16.840.1.113883.1.11.16926HL7FinanciallyResponsiblePartyType2.16.840.1.113883.1.11.10416HPDocumentType2.16.840.1.113883.1.11.20.22INDRoleclassCodes2.16.840.1.113883.11.20.9.33Intervention moodCode (Act/Encounter/Procedure)2.16.840.1.113883.11.20.9.54Language2.16.840.1.113883.1.11.11526LanguageAbilityMode Value Set2.16.840.1.113883.1.11.12249LanguageAbilityProficiency2.16.840.1.113883.1.11.12199Marital Status Value Set2.16.840.1.113883.1.11.12212Medication ConsumableTemp-ValueSet-medicationsMedication ConsumableTemp-ValueSet-medicationsMedication Fill Status2.16.840.1.113883.3.88.12.80.64Medication Product Form Value Set2.16.840.1.113883.3.88.12.3221.8.11Medication Product Form Value Set2.16.840.1.113883.3.88.12.3221.8.11Medication Route FDA Value Set2.16.840.1.113883.3.88.12.3221.8.7Medication Route FDA Value Set2.16.840.1.113883.3.88.12.3221.8.7Mental and Functional Status Response Value Set2.16.840.1.113883.11.20.9.44Mental and Functional Status Response Value Set2.16.840.1.113883.11.20.9.44Mental and Functional Status Response Value Set2.16.840.1.113883.11.20.9.44Mental Status Observation Type2.16.840.1.113883.11.20.9.43MoodCodeEvnInt2.16.840.1.113883.11.20.9.18MoodCodeEvnInt2.16.840.1.113883.11.20.9.18MoodCodeEvnInt2.16.840.1.113883.11.20.9.18MoodCodeEvnInt2.16.840.1.113883.11.20.9.18MoodCodeEvnInt2.16.840.1.113883.11.20.9.18MoodCodeEvnInt2.16.840.1.113883.11.20.9.18MoodCodeEvnInt2.16.840.1.113883.11.20.9.18MoodCodeEvnInt2.16.840.1.113883.11.20.9.18No Immunization Reason Value Set2.16.840.1.113883.1.11.19717Nutrition Assessment2.16.840.1.113883.1.11.20.2.8Nutrition Recommendations2.16.840.1.113883.1.11.20.2.9Nutritional Status2.16.840.1.113883.1.11.20.2.7ParticipationFunction2.16.840.1.113883.1.11.10267Patient Education2.16.840.1.113883.11.20.9.34Personal And Legal Relationship Role Type2.16.840.1.113883.11.20.12.1Personal And Legal Relationship Role Type2.16.840.1.113883.11.20.12.1Plan of Care moodCode (Act/Encounter/Procedure)2.16.840.1.113883.11.20.9.23Plan of Care moodCode (Act/Encounter/Procedure)2.16.840.1.113883.11.20.9.23Plan of Care moodCode (Act/Encounter/Procedure)2.16.840.1.113883.11.20.9.23Plan of Care moodCode (Observation)2.16.840.1.113883.11.20.9.25Plan of Care moodCode (SubstanceAdministration/Supply)2.16.840.1.113883.11.20.9.24Plan of Care moodCode (SubstanceAdministration/Supply)2.16.840.1.113883.11.20.9.24PostalAddressUse2.16.840.1.113883.1.11.10637PostalCodeValueSet2.16.840.1.113883.3.88.12.80.2PostalCodeValueSet2.16.840.1.113883.3.88.12.80.2Pressure Point2.16.840.1.113883.11.20.9.36Pressure Ulcer Stage2.16.840.1.113883.11.20.9.35Pressure Ulcer Stage2.16.840.1.113883.11.20.9.35Priority Level2.16.840.1.113883.11.20.9.60Priority Level2.16.840.1.113883.11.20.9.60Priority Order2.16.840.1.113883.11.20.9.57Priority Order2.16.840.1.113883.11.20.9.57Problem Severity2.16.840.1.113883.3.88.12.3221.6.8Problem Status Value Set2.16.840.1.113883.3.88.12.80.68Problem Status Value Set2.16.840.1.113883.3.88.12.80.68Problem Type2.16.840.1.113883.3.88.12.3221.7.2Problem Type2.16.840.1.113883.3.88.12.3221.7.2Problem Type2.16.840.1.113883.3.88.12.3221.7.2Problem Value Set2.16.840.1.113883.3.88.12.3221.7.4Problem Value Set2.16.840.1.113883.3.88.12.3221.7.4Problem Value Set2.16.840.1.113883.3.88.12.3221.7.4Problem Value Set2.16.840.1.113883.3.88.12.3221.7.4Problem Value Set2.16.840.1.113883.3.88.12.3221.7.4Problem Value Set2.16.840.1.113883.3.88.12.3221.7.4ProblemAct statusCode2.16.840.1.113883.11.20.9.19ProblemAct statusCode2.16.840.1.113883.11.20.9.19ProcedureAct statusCode2.16.840.1.113883.11.20.9.22ProcedureAct statusCode2.16.840.1.113883.11.20.9.22ProcedureAct statusCode2.16.840.1.113883.11.20.9.22ProcedureAct statusCode2.16.840.1.113883.11.20.9.22ProcedureNoteDocumentTypeCodes2.16.840.1.113883.11.20.6.1ProgressNoteDocumentTypeCode2.16.840.1.113883.11.20.8.1Provider Role Value Set2.16.840.1.113883.3.88.12.3221.4Race Value Set2.16.840.1.113883.1.11.14914Referral Types Valueset2.16.840.1.113883.11.20.9.56ReferralDocumentType2.16.840.1.113883.1.11.20.2.3Religious Affiliation Value Set2.16.840.1.113883.1.11.19185Residence and Accomodation Type2.16.840.1.113883.11.20.9.49Result Status2.16.840.1.113883.11.20.9.39Result Status2.16.840.1.113883.11.20.9.39Result Status2.16.840.1.113883.11.20.9.39Sensory and Speech Problem Type2.16.840.1.113883.11.20.9.50Social History Type Set Definition (V2)2.16.840.1.113883.3.88.12.80.60.2StateValueSet2.16.840.1.113883.3.88.12.80.1Substance / Reactant for IntoleranceTemp-ValueSet-substanceReactantForIntoleranceSubstance / Reactant for IntoleranceTemp-ValueSet-substanceReactantForIntoleranceSupportedFileFormats2.16.840.1.113883.11.20.7.1SurgicalOperationNoteDocumentTypeCode2.16.840.1.113883.11.20.1.1TargetSite Qualifiers2.16.840.1.113883.11.20.9.37TargetSite Qualifiers2.16.840.1.113883.11.20.9.37Telecom Use (US Realm Header)2.16.840.1.113883.11.20.9.20Tobacco Use2.16.840.1.113883.11.20.9.41TransferDocumentType2.16.840.1.113883.1.11.20.2.4UnitsOfMeasureCaseSensitive2.16.840.1.113883.1.11.12839UnitsOfMeasureCaseSensitive2.16.840.1.113883.1.11.12839Vaccine Administered Value Set2.16.840.1.113883.3.88.12.80.22Vaccine Administered Value Set2.16.840.1.113883.3.88.12.80.22Vital Sign Result Value Set2.16.840.1.113883.3.88.12.80.62Wound Charactersitic2.16.840.1.113883.11.20.9.58Wound Measurements2.16.840.1.113883.1.11.20.2.5Wound Type2.16.840.1.113883.1.11.20.2.6 ................
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