AALLC Style Guide



CDAR2_IG_QRDA_R2_D1_2012MAYQuality Reporting Document ArchitectureImplementation Guide for CDA Release 2(US Realm)Based on HL7 CDA Release 2.0First BallotMay 2012? 2012 Health Level Seven, Inc.Ann Arbor, MIAll rights reserved.Primary Editor:Gaye Dolin, MSN RNLantana Consulting Groupgaye.dolin@Co-Editor:Floyd Eisenberg, MD National Quality Forumfeisenberg@Co-Chair/ Co-EditorRobert H. Dolin, MDLantana Consulting Groupbob.dolin@Co-Editor:Chad BennettTelligen cbennett@Co-Chair:Brett Marquard Lantana Consulting Groupbrett.marquard@Co-Editor:Saul Kravitz, MDMitre Corporationskravitz@Co-Chair:Calvin BeebeMayo Cliniccbeebe@mayo.eduCo-Editor:Crystal KallemLantana Consulting GroupCrystal.kallem@ Co-Chair:Austin KreislerSAIC Consultant to CDC/NHSN duz1@Co-Editor:Joy KuhlOptimal Accordjoy.kuhl@ Co-Chair:Grahame GrieveKestral Computing Pty Ltdgrahame@.auCo-Editor:Co-Editor:Sarah GauntLantana Consulting Groupsarah.gaunt@ Co-Editor:Co-Editor:Yan HerasLantana Consulting Groupyan.heras@Co-Editor:Co-Editor:Jingdong LiLantana Consulting Groupjingdong.li@ Co-Editor:Co-Editor:Liora AlschulerLantana Consulting Groupliora.alschuler@Technical Editor:Susan HardyLantana Consulting Groupsusan.hardy@Current Work Group: David StumpfJulie SteeleJohn RobertsFred MillerJuliet RubiniJonathan IvesEmma JonesRute MartinsJeff JamesKaren NakanoDan GreenAnne SmithPele YuLura DaussatLinda HydeSavithri DevarajTodd HarpsterVinayak KulkarniStan RankinsBrian PeckFred RahmanianDebbie KraussRob SamplesKim SchwartzRobert WardonMary PrattAcknowledgmentsThis implementation guide was produced and developed by Lantana Consulting Group in conjunction with the Office of Clinical Standards and Quality of the Centers for Medicare and Medicaid Services (CMS). Throughout the development of this guide, multiple industry stakeholders provided input and translation of business and technical requirements, including representatives from the Joint Commission, Telligen and National Quality ForumThis guide was originally produced and developed through the efforts of the Quality Reporting Document Architecture (QRDA) Project supported by the Child Health Corporation of America (CHCA) to develop and support a standard for quality reporting. The QRDA committee was comprised of representatives from the American Health Information Management Association (AHIMA), Integrating the Healthcare Enterprise (IHE), CHCA, the Collaborative for Performance Measure Integration with EHR Systems, MedAllies, and the Nationwide Health Information Network (NHIN). This specification is a set of constraints on existing work, and the extent to which it can accommodate the expressive requirements of quality reporting over time is a function of the richness of the model on which it is built, the Health Level Seven (HL7) Reference Information Model (RIM) and the RIM document standard, and the Clinical Document Architecture Release 2 (CDA R2). We thank all those who have worked for over a decade to produce these fundamental specifications; we especially thank structured documents co-chairs Bob Dolin, Keith Boone, Calvin Beebe, and Grahame Grieve for their support of this project.This material contains content from SNOMED CT? (). SNOMED CT is a registered trademark of the International Health Terminology Standard Development Organisation (IHTSDO).This material contains content from LOINC? (). The LOINC table, LOINC codes, and LOINC panels and forms file are copyright ? 1995-2010, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and available at no cost under the license at History RevDateBy WhomChanges1.64/4/12G. DolinPrepped for posting draft to project WIKI.Work Remaining:QA QDM/QRDA pattern entry templates and add to the Patient Data Section QDMComplete remaining HQMF QDM pattern to CDA template mapping and template designAdd Sample xml examplesComplete Quality Data Type to QRDA Template mapping tableComplete “Contents of Ballot” tableCreate full sample instance of a QDM Based QRDAAdd remaining footnotes and referencesUpdate value set oids in tables in chapter 3Complete all tables/material in appendixFix linksRepair diagrams in chapter 3Final technical editTable of Contents TOC \o "1-3" 1Introduction PAGEREF _Toc321346022 \h 211.1Purpose PAGEREF _Toc321346023 \h 211.2Audience PAGEREF _Toc321346024 \h 211.3Approach PAGEREF _Toc321346025 \h 211.4CDA R2 PAGEREF _Toc321346026 \h 221.5Background PAGEREF _Toc321346027 \h 221.5.1QRDA Category?I – Single Patient Report PAGEREF _Toc321346028 \h 221.5.2QRDA Category II – Patient List Report PAGEREF _Toc321346029 \h 231.5.3QRDA Category?III – Calculated Report PAGEREF _Toc321346030 \h 231.6Relationship to Health Quality Measures Format: eMeasures PAGEREF _Toc321346031 \h 231.7Current Project PAGEREF _Toc321346032 \h 241.8Scope PAGEREF _Toc321346033 \h 251.9Organization of This Guide PAGEREF _Toc321346034 \h 251.10Use of Templates PAGEREF _Toc321346035 \h 261.10.1Originator Responsibilities: General Case PAGEREF _Toc321346036 \h 261.10.2Recipient Responsibilities: General Case PAGEREF _Toc321346037 \h 261.11Conformance Conventions Used in This Guide PAGEREF _Toc321346038 \h 261.11.1Templates Not Open for Comment PAGEREF _Toc321346039 \h 261.11.2Templates and Conformance Statements PAGEREF _Toc321346040 \h 261.11.3Open and Closed Templates PAGEREF _Toc321346041 \h 281.11.4Keywords PAGEREF _Toc321346042 \h 281.11.5Cardinality PAGEREF _Toc321346043 \h 281.11.6Vocabulary Conformance PAGEREF _Toc321346044 \h 291.11.7Null Flavor PAGEREF _Toc321346045 \h 301.11.8Unknown Information PAGEREF _Toc321346046 \h 321.11.9Asserting an Act Did Not Occur PAGEREF _Toc321346047 \h 331.11.10Data Types PAGEREF _Toc321346048 \h 341.12XML Conventions Used in This Guide PAGEREF _Toc321346049 \h 341.12.1XPath Notation PAGEREF _Toc321346050 \h 341.12.2XML Examples and Sample Documents PAGEREF _Toc321346051 \h 351.13Rendering Header Information for Human Presentation PAGEREF _Toc321346052 \h 351.14Content of the Package PAGEREF _Toc321346053 \h 362QRDA Framework PAGEREF _Toc321346054 \h 372.1Measure Section PAGEREF _Toc321346055 \h 372.2Reporting Parameters Section PAGEREF _Toc321346056 \h 372.3Patient Data Section PAGEREF _Toc321346057 \h 373Quality Data Model-Based QRDA IG PAGEREF _Toc321346058 \h 393.1Introduction PAGEREF _Toc321346059 \h 393.2QDM-Based QRDA Category I Construction Rules PAGEREF _Toc321346060 \h 443.2.1How Many QRDAs Should be Created? PAGEREF _Toc321346061 \h 443.2.2Generate a QRDA for Which Patients? PAGEREF _Toc321346062 \h 443.2.3How Many Data Should be Sent? PAGEREF _Toc321346063 \h 443.2.4What if There are No Data in the EHR? PAGEREF _Toc321346064 \h 453.3Generating a QDM-Based QRDA Category I Instance from a QDM-Based eMeasure PAGEREF _Toc321346065 \h 463.4QDM-Based QRDA Category I Instance Validation PAGEREF _Toc321346066 \h 484Clinical-Document-Level Templates PAGEREF _Toc321346067 \h 494.1US Realm Header PAGEREF _Toc321346068 \h 494.1.1RecordTarget PAGEREF _Toc321346069 \h 514.1.2Author PAGEREF _Toc321346070 \h 634.1.3DataEnterer PAGEREF _Toc321346071 \h 644.1.4Informant PAGEREF _Toc321346072 \h 664.1.5Custodian PAGEREF _Toc321346073 \h 674.1.6InformationRecipient PAGEREF _Toc321346074 \h 684.1.7LegalAuthenticator PAGEREF _Toc321346075 \h 694.1.8Authenticator PAGEREF _Toc321346076 \h 714.1.9Participant (Support) PAGEREF _Toc321346077 \h 724.1.10InFulfillmentOf PAGEREF _Toc321346078 \h 744.1.11Authorization/consent PAGEREF _Toc321346079 \h 744.1.12componentOf PAGEREF _Toc321346080 \h 754.2US Realm Address (AD.US.FIELDED) PAGEREF _Toc321346081 \h 754.3US Realm Date and Time (DT.US.FIELDED) PAGEREF _Toc321346082 \h 764.4US Realm Date and Time (DTM.US.FIELDED) PAGEREF _Toc321346083 \h 774.5US Realm Patient Name (PTN.US.FIELDED) PAGEREF _Toc321346084 \h 774.6US Realm Person Name (PN.US.FIELDED) PAGEREF _Toc321346085 \h 794.7QRDA Category I Framework Header Constraints PAGEREF _Toc321346086 \h 794.7.2ClinicalDocument/participants PAGEREF _Toc321346087 \h 804.8QRDA Category I Framework Body Constraints PAGEREF _Toc321346088 \h 814.9QDM-Based QRDA PAGEREF _Toc321346089 \h 825Section-Level Templates PAGEREF _Toc321346090 \h 835.1Measure Section PAGEREF _Toc321346091 \h 845.1.1Measure Section QDM PAGEREF _Toc321346092 \h 845.2Patient Data Section PAGEREF _Toc321346093 \h 855.2.1Patient Data Section QDM PAGEREF _Toc321346094 \h 865.3Reporting Parameters Section PAGEREF _Toc321346095 \h 906Entry-Level Templates PAGEREF _Toc321346096 \h 916.1Age Observation PAGEREF _Toc321346097 \h 916.2Communication from Patient to Provider PAGEREF _Toc321346098 \h 926.3Communication from Provider to Patient PAGEREF _Toc321346099 \h 956.4Communication from Provider to Provider PAGEREF _Toc321346100 \h 986.5Device Adverse Event PAGEREF _Toc321346101 \h 1016.6Device Allergy PAGEREF _Toc321346102 \h 1046.7Device Intolerance PAGEREF _Toc321346103 \h 1076.8Diagnostic Study Adverse Event PAGEREF _Toc321346104 \h 1106.9Diagnostic Study Intolerance PAGEREF _Toc321346105 \h 1136.10Drug Vehicle PAGEREF _Toc321346106 \h 1166.11eMeasure Reference QDM PAGEREF _Toc321346107 \h 1176.12Encounter Activities PAGEREF _Toc321346108 \h 1196.12.1Encounter Active PAGEREF _Toc321346109 \h 1236.12.2Encounter Performed PAGEREF _Toc321346110 \h 1266.13Functional Status Performed PAGEREF _Toc321346111 \h 1296.14Health Status Observation PAGEREF _Toc321346112 \h 1326.15Immunization Medication Information PAGEREF _Toc321346113 \h 1336.16Incision Datetime PAGEREF _Toc321346114 \h 1356.17Indication PAGEREF _Toc321346115 \h 1376.18Instructions PAGEREF _Toc321346116 \h 1396.19Intervention Adverse Event PAGEREF _Toc321346117 \h 1416.20Intervention Intolerance PAGEREF _Toc321346118 \h 1446.21Laboratory Test Adverse Event PAGEREF _Toc321346119 \h 1476.22Laboratory Test Intolerance PAGEREF _Toc321346120 \h 1506.23Laboratory Test Performed PAGEREF _Toc321346121 \h 1506.24Measure Reference PAGEREF _Toc321346122 \h 1526.25Medication Activity PAGEREF _Toc321346123 \h 1536.25.1Medication Active PAGEREF _Toc321346124 \h 1596.26Medication Administered PAGEREF _Toc321346125 \h 1616.27Medication Dispense PAGEREF _Toc321346126 \h 1646.28Medication Information PAGEREF _Toc321346127 \h 1676.29Medication Supply Order PAGEREF _Toc321346128 \h 1686.30Ordinality PAGEREF _Toc321346129 \h 1716.31Patient Care Experience PAGEREF _Toc321346130 \h 1726.32Patient Characteristic Clinical Trial Participant PAGEREF _Toc321346131 \h 1746.33Patient Characteristic Expired PAGEREF _Toc321346132 \h 1766.34Patient Characteristic Payer PAGEREF _Toc321346133 \h 1786.35Patient Preference PAGEREF _Toc321346134 \h 1806.36Plan of Care Activity Encounter PAGEREF _Toc321346135 \h 1826.36.1Encounter Order PAGEREF _Toc321346136 \h 1836.36.2Encounter Recommended PAGEREF _Toc321346137 \h 1866.37Plan of Care Activity Observation PAGEREF _Toc321346138 \h 1896.37.1Care Goal PAGEREF _Toc321346139 \h 1896.37.2Functional Status Order PAGEREF _Toc321346140 \h 1926.37.3Functional Status Recommended PAGEREF _Toc321346141 \h 1956.37.4Laboratory Test Order PAGEREF _Toc321346142 \h 1986.37.5Laboratory Test Recommended PAGEREF _Toc321346143 \h 2016.37.6Physical Exam Order PAGEREF _Toc321346144 \h 2046.37.7Physical Exam Recommended PAGEREF _Toc321346145 \h 2076.38Plan of Care Activity Procedure PAGEREF _Toc321346146 \h 2106.38.1Procedure Order PAGEREF _Toc321346147 \h 2106.38.2Procedure Recommended PAGEREF _Toc321346148 \h 2146.39Plan of Care Activity Supply PAGEREF _Toc321346149 \h 2176.39.1Device Order PAGEREF _Toc321346150 \h 2176.39.2Device Recommended PAGEREF _Toc321346151 \h 2206.40Precondition for Substance Administration PAGEREF _Toc321346152 \h 2236.41Problem Observation PAGEREF _Toc321346153 \h 2246.41.1Diagnosis Active PAGEREF _Toc321346154 \h 2276.41.2Diagnosis Inactive PAGEREF _Toc321346155 \h 2316.41.3Diagnosis Resolved PAGEREF _Toc321346156 \h 2346.41.4Symptom Active PAGEREF _Toc321346157 \h 2386.41.5Symptom Assessed PAGEREF _Toc321346158 \h 2416.41.6Symptom Inactive PAGEREF _Toc321346159 \h 2446.41.7Symptom Resolved PAGEREF _Toc321346160 \h 2476.42Problem Status PAGEREF _Toc321346161 \h 2506.42.1Problem Status Active PAGEREF _Toc321346162 \h 2526.42.2Problem Status Inactive PAGEREF _Toc321346163 \h 2526.42.3Problem Status Resolved PAGEREF _Toc321346164 \h 2536.43Procedure Activity Act PAGEREF _Toc321346165 \h 2546.43.1Intervention Order PAGEREF _Toc321346166 \h 2596.43.2Intervention Performed PAGEREF _Toc321346167 \h 2616.43.3Intervention Recommended PAGEREF _Toc321346168 \h 2646.43.4Intervention Result PAGEREF _Toc321346169 \h 2686.44Procedure Activity Observation PAGEREF _Toc321346170 \h 2716.44.1Diagnostic Study Performed PAGEREF _Toc321346171 \h 2766.44.2Physical Exam Performed PAGEREF _Toc321346172 \h 2796.45Procedure Activity Procedure PAGEREF _Toc321346173 \h 2826.45.1Device Applied PAGEREF _Toc321346174 \h 2876.45.2Procedure Performed PAGEREF _Toc321346175 \h 2906.45.3Procedure Result PAGEREF _Toc321346176 \h 2936.46Procedure Adverse Event PAGEREF _Toc321346177 \h 2976.47Procedure Intolerance PAGEREF _Toc321346178 \h 3006.48Product Instance PAGEREF _Toc321346179 \h 3036.49Provider Care Experience PAGEREF _Toc321346180 \h 3046.50Provider Preference PAGEREF _Toc321346181 \h 3076.51Radiation Dosage and Duration PAGEREF _Toc321346182 \h 3106.52Reaction Observation PAGEREF _Toc321346183 \h 3116.52.1Reaction PAGEREF _Toc321346184 \h 3146.53Reason PAGEREF _Toc321346185 \h 3166.54Reporting Parameters Act PAGEREF _Toc321346186 \h 3186.55Result Observation PAGEREF _Toc321346187 \h 3186.55.1Functional Status Result PAGEREF _Toc321346188 \h 3216.55.2Laboratory Test Result PAGEREF _Toc321346189 \h 3236.55.3Physical Exam Finding PAGEREF _Toc321346190 \h 3256.55.4Result PAGEREF _Toc321346191 \h 3276.56Risk Category Assessment PAGEREF _Toc321346192 \h 3286.57Service Delivery Location PAGEREF _Toc321346193 \h 3306.58Severity Observation PAGEREF _Toc321346194 \h 3326.59Status PAGEREF _Toc321346195 \h 3347Supporting Templates PAGEREF _Toc321346196 \h 3367.1Facility Location PAGEREF _Toc321346197 \h 3367.2Transfer From PAGEREF _Toc321346198 \h 3387.3Transfer To PAGEREF _Toc321346199 \h 3398References PAGEREF _Toc321346200 \h 341Appendix A —QDM to QRDA MappiNG Table PAGEREF _Toc321346201 \h 342Appendix B —Acronyms and Abbreviations PAGEREF _Toc321346202 \h 348Appendix C —Change Log (r1 vs R2) PAGEREF _Toc321346203 \h 349Appendix D —Document and Section Codes?(Non-normative) PAGEREF _Toc321346204 \h 350Appendix E —Template IDs Used in this Guide PAGEREF _Toc321346205 \h 351Appendix F —Summary of Vocabularies PAGEREF _Toc321346206 \h 365Appendix G —Summary of Single-Value Bindings PAGEREF _Toc321346207 \h 366Appendix H —Previously Published Templates PAGEREF _Toc321346208 \h 367Appendix I —QRDA Category II Report Draft PAGEREF _Toc321346209 \h 368Header Constraints PAGEREF _Toc321346210 \h 368Header Attributes PAGEREF _Toc321346211 \h 368Participants PAGEREF _Toc321346212 \h 369Body Constraints PAGEREF _Toc321346213 \h 372Section Constraints PAGEREF _Toc321346214 \h 375Reporting Parameters Section PAGEREF _Toc321346215 \h 375Measure Section PAGEREF _Toc321346216 \h 376Appendix J —QRDA Category III Report Draft PAGEREF _Toc321346217 \h 380Header Constraints PAGEREF _Toc321346218 \h 380Header Attributes PAGEREF _Toc321346219 \h 380Participants PAGEREF _Toc321346220 \h 381Body Constraints PAGEREF _Toc321346221 \h 383Section Constraints PAGEREF _Toc321346222 \h 386Reporting Parameters Section PAGEREF _Toc321346223 \h 386Measure Section PAGEREF _Toc321346224 \h 388Table of Figures TOC \c "Figure" Figure 1: Overview of quality framework PAGEREF _Toc321346227 \h 24Figure 2: Constraints format example PAGEREF _Toc321346228 \h 27Figure 3: Constraints format – only one allowed PAGEREF _Toc321346229 \h 29Figure 4: Constraints format – only one like this allowed PAGEREF _Toc321346230 \h 29Figure 5: Binding to a single code PAGEREF _Toc321346231 \h 29Figure 6: XML expression of a single-code binding PAGEREF _Toc321346232 \h 30Figure 7: Translation code example PAGEREF _Toc321346233 \h 30Figure 8: nullFlavor example PAGEREF _Toc321346234 \h 30Figure 9: Attribute required PAGEREF _Toc321346235 \h 31Figure 10: Allowed nullFlavors when element is required (with xml examples) PAGEREF _Toc321346236 \h 31Figure 11: nullFlavor explicitly disallowed PAGEREF _Toc321346237 \h 32Figure 12: Unknown medication example PAGEREF _Toc321346238 \h 32Figure 13: Unknown medication use of anticoagulant drug example PAGEREF _Toc321346239 \h 33Figure 14: No known medications example PAGEREF _Toc321346240 \h 33Figure 15: Asserting an act did not occur PAGEREF _Toc321346241 \h 34Figure 16: XML document example PAGEREF _Toc321346242 \h 35Figure 17: XPath expression example PAGEREF _Toc321346243 \h 35Figure 18: ClinicalDocument example PAGEREF _Toc321346244 \h 35Figure 19: Prototypic quality data element PAGEREF _Toc321346245 \h 39Figure 20: Relationship between QDM, eMeasure, and QRDA PAGEREF _Toc321346246 \h 40Figure 21: TemplateId construction in a QRDA Category I instance PAGEREF _Toc321346247 \h 42Figure 22: Fully formed templateId in a QRDA Category I instance PAGEREF _Toc321346248 \h 48Figure 23: US realm header example PAGEREF _Toc321346249 \h 51Figure 24: effectiveTime with timezone example PAGEREF _Toc321346250 \h 51Figure 25: recordTarget example PAGEREF _Toc321346251 \h 61Figure 26: Person author example PAGEREF _Toc321346252 \h 64Figure 27: Device author example PAGEREF _Toc321346253 \h 64Figure 28: dataEnterer example PAGEREF _Toc321346254 \h 66Figure 29: Informant with assignedEntity example PAGEREF _Toc321346255 \h 67Figure 30: Custodian example PAGEREF _Toc321346256 \h 68Figure 31: informationRecipient example PAGEREF _Toc321346257 \h 69Figure 32: legalAuthenticator example PAGEREF _Toc321346258 \h 71Figure 33: Authenticator example PAGEREF _Toc321346259 \h 72Figure 34: Participant example for a supporting person PAGEREF _Toc321346260 \h 74Figure 35: Consent example PAGEREF _Toc321346261 \h 75Figure 36: realmCode Category?II example PAGEREF _Toc321346262 \h 368Figure 37: ClinicalDocument/templateId Category II example PAGEREF _Toc321346263 \h 368Figure 38: Null flavor recordTarget Category?II example PAGEREF _Toc321346264 \h 369Figure 39: AssignedAuthor as a processing entity Category?II example PAGEREF _Toc321346265 \h 369Figure 40: Informant Category?II example PAGEREF _Toc321346266 \h 370Figure 41: Custodian Category?II example PAGEREF _Toc321346267 \h 370Figure 42: legalAuthenticator Category?II example PAGEREF _Toc321346268 \h 371Figure 43: Category?II/III use of Measure Set and Measure sections PAGEREF _Toc321346269 \h 373Figure 44: Sample QRDA Category?II Patient List Report PAGEREF _Toc321346270 \h 374Figure 45: Reporting parameters section Catgory II example PAGEREF _Toc321346271 \h 376Figure 46: Measure section Category?II example PAGEREF _Toc321346272 \h 378Figure 47: realmCode Category?III example PAGEREF _Toc321346273 \h 380Figure 48: ClinicalDocument/templateId Category III example PAGEREF _Toc321346274 \h 380Figure 49: Null flavor recordTarget Category?III example PAGEREF _Toc321346275 \h 381Figure 50: AssignedAuthor as a processing entity Category?III example PAGEREF _Toc321346276 \h 381Figure 51: Informant Category?III example PAGEREF _Toc321346277 \h 382Figure 52: Custodian Category?III example PAGEREF _Toc321346278 \h 382Figure 53: legalAuthenticator Category?III example PAGEREF _Toc321346279 \h 383Figure 54: Sample Category?III QRDA Calculated Summary Report PAGEREF _Toc321346280 \h 385Figure 55: Reporting parameters section Category?III example PAGEREF _Toc321346281 \h 387Figure 56: Act/performer Category?III example representing a provider with which to group data PAGEREF _Toc321346282 \h 390Figure 57: Location Category?III example representing a clinic with which to group data PAGEREF _Toc321346283 \h 390Figure 58: entryRelationship Category?III example referring to the reporting parameters PAGEREF _Toc321346284 \h 390Figure 59: entryRelationship Category?III observation of an integer value as a numerator example PAGEREF _Toc321346285 \h 391Table of Tables TOC \c "Table" Table 1: Content of the Package PAGEREF _Toc321346286 \h 36Table 2: Union of Quality Data Types from eMeasures of Interest PAGEREF _Toc321346287 \h 47Table 3: QDM HQMF Pattern to CDA Mapping Table PAGEREF _Toc321346288 \h 47Table 4: Basic Confidentiality Kind Value Set PAGEREF _Toc321346289 \h 50Table 5: Language Value Set (excerpt) PAGEREF _Toc321346290 \h 50Table 6: Telecom Use (US Realm Header) Value Set PAGEREF _Toc321346291 \h 55Table 7: Administrative Gender (HL7) Value Set PAGEREF _Toc321346292 \h 55Table 8: Marital Status Value Set PAGEREF _Toc321346293 \h 56Table 9: Religious Affiliation Value Set (excerpt) PAGEREF _Toc321346294 \h 56Table 10: Race Value Set (excerpt) PAGEREF _Toc321346295 \h 57Table 11: Ethnicity Value Set PAGEREF _Toc321346296 \h 57Table 12: Personal Relationship Role Type Value Set (excerpt) PAGEREF _Toc321346297 \h 58Table 13: State Value Set (excerpt) PAGEREF _Toc321346298 \h 58Table 14: Postal Code Value Set (excerpt) PAGEREF _Toc321346299 \h 59Table 15: Country Value Set (excerpt) PAGEREF _Toc321346300 \h 59Table 16: Language Ability Value Set PAGEREF _Toc321346301 \h 60Table 17: Language Ability Proficiency Value Set PAGEREF _Toc321346302 \h 60Table 18: IND Role classCode Value Set PAGEREF _Toc321346303 \h 73Table 19: PostalAddressUse Value Set PAGEREF _Toc321346304 \h 76Table 20: EntityNameUse Value Set PAGEREF _Toc321346305 \h 78Table 21: EntityPersonNamePartQualifier Value Set PAGEREF _Toc321346306 \h 78Table 1: QRDA Category I Framework Contexts PAGEREF _Toc321346307 \h 79Table 22: Participant Scenarios PAGEREF _Toc321346308 \h 81Table 3: QDM-Based QRDA Contexts PAGEREF _Toc321346309 \h 82Table 23: Measure Section Contexts PAGEREF _Toc321346310 \h 84Table 24: Measure Section QDM Contexts PAGEREF _Toc321346311 \h 84Table 25: Patient Data Section Contexts PAGEREF _Toc321346312 \h 85Table 26: Patient Data Section QDM Contexts PAGEREF _Toc321346313 \h 86Table 27: Reporting Parameters Section Contexts PAGEREF _Toc321346314 \h 90Table 28: Age Observation Contexts PAGEREF _Toc321346315 \h 91Table 29: Age Observation Constraints Overview PAGEREF _Toc321346316 \h 91Table 30: Communication from Patient to Provider Contexts PAGEREF _Toc321346317 \h 92Table 31: Communication from Patient to Provider Constraints Overview PAGEREF _Toc321346318 \h 93Table 32: Communication from Provider to Patient Contexts PAGEREF _Toc321346319 \h 95Table 33: Communication from Provider to Patient Constraints Overview PAGEREF _Toc321346320 \h 96Table 34: Communication from Provider to Provider Contexts PAGEREF _Toc321346321 \h 98Table 35: Communication from Provider to Provider Constraints Overview PAGEREF _Toc321346322 \h 99Table 36: Device Adverse Event Contexts PAGEREF _Toc321346323 \h 101Table 37: Device Adverse Event Constraints Overview PAGEREF _Toc321346324 \h 102Table 38: Device Allergy Contexts PAGEREF _Toc321346325 \h 104Table 39: Device Allergy Constraints Overview PAGEREF _Toc321346326 \h 105Table 40: Device Intolerance Contexts PAGEREF _Toc321346327 \h 107Table 41: Device Intolerance Constraints Overview PAGEREF _Toc321346328 \h 108Table 42: Diagnostic Study Adverse Event Contexts PAGEREF _Toc321346329 \h 110Table 43: Diagnostic Study Adverse Event Constraints Overview PAGEREF _Toc321346330 \h 111Table 44: Diagnostic Study Intolerance Contexts PAGEREF _Toc321346331 \h 113Table 45: Diagnostic Study Intolerance Constraints Overview PAGEREF _Toc321346332 \h 114Table 46: Drug Vehicle Contexts PAGEREF _Toc321346333 \h 116Table 47: Drug Vehicle Constraints Overview PAGEREF _Toc321346334 \h 116Table 48: eMeasure Reference QDM Contexts PAGEREF _Toc321346335 \h 117Table 49: eMeasure Reference QDM Constraints Overview PAGEREF _Toc321346336 \h 118Table 50: Encounter Activities Contexts PAGEREF _Toc321346337 \h 120Table 51: Encounter Activities Constraints Overview PAGEREF _Toc321346338 \h 121Table 52: Encounter Active Contexts PAGEREF _Toc321346339 \h 123Table 53: Encounter Active Constraints Overview PAGEREF _Toc321346340 \h 124Table 54: Encounter Performed Contexts PAGEREF _Toc321346341 \h 126Table 55: Encounter Performed Constraints Overview PAGEREF _Toc321346342 \h 127Table 56: Functional Status Performed Contexts PAGEREF _Toc321346343 \h 129Table 57: Functional Status Performed Constraints Overview PAGEREF _Toc321346344 \h 130Table 58: Health Status Observation Contexts PAGEREF _Toc321346345 \h 132Table 59: Health Status Observation Constraints Overview PAGEREF _Toc321346346 \h 132Table 60: Immunization Medication Information Contexts PAGEREF _Toc321346347 \h 133Table 61: Immunization Medication Information Constraints Overview PAGEREF _Toc321346348 \h 134Table 62: Incision Datetime Contexts PAGEREF _Toc321346349 \h 135Table 63: Incision Datetime Constraints Overview PAGEREF _Toc321346350 \h 136Table 64: Indication Contexts PAGEREF _Toc321346351 \h 137Table 65: Indication Constraints Overview PAGEREF _Toc321346352 \h 138Table 66: Instructions Contexts PAGEREF _Toc321346353 \h 139Table 67: Instructions Constraints Overview PAGEREF _Toc321346354 \h 140Table 68: Intervention Adverse Event Contexts PAGEREF _Toc321346355 \h 141Table 69: Intervention Adverse Event Constraints Overview PAGEREF _Toc321346356 \h 142Table 70: Intervention Intolerance Contexts PAGEREF _Toc321346357 \h 144Table 71: Intervention Intolerance Constraints Overview PAGEREF _Toc321346358 \h 145Table 72: Laboratory Test Adverse Event Contexts PAGEREF _Toc321346359 \h 147Table 73: Laboratory Test Adverse Event Constraints Overview PAGEREF _Toc321346360 \h 148Table 74: Laboratory Test Intolerance Contexts PAGEREF _Toc321346361 \h 150Table 75: Laboratory Test Intolerance Constraints Overview PAGEREF _Toc321346362 \h 150Table 76: Laboratory Test Performed Contexts PAGEREF _Toc321346363 \h 150Table 77: Laboratory Test Performed Constraints Overview PAGEREF _Toc321346364 \h 151Table 78: Measure Reference Contexts PAGEREF _Toc321346365 \h 152Table 79: Measure Reference Constraints Overview PAGEREF _Toc321346366 \h 153Table 80: Medication Activity Contexts PAGEREF _Toc321346367 \h 154Table 81: Medication Activity Constraints Overview PAGEREF _Toc321346368 \h 155Table 82: Medication Active Contexts PAGEREF _Toc321346369 \h 159Table 83: Medication Active Constraints Overview PAGEREF _Toc321346370 \h 160Table 84: Medication Administered Contexts PAGEREF _Toc321346371 \h 161Table 85: Medication Administered Constraints Overview PAGEREF _Toc321346372 \h 162Table 88: Medication Dispense Contexts PAGEREF _Toc321346373 \h 164Table 89: Medication Dispense Constraints Overview PAGEREF _Toc321346374 \h 165Table 90: Medication Information Contexts PAGEREF _Toc321346375 \h 167Table 91: Medication Information Constraints Overview PAGEREF _Toc321346376 \h 167Table 92: Medication Supply Order Contexts PAGEREF _Toc321346377 \h 168Table 93: Medication Supply Order Constraints Overview PAGEREF _Toc321346378 \h 169Table 94: Ordinality Contexts PAGEREF _Toc321346379 \h 171Table 95: Ordinality Constraints Overview PAGEREF _Toc321346380 \h 171Table 96: Patient Care Experience Contexts PAGEREF _Toc321346381 \h 172Table 97: Patient Care Experience Constraints Overview PAGEREF _Toc321346382 \h 173Table 98: Patient Characteristic Clinical Trial Participant Contexts PAGEREF _Toc321346383 \h 174Table 99: Patient Characteristic Clinical Trial Participant Constraints Overview PAGEREF _Toc321346384 \h 175Table 100: Patient Characteristic Expired Contexts PAGEREF _Toc321346385 \h 176Table 101: Patient Characteristic Expired Constraints Overview PAGEREF _Toc321346386 \h 177Table 102: Patient Characteristic Payer Constraints Overview PAGEREF _Toc321346387 \h 179Table 103: Patient Preference Contexts PAGEREF _Toc321346388 \h 180Table 104: Patient Preference Constraints Overview PAGEREF _Toc321346389 \h 181Table 105: Plan of Care Activity Encounter Constraints Overview PAGEREF _Toc321346390 \h 182Table 106: Encounter Order Contexts PAGEREF _Toc321346391 \h 183Table 107: Encounter Order Constraints Overview PAGEREF _Toc321346392 \h 184Table 108: Encounter Recommended Contexts PAGEREF _Toc321346393 \h 186Table 109: Encounter Recommended Constraints Overview PAGEREF _Toc321346394 \h 187Table 110: Plan of Care Activity Observation Constraints Overview PAGEREF _Toc321346395 \h 189Table 111: Care Goal Contexts PAGEREF _Toc321346396 \h 189Table 112: Care Goal Constraints Overview PAGEREF _Toc321346397 \h 190Table 113: Functional Status Order Contexts PAGEREF _Toc321346398 \h 192Table 114: Functional Status Order Constraints Overview PAGEREF _Toc321346399 \h 193Table 115: Functional Status Recommended Contexts PAGEREF _Toc321346400 \h 195Table 116: Functional Status Recommended Constraints Overview PAGEREF _Toc321346401 \h 196Table 117: Laboratory Test Order Contexts PAGEREF _Toc321346402 \h 198Table 118: Laboratory Test Order Constraints Overview PAGEREF _Toc321346403 \h 199Table 119: Laboratory Test Recommended Contexts PAGEREF _Toc321346404 \h 201Table 120: Laboratory Test Recommended Constraints Overview PAGEREF _Toc321346405 \h 202Table 121: Physical Exam Order Contexts PAGEREF _Toc321346406 \h 204Table 122: Physical Exam Order Constraints Overview PAGEREF _Toc321346407 \h 205Table 123: Physical Exam Recommended Contexts PAGEREF _Toc321346408 \h 207Table 124: Physical Exam Recommended Constraints Overview PAGEREF _Toc321346409 \h 208Table 125: Plan of Care Activity Procedure Constraints Overview PAGEREF _Toc321346410 \h 210Table 126: Procedure Order Contexts PAGEREF _Toc321346411 \h 210Table 127: Procedure Order Constraints Overview PAGEREF _Toc321346412 \h 212Table 128: Procedure Recommended Contexts PAGEREF _Toc321346413 \h 214Table 129: Procedure Recommended Constraints Overview PAGEREF _Toc321346414 \h 215Table 130: Plan of Care Activity Supply Constraints Overview PAGEREF _Toc321346415 \h 217Table 131: Device Order Contexts PAGEREF _Toc321346416 \h 217Table 132: Device Order Constraints Overview PAGEREF _Toc321346417 \h 218Table 133: Device Recommended Contexts PAGEREF _Toc321346418 \h 220Table 134: Device Recommended Constraints Overview PAGEREF _Toc321346419 \h 221Table 135: Precondition for Substance Administration Contexts PAGEREF _Toc321346420 \h 223Table 136: Precondition for Substance Administration Constraints Overview PAGEREF _Toc321346421 \h 224Table 137: Problem Observation Contexts PAGEREF _Toc321346422 \h 224Table 138: Problem Observation Constraints Overview PAGEREF _Toc321346423 \h 225Table 139: Diagnosis Active Contexts PAGEREF _Toc321346424 \h 227Table 140: Diagnosis Active Constraints Overview PAGEREF _Toc321346425 \h 228Table 141: Diagnosis Inactive Contexts PAGEREF _Toc321346426 \h 231Table 142: Diagnosis Inactive Constraints Overview PAGEREF _Toc321346427 \h 232Table 143: Diagnosis Resolved Contexts PAGEREF _Toc321346428 \h 234Table 144: Diagnosis Resolved Constraints Overview PAGEREF _Toc321346429 \h 236Table 145: Symptom Active Contexts PAGEREF _Toc321346430 \h 238Table 146: Symptom Active Constraints Overview PAGEREF _Toc321346431 \h 239Table 147: Symptom Assessed Contexts PAGEREF _Toc321346432 \h 241Table 148: Symptom Assessed Constraints Overview PAGEREF _Toc321346433 \h 242Table 149: Symptom Inactive Contexts PAGEREF _Toc321346434 \h 244Table 150: Symptom Inactive Constraints Overview PAGEREF _Toc321346435 \h 245Table 151: Symptom Resolved Contexts PAGEREF _Toc321346436 \h 247Table 152: Symptom Resolved Constraints Overview PAGEREF _Toc321346437 \h 248Table 153: Problem Status Contexts PAGEREF _Toc321346438 \h 250Table 154: Problem Status Constraints Overview PAGEREF _Toc321346439 \h 251Table 155: Problem Status Active Contexts PAGEREF _Toc321346440 \h 252Table 156: Problem Status Active Constraints Overview PAGEREF _Toc321346441 \h 252Table 157: Problem Status Inactive Contexts PAGEREF _Toc321346442 \h 252Table 158: Problem Status Inactive Constraints Overview PAGEREF _Toc321346443 \h 253Table 159: Problem Status Resolved Contexts PAGEREF _Toc321346444 \h 253Table 160: Problem Status Resolved Constraints Overview PAGEREF _Toc321346445 \h 253Table 161: Procedure Activity Act Contexts PAGEREF _Toc321346446 \h 254Table 162: Procedure Activity Act Constraints Overview PAGEREF _Toc321346447 \h 255Table 163: Intervention Order Contexts PAGEREF _Toc321346448 \h 259Table 164: Intervention Order Constraints Overview PAGEREF _Toc321346449 \h 260Table 165: Intervention Performed Contexts PAGEREF _Toc321346450 \h 261Table 166: Intervention Performed Constraints Overview PAGEREF _Toc321346451 \h 263Table 167: Intervention Recommended Contexts PAGEREF _Toc321346452 \h 264Table 168: Intervention Recommended Constraints Overview PAGEREF _Toc321346453 \h 266Table 169: Intervention Result Contexts PAGEREF _Toc321346454 \h 268Table 170: Intervention Result Constraints Overview PAGEREF _Toc321346455 \h 269Table 171: Procedure Activity Observation Contexts PAGEREF _Toc321346456 \h 271Table 172: Procedure Activity Observation Constraints Overview PAGEREF _Toc321346457 \h 272Table 173: Diagnostic Study Performed Contexts PAGEREF _Toc321346458 \h 276Table 174: Diagnostic Study Performed Constraints Overview PAGEREF _Toc321346459 \h 277Table 175: Physical Exam Performed Contexts PAGEREF _Toc321346460 \h 279Table 176: Physical Exam Performed Constraints Overview PAGEREF _Toc321346461 \h 280Table 177: Procedure Activity Procedure Contexts PAGEREF _Toc321346462 \h 282Table 178: Procedure Activity Procedure Constraints Overview PAGEREF _Toc321346463 \h 283Table 179: Device Applied Contexts PAGEREF _Toc321346464 \h 287Table 180: Device Applied Constraints Overview PAGEREF _Toc321346465 \h 288Table 181: Procedure Performed Contexts PAGEREF _Toc321346466 \h 290Table 182: Procedure Performed Constraints Overview PAGEREF _Toc321346467 \h 291Table 183: Procedure Result Contexts PAGEREF _Toc321346468 \h 293Table 184: Procedure Result Constraints Overview PAGEREF _Toc321346469 \h 294Table 185: Procedure Adverse Event Contexts PAGEREF _Toc321346470 \h 297Table 186: Procedure Adverse Event Constraints Overview PAGEREF _Toc321346471 \h 298Table 187: Procedure Intolerance Contexts PAGEREF _Toc321346472 \h 300Table 188: Procedure Intolerance Constraints Overview PAGEREF _Toc321346473 \h 301Table 189: Product Instance Contexts PAGEREF _Toc321346474 \h 303Table 190: Product Instance Constraints Overview PAGEREF _Toc321346475 \h 304Table 191: Provider Care Experience Contexts PAGEREF _Toc321346476 \h 304Table 192: Provider Care Experience Constraints Overview PAGEREF _Toc321346477 \h 305Table 193: Provider Preference Contexts PAGEREF _Toc321346478 \h 307Table 194: Provider Preference Constraints Overview PAGEREF _Toc321346479 \h 309Table 195: Radiation Dosage and Duration Contexts PAGEREF _Toc321346480 \h 310Table 196: Radiation Dosage and Duration Constraints Overview PAGEREF _Toc321346481 \h 310Table 197: Reaction Observation Contexts PAGEREF _Toc321346482 \h 311Table 198: Reaction Observation Constraints Overview PAGEREF _Toc321346483 \h 312Table 199: Reaction Contexts PAGEREF _Toc321346484 \h 314Table 200: Reaction Constraints Overview PAGEREF _Toc321346485 \h 315Table 201: Reason Contexts PAGEREF _Toc321346486 \h 316Table 202: Reason Constraints Overview PAGEREF _Toc321346487 \h 317Table 203: Reporting Parameters Act Contexts PAGEREF _Toc321346488 \h 318Table 204: Reporting Parameters Act Constraints Overview PAGEREF _Toc321346489 \h 318Table 205: Result Observation Constraints Overview PAGEREF _Toc321346490 \h 319Table 206: Functional Status Result Contexts PAGEREF _Toc321346491 \h 321Table 207: Functional Status Result Constraints Overview PAGEREF _Toc321346492 \h 322Table 208: Laboratory Test Result Contexts PAGEREF _Toc321346493 \h 323Table 209: Laboratory Test Result Constraints Overview PAGEREF _Toc321346494 \h 324Table 210: Physical Exam Finding Contexts PAGEREF _Toc321346495 \h 325Table 211: Physical Exam Finding Constraints Overview PAGEREF _Toc321346496 \h 326Table 212: Result Contexts PAGEREF _Toc321346497 \h 327Table 213: Result Constraints Overview PAGEREF _Toc321346498 \h 327Table 214: Risk Category Assessment Contexts PAGEREF _Toc321346499 \h 328Table 215: Risk Category Assessment Constraints Overview PAGEREF _Toc321346500 \h 329Table 216: Service Delivery Location Contexts PAGEREF _Toc321346501 \h 330Table 217: Service Delivery Location Constraints Overview PAGEREF _Toc321346502 \h 331Table 218: Severity Observation Contexts PAGEREF _Toc321346503 \h 332Table 219: Severity Observation Constraints Overview PAGEREF _Toc321346504 \h 333Table 220: Status Contexts PAGEREF _Toc321346505 \h 334Table 221: Status Constraints Overview PAGEREF _Toc321346506 \h 335Table 222: Facility Location Contexts PAGEREF _Toc321346507 \h 336Table 223: Facility Location Constraints Overview PAGEREF _Toc321346508 \h 337Table 224: Transfer From Contexts PAGEREF _Toc321346509 \h 338Table 225: Transfer From Constraints Overview PAGEREF _Toc321346510 \h 339Table 226: Transfer To Contexts PAGEREF _Toc321346511 \h 339Table 227: Transfer To Constraints Overview PAGEREF _Toc321346512 \h 340Table 228: HQMF QDM Pattern to CDA Template Mapping Table PAGEREF _Toc321346513 \h 343Table 229: Document and Section Codes PAGEREF _Toc321346514 \h 350Table 230: Alphabetical List of Template IDs in This Guide PAGEREF _Toc321346515 \h 351Table 231: Hierarchical List of Template IDs in This Guide PAGEREF _Toc321346516 \h 354Table 232: List of Vocabularies PAGEREF _Toc321346517 \h 365Table 233: Single-value Bindings from SNOMED CT PAGEREF _Toc321346518 \h 366Table 234: Previously Published Templates (Closed for Ballot) PAGEREF _Toc321346519 \h 367Table 235: QRDA Category?II/III Participant Scenarios PAGEREF _Toc321346520 \h 372Introduction"If you cannot measure it, you cannot improve it."Lord Kelvin (1824-1907)PurposeThis document describes constraints on the Clinical Document Architecture Release 2 (CDA R2) header and body elements for Quality Reporting Document Architecture (QRDA) documents. The Institute of Medicine (IOM) definition of quality is: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. For care quality to be evaluated, it must be standardized and communicated to the appropriate organizations.QRDA is a document format that provides a standard structure with which to report quality measure data to organizations that will analyze and interpret the data. Quality measurement in health care is complex. Accurate, interpretable data efficiently gathered and communicated is key in correctly assessing that quality care is deliveredAudienceThe audience for this document includes software developers and implementers with reporting capabilities within their electronic health record (EHR) systems; developers and analysts in receiving institutions; and local, regional, and national health information exchange networks who wish to create and/or process CDA reporting documents created according to this specification.ApproachOverall, the approach taken here is consistent with balloted implementation guides for CDA. These publications view the ultimate implementation specification as a series of layered constraints. CDA itself is a set of constraints on the Health Level Seven (HL7) Reference Information Model (RIM). Implementation guides such as this add constraints to CDA through conformance statements that further define and restrict the sequence and cardinality of CDA objects and the vocabulary sets for coded elements.This implementation guide is release 2 (R2) of the QRDA Draft Standard for Trial Use (DSTU). The Background and Current Project sections describe the development of the DSTU.CDA R2CDA R2 is “… a document markup standard that specifies the structure and semantics of ‘clinical documents’ for the purpose of exchange” [CDA R2, Section?1.1; see References]. Clinical documents, according to CDA, have six characteristics:PersistenceStewardshipPotential for authenticationContextWholenessHuman readabilityCDA defines a header for classification and management and a document body that carries the clinical record. While the header metadata are prescriptive and designed for consistency across all instances, the body is highly generic, leaving the designation of semantic requirements to implementation guides such as this one.BackgroundIn early pilots of the QRDA initiative, participating organizations confirmed the feasibility of using the HL7 Clinical Document Architecture (CDA) as the foundation for the QRDA specification. The participants concluded that CDA provided the technical underpinnings for communicating pediatric and adult quality measures for both inpatient and ambulatory care settings.In later pilots, the HL7 Child Health Work Group and the Structured Documents Work Group developed a QRDA DSTU, Release 1 (R1), first published in September 2008.The QRDA DSTU R1 defined three categories of quality reporting. A QRDA Category I – Single Patient Report, a QRDA Category II – Patient List Report, and a QRDA Category III – Calculated Report. Only the QRDA Category?I report was balloted, while the sections of the DSTU that define QRDA Category?II and Category?III reports were for comment only. The concept of the report types at the time of ballot and publication are described below.QRDA Category?I – Single Patient ReportA QRDA Category?I report is an individual-patient-level quality report. Each report contains quality data for one patient for one or more quality measures, where the data elements in the report are defined by the particular measure(s) being reported on. A QRDA Category?I report contains raw applicable patient data. When pooled and analyzed, each report contributes the quality data necessary to calculate population measure metrics.QRDA R1 defined the CDA framework for quality reports and a method for referencing a quality measure. The DSTU recommended the re-use of Continuity of Care Document (CCD) clinical statements to send measure data elements. Two measure-specific implementation guides were created.QRDA Category II – Patient List ReportA QRDA Category?II report is a multi-patient-level quality report. Each report contains quality data for a set of patients for one or more quality measures, where the data elements in the report are defined by the particular measure(s) being reported on.Whereas a QRDA Category?I report contains only raw applicable patient data, a QRDA Category?II report includes flags for each patient indicating whether the patient qualifies for a measure’s numerator, denominator, exclusion, or other aggregate data element. These qualifications can be pooled and counted to create the QRDA Category?III report.The QRDA Category II Draft appendix contains the header, body, and section constraints for the Patient List Report from QRDA R1 (March 2009).QRDA Category?III – Calculated ReportA QRDA Category?III report is an aggregate quality report. Each report contains calculated summary data for one or more measures for a specified population of patients within a particular health system over a specific period of time.Data needed to generate QRDA Category?II and QRDA Category?III reports must be included in the collected QRDA Category?I reports, as the processing entity will not have access to additional data sources.The QRDA Category III Draft appendix contains the header, body, and section constraints for the Calculated Report from the QRDA R1 (March 2009).Relationship to Health Quality Measures Format: eMeasuresThe HL7 Health Quality Measures Format (HQMF) is a standard for representing a health quality measure as an electronic document. A quality measure is a quantitative tool that provides an indication of an individual or organization’s performance in relation to a specified process or outcome via the measurement of an action, process or outcome of clinical care. Quality measures are often derived from clinical guidelines and are designed to determine whether the appropriate care has been provided given a set of clinical criteria and an evidence base. Quality measures are also often referred to as performance measures or quality indicators. A quality measure expressed in HQMF format is referred to as an "eMeasure".Measure developers, often drawing upon available evidence devise measureable parameters to gauge the quality of care in a particular area. These measureable parameters are assembled into quality measures, which are then expressible as eMeasures. eMeasures may be understood by providers to guide optimal care, and to guide collection of EHR and other data, which is then assembled into QRDA quality reports and submitted to quality or other organizations. This relationship is summarized in the Overview of quality framework figure.While there is no prerequisite that a QRDA must be generated based on an eMeasure, the QRDA standard is written to tightly align with HQMF.Figure SEQ Figure \* ARABIC 1: Overview of quality frameworkCurrent ProjectSince the creation of QRDA R1 there has been an increase in understanding of the end to end electronic quality reporting process. HL7 created a standard, eMeasure: Representation of the Health Quality Measures Format (HQMF). Using this standard, quality measures are redefined using HL7 RIM semantics thus expressing the measures using a well-vetted model. This process is called “re-tooling”. Formally expressed criteria within an eMeasure can be converted into queries, expressed against an EHR.The current project simplifies the QRDA framework and correlates the QRDA CDA with the HQMF standard. QRDA R2 re-uses the US Realm header from the Consolidated CDA implementation guide. QRDA R2 will not require the nesting of sections and no longer recommends a measure set section. At the time of development of QRDA R1, measures were referenced using an act/code. QRDA R2 references the measure through reference to an externalDocument. The externalDocument/ids and version numbers are used to reference the measure. The QRDA R2 provides guidance such that conformant measure specific QRDA implementation guides can be developed through the HL7 process, by quality organizations, provider organization and other quality stakeholder.In addition to updating the QRDA Category I DSTU, this ballot also introduces a specific QRDA Category I DSTU Implementation Guide, designed to carry data based against Meaningful Use Stage 2 quality measures expressed in HQMF format. This specific implementation guide defines CDA templates based on the National Quality Forum Quality Data Model, the same model used in the construction of Meaningful Use Stage 2 quality measures. We call this specific guide the "Quality Data Model based QRDA Implementation Guide". Rather than a specific implementation guide for each measure or set of measures, reporting organizations will be able to dynamically generate QRDA instances based on the corresponding eMeasure(s). This is described in detail in the Quality Data Model-Based QRDA IG.ScopeThis implementation guide is a conformance profile, as described in the “Refinement and Localization” section of the HL7 Version 3 Interoperability Standards. The base standard for this implementation guide is the HL7 Clinical Document Architecture, Release 2.0. As defined in that document, this implementation guide is both an annotation profile and a localization profile. It does not describe every aspect of CDA.This specification defines additional constraints on CDA used in a QRDA document in the US realm. Additional optional CDA elements, not included here, can be included and the result will be compliant with this anization of This GuideThis guide includes a set of CDA Templates, and prescribes their use within a QRDA document. The main chapters are:Chapter 2. QRDA Framework describes the QRDA Framework changes. Release 2 simplifies the QRDA framework and clarifies quality measure referencing.Chapter 3. Quality Data Model Approach to QRDA describes the relationship between the National Quality Forum’s (NQF) Quality Data Model (QDM), HQMF and QRDA. It also describes the concept of dynamic generation of QDM QRDAs.Chapter 4. Clinical-Document-Level Templates defines the document constraints that apply to QRDA Category I documents.Chapter 5. Section-Level Templates defines the section templates in a QRDA Category I document.Chapter 6. Entry-Level Templates defines the entry templates in a QDM approach to a QRDA Category I document. For every HQMF QDM pattern there is a QRDA template.Use of TemplatesWhen valued in an instance, the template identifier (templateId) signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question.Originator Responsibilities: General CaseAn originator can apply a templateId if there is a desire to assert conformance with a particular template.In the most general forms of CDA exchange, an originator need not apply a templateId for every template that an object in an instance document conforms to.Recipient Responsibilities: General CaseA recipient may reject an instance that does not contain a particular templateId (e.g., a recipient looking to only receive CCD documents can reject an instance without the appropriate templateId).A recipient may process objects in an instance document that do not contain a templateId (e.g., a recipient can process entries that contain substanceAdministration acts within a Medications section, even if the entries do not have templateIds).Conformance Conventions Used in This GuideTemplates Not Open for CommentThis implementation guide includes several templates that that have already been balloted and published and are therefore closed for comment in this ballot. These templates are indicated throughout this guide with a notation such as [Closed for comments; published December 2011] after the template name. The Previously Published Templates appendix lists these templates. If errors are found or enhancements are desired in these templates, please document them on Consolidated CDA Templates Errata or Consolidated CDA Templates Suggested Enhancements HL7 structured Document WIKI pages.Templates and Conformance StatementsConformance statements within this implementation guide are presented as constraints from a Template Database (Tdb). An algorithm converts constraints recorded in a Templates Database to a printable presentation. Each constraint is uniquely identified by an identifier at or near the end of the constraint (e.g., CONF:7345). These identifiers are persistent but not sequential.Bracketed information following each template title indicates the template type (section, observation, act, procedure, etc.), the templateId, and whether the template is open or closed. Each section and entry template in the guide includes a context table. The "Used By" column indicates which documents or sections use this template, and the "Contains Entries" column contained templates. Value set tables, where applicable, and brief XML example figures are included with most explanations.A typical template, as presented in this guide, is shown in the Constraints format example figure. The next sections describe specific aspects of conformance statements—open vs. closed statements, conformance verbs, cardinality, vocabulary conformance, containment relationships, and null flavors.16637022669500Figure SEQ Figure \* ARABIC 2: Constraints format exampleSeverity Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.8(open)]Table xxx: Severity Observation ContextsUsed By:Contains Entries:Reaction ObservationAllergy Observation This clinical statement represents the severity of the reaction to an agent. A person may manifest many symptoms …SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) STATIC (CONF:7345).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 ActMood) STATIC (CONF:7346).SHALL contain exactly one [1..1] templateId/@root="2.16.840.1.113883.10.20.22.4.8" (CONF:7347).SHALL contain exactly one [1..1] code="SEV" Severity Observation (CodeSystem: 2.16.840.1.113883.5.4 ActCode) STATIC (CONF:7349).SHOULD contain zero or one [0..1] text (CONF:7350).This text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7351).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:7378).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: 2.16.840.1.113883.5.14 ActStatus) STATIC (CONF:7352).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.3221.6.8 Problem Severity DYNAMIC (CONF:7356).SHOULD contain zero or more [0..*] interpretationCode (CONF:9117).Such interpretationCodes, if present, SHOULD contain @code, which SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) DYNAMIC (CONF:9118).Open and Closed TemplatesIn open templates, all of the features of the CDA R2 base specification are allowed except as constrained by the templates. By contrast, a closed template specifies everything that is allowed and nothing further may be included. Templates in a QRDA document are open.KeywordsThe keywords shall, should, may, need not, should not, and shall not in this document are to be interpreted as described in the HL7 Version 3 Publishing Facilitator's Guide:shall: an absolute requirement for the particular element. Where a SHALL constraint is applied to an XML element, that element must be present in an instance, but may have an exceptional value (i.e., may have a nullFlavor), unless explicitly precluded. Where a SHALL constraint is applied to an XML attribute, that attribute must be present, and must contain a conformant value.shall not: an absolute prohibition against inclusionshould/should not: best practice or recommendation. There may be valid reasons to ignore an item, but the full implications must be understood and carefully weighed before choosing a different coursemay/need not: truly optional; can be included or omitted as the author decides with no implicationsCardinalityThe cardinality indicator (0..1, 1..1, 1..*, etc.) specifies the allowable occurrences within a document instance. The cardinality indicators are interpreted with the following format “m…n” where m represents the least and n the most:0..1 zero or one1..1 exactly one1..* at least one0..* zero or more1..n at least one and not more than nWhen a constraint has subordinate clauses, the scope of the cardinality of the parent constraint must be clear. In the next figure, the constraint says exactly one participant is to be present. The subordinate constraint specifies some additional characteristics of that participant.Figure SEQ Figure \* ARABIC 3: Constraints format – only one allowed1. SHALL contain exactly one [1..1] participant (CONF:2777). a. This participant SHALL contain exactly one [1..1] @typeCode="LOC" (CodeSystem: 2.16.840.1.113883.5.90 HL7ParticipationType) (CONF:2230).In the next figure, the constraint says only one participant “like this” is to be present. Other participant elements are not precluded by this constraint.Figure SEQ Figure \* ARABIC 4: Constraints format – only one like this allowed1. SHALL contain exactly one [1..1] participant (CONF:2777) such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" (CodeSystem: 2.16.840.1.113883.5.90 HL7ParticipationType) (CONF:2230).Vocabulary ConformanceThe templates in this document use terms from several code systems. These vocabularies are defined in various supporting specifications and may be maintained by other bodies, as is the case for the LOINC? and SNOMED CT? vocabularies.Note that value-set identifiers (e.g., ValueSet 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) DYNAMIC) do not appear in CDA instances; they tie the conformance requirements of an implementation guide to the allowable codes for validation.Value-set bindings adhere to HL7 Vocabulary Working Group best practices, and include both a conformance verb (shall, should, may, etc.) and an indication of dynamic vs. static binding. Value-set constraints can be static, meaning that they are bound to a specified version of a value set, or dynamic, meaning that they are bound to the most current version of the value set. A simplified constraint, used when the binding is to a single code, includes the meaning of the code, as follows.Figure SEQ Figure \* ARABIC 5: Binding to a single code1. … code/@code="11450-4" Problem List (CodeSystem: 2.16.840.1.113883.6.1 LOINC).The notation conveys the actual code (11450-4), the code’s displayName (Problem List), the OID of the codeSystem from which the code is drawn (2.16.840.1.113883.6.1), and the codeSystemName (LOINC).HL7 Data Types Release 1 requires the codeSystem attribute unless the underlying data type is “Coded Simple” or “CS”, in which case it is prohibited. The displayName and the codeSystemName are optional, but often useful to include in an instance.The above example would be properly expressed as follows.Figure SEQ Figure \* ARABIC 6: XML expression of a single-code binding<code code="11450-4" codeSystem="2.16.840.1.113883.6.1"/><!-- or --><code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List" codeSystemName=”LOINC”/>A full discussion of the representation of vocabulary is outside the scope of this document; for more information, see the HL7 Version 3 Interoperability Standards, Normative Edition 2010 sections on Abstract Data Types and XML Data Types R1.There is a discrepancy in the implementation of translation code versus the original code between HL7 Data Types R1 and the convention agreed upon for this specification. The R1 data type requires the original code in the root. This implementation guide specifies the standard code in the root, whether it is original or a translation. This discrepancy is resolved in HL7 Data Types R2.Figure SEQ Figure \* ARABIC 7: Translation code example<code code='206525008’ displayName='neonatal necrotizing enterocolitis' standard code codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'> <translation code='NEC-1' source’s orginal code displayName='necrotizing enterocolitis' codeSystem='2.16.840.1.113883.19'/></code>Null FlavorInformation technology solutions store and manage data, but sometimes data are not available: an item may be unknown, not relevant, or not computable or measureable. In HL7, a flavor of null, or nullFlavor, describes the reason for missing data.Figure SEQ Figure \* ARABIC 8: nullFlavor example<birthTime nullFlavor=”NI”/> <!--coding a birthdate when there is no birthdate available-->Use null flavors for unknown, required, or optional attributes:NI No information. This is the most general and default null flavor.NA Not applicable. Known to have no proper value (e.g., last menstrual period for a male).UNK Unknown. A proper value is applicable, but is not known.ASKU Asked, but not known. Information was sought, but not found (e.g., the patient was asked but did not know).NAV Temporarily unavailable. The information is not available, but is expected to be available later.NASK Not asked. The patient was not asked.MSKThere is information on this item available but it has not been provided by the sender due to security, privacy, or other reasons. There may be an alternate mechanism for gaining access to this information.OTHThe actual value is not and will not be assigned a standard coded value. An example is the name or identifier of a clinical trial.This above list contains those null flavors that are commonly used in clinical documents. For the full list and descriptions, see the nullFlavor vocabulary domain in the CDA normative edition.Any SHALL conformance statement may use nullFlavor, unless the attribute is required or the nullFlavor is explicitly disallowed. SHOULD and MAY conformance statement may also use nullFlavor.Figure SEQ Figure \* ARABIC 9: Attribute required1. SHALL contain exactly one [1..1] code/@code="11450-4" Problem List (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7878) or2. SHALL contain exactly one [1..1] effectiveTime/@value (CONF:5256).Figure SEQ Figure \* ARABIC 10: Allowed nullFlavors when element is required (with xml examples)1. SHALL contain at least one [1..*] id2. SHALL contain exactly one [1..1] code3. SHALL contain exactly one [1..1] effectiveTime<entry> <observation classCode="OBS" moodCode="EVN"> <id nullFlavor="NI"/> <code nullFlavor="OTH"> <originalText>New Grading system</originalText> </code> <statusCode code="completed"/> <effectiveTime nullFlavor="UNK"/> <value xsi:type="CD" nullFlavor="OTH"> <originalText>Spiculated mass grade 5</originalText> </value> </observation></entry>Figure SEQ Figure \* ARABIC 11: nullFlavor explicitly disallowed1. SHALL contain exactly one [1..1] effectiveTime (CONF:5256). a. SHALL NOT contain [0..0] @nullFlavor (CONF:52580).Unknown InformationIf a sender wants to state that a piece of information is unknown, the following principles apply:1.If the sender doesn’t know an attribute of an act, that attribute can be null.Figure SEQ Figure \* ARABIC 12: Unknown medication example<entry> <text>patient was given a medication but I do not know what it was</text> <substanceAdministration moodCode="EVN" classCode="SBADM"> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <code nullFlavor="NI"/> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration></entry>2.If the sender doesn’t know if an act occurred, the nullFlavor is on the act (detail could include specific allergy, drug, etc.).Figure SEQ Figure \* ARABIC 13: Unknown medication use of anticoagulant drug example<entry> <substanceAdministration moodCode="EVN" classCode="SBADM" nullFlavor="NI"> <text>I do not know whether or not patient received an anticoagulant drug</text> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <code code="81839001" displayName="anticoagulant drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration></entry>3. If the sender wants to state ‘no known’, a negationInd can be used on the corresponding act (substanceAdministration, Procedure, etc.)Figure SEQ Figure \* ARABIC 14: No known medications example<entry> <substanceAdministration moodCode="EVN" classCode="SBADM" negationInd=”true”> <text>No known medications</text> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <code code="410942007" displayName="drug or medication" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration></entry>Previously CCD, IHE, and HITSP recommended using specific codes to assert no known content, for example 160244002 No known allergies or 160245001 No current problems or disability. Specific codes are still allowed; however, use of these codes is not recommended.Asserting an Act Did Not OccurThe negationInd attribute, if true, specifies that the act indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). NegationInd='true' is an acceptable way to make a clinical assertion that something did not occur, for example, "no gestational diabetes".Figure SEQ Figure \* ARABIC 15: Asserting an act did not occur<entry> <observation classCode="OBS" moodCode="EVN" negationInd="true"> <templateId root="2.16.840.1.113883.10.20.17.3.57" /> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" /> <statusCode code="completed" /> <value xsi:type="CD" code="11687002" codeSystem="2.16.840.1.113883.6.96" displayName="gestational diabetes mellitus" /> </observation></entry>Data TypesAll data types used in a CDA document are described in the CDA R2 normative edition. All attributes of a data type are allowed unless explicitly prohibited by this specification.XML Conventions Used in This GuideXPath NotationInstead of the traditional dotted notation used by HL7 to represent Reference Information Model (RIM) classes, this document uses XML Path Language (XPath) notation in conformance statements and elsewhere to identify the Extended Markup Language (XML) elements and attributes within the CDA document instance to which various constraints are applied. The implicit context of these expressions is the root of the document. This notation provides a mechanism that will be familiar to developers for identifying parts of an XML document.Xpath statements appear in this document in a monospace font.XPath syntax selects nodes from an XML document using a path containing the context of the node(s). The path is constructed from node names and attribute names (prefixed by a ‘@’) and catenated with a ‘/’ symbol.Figure SEQ Figure \* ARABIC 16: XML document example<author> <assignedAuthor> ... <code codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT' code='17561000' displayName='Cardiologist' /> </assignedAuthor></author>In the above example, the code attribute of the code could be selected with the XPath expression in the next figure.Figure SEQ Figure \* ARABIC 17: XPath expression exampleauthor/assignedAuthor/code/@codeXML Examples and Sample DocumentsExtended Mark-up Language (XML) examples appear in figures in this document in this monospace font. Portions of the XML content may be omitted from the content for brevity, marked by an ellipsis (...) as shown in the example below.Figure SEQ Figure \* ARABIC 18: ClinicalDocument example<ClinicalDocument xmls="urn:h17-org:v3"> ...</ClinicalDocument>Within the narrative, XML element (code, assignedAuthor, etc.) and attribute (SNOMED CT, 17561000, etc.) names also appear in this monospace font.This package includes complete sample documents as listed in the Content of the Package table below.Rendering Header Information for Human PresentationMetadata carried in the header may already be available for rendering from EHRs or other sources external to the document; therefore, there is no strict requirement to render directly from the document header. An example of this would be a doctor using an EHR that already contains the patient’s name, date of birth, current address, and phone number. When a CDA document is rendered within that EHR, those pieces of information may not need to be displayed since they are already known and displayed within the EHR’s user interface.Good practice would recommend that the following information be present whenever the document is viewed:Document title and document datesService and encounter types, and date ranges as appropriateNames of all persons along with their roles, participations, participation date ranges, identifiers, address, and telecommunications informationNames of selected organizations along with their roles, participations, participation date ranges, identifiers, address, and telecommunications informationDate of birth for recordTarget(s)Content of the PackageThe following files comprise this package.Table SEQ Table \* ARABIC 1: Content of the PackageFilenameDescriptionCDAR2_IG_QRDA_R2_D1_2012MAY.pdfThis guideSampleName.xmlThe sample ….cda.xslStylesheet for display of CDA instancesQRDA FrameworkThis section introduces the QRDA Release 2 Framework changes. Release 2 simplifies the QRDA framework by not requiring the nesting of sections and no longer recommends a measure set section. The quality measure referencing has been clarified to use available measure IDs as opposed to requiring standardized terminology codes. Existing implementations of QRDA R1 should be able to update their implementations incrementally by first conforming to the QRDA R2 framework only and re-using what has been implemented within their patient data section.Measure SectionThe Measure Section contains information about the measure or measures being reported. QRDA R1 referenced a quality measure by using an act/code under the assumption that standard codes, such as LOINC codes would be created for the measures. As it turned out, this created an unnecessary burden. Endorsed measures had a system for creating unique IDs for measures that did not include standardized codes. Meaningless, non-standardized OIDs were being used in act/code to comply with the standard. QRDA R2 references the measure through reference to an externalDocument. The externalDocument/ids and version numbers are used to reference the measure. The measure section must contain a reference to at least one externalDocument id of all the measures being reported in the QRDA instance.Reporting Parameters SectionThe Reporting Parameters Section is unchanged over QRDA R1. The reporting parameters section provides information about the reporting time interval, and may contain other information that provides context for the patient data being reported. The receiving organization may tell the reporting organizations what information they want in this section.Patient Data SectionEntry templates in a QRDA Framework Patient Data Section will convey all the patient data elements expected in the measure(s) stated in the measure section. A patient data element is information about a particular person (as opposed to a population). Examples include: individual’s test results, individual’s encounter location and an individual’s date of birth.In the QDM approach to QRDA corresponding template patterns exist for every QDM Quality Data Type and thus a very specific structure is required. This is not a requirement of the QRDA framework. However, where possible, data elements in a QRDA Framework instance should be communicated with entry level templates from the Implementation Guide for CDA Release 2.0 Consolidated CDA Templates (US Realm) December 2011. In many cases these templates will require further constraint to convey the exact data elements required by a measure or set of measures. Data elements should always be sent with the time of the act.For short term incremental implementation needs, a valid QRDA Framework Patient Data Section could send data elements using clinical statement templates from an earlier version of CCD, C32 or other HL7 implementation guide.Quality Data Model-Based QRDA IGIntroductionThis section introduces the National Quality Forum (NQF) Quality Data Model (QDM), and describes how it is used both in the construction of QDM-based eMeasures, and here, in the construction of corresponding QDM-based QRDAs.From HL7's perspective, the QDM is a domain analysis model that defines concepts recurring across quality measures. The figure below illustrates components of the QDM relevant to understanding how that model guides the construction of CDA templates in QRDA.Figure SEQ Figure \* ARABIC 19: Prototypic quality data elementQuality Data AttributesQuality Data TypeValue setQuality Data AttributesQuality Data TypeValue setThe QDM breaks a concept down into a "Quality Data Type", "Quality Data Attributes", and a "Value Set". A "Quality Data Element" is a Quality Data Type, along with its Quality Data Attributes and associated value set. Quality Data Types (e.g., Medication Administered, Diagnosis Active) represent a clinical category (e.g., Medication, Diagnosis) coupled with a "state" (e.g., Administered, Active). Quality Data Attributes represent various components of the Quality Data Type, such as timing, or category-specific characteristics, as shown above in the Medication Administered example.The next figure illustrates the relationship between QDM and QRDA (and eMeasure).Figure SEQ Figure \* ARABIC 20: Relationship between QDM, eMeasure, and QRDAQuality Data TypeQDSNQF QDMPattern LibraryQuality Data TypeQuality Data TypePatterneMeasurePatternPatternPatternPatternQuality Data TypeTypeQuality Data TypePatternQuality Data ElementValue SetQuality Data ElementQDS ElementQDS ElementQuality Data Element Data CriteriaPopulation CriteriaDenominatorNumeratorInitial Patient PopulationQRDA TemplateQuality Data TypeQDSNQF QDMPattern LibraryQuality Data TypeQuality Data TypePatterneMeasurePatternPatternPatternPatternQuality Data TypeTypeQuality Data TypePatternQuality Data ElementValue SetQuality Data ElementQDS ElementQDS ElementQuality Data Element Data CriteriaPopulation CriteriaDenominatorNumeratorInitial Patient PopulationQRDA TemplateQRDA TemplateQRDA TemplateCDA Template LibraryQuality Data Types are converted into RIM-derived XML patterns that, when coupled with value sets, become Quality Data Elements that can be used as data criteria within a QDM-based eMeasure.Each Quality Data Type pattern is assigned a unique ID, which is present in the eMeasure, and which is mapped to a corresponding CDA template.A Quality Data Element further constrains a Quality Data Type pattern via vocabulary binding to a value set. The linked CDA template can be further constrained through a corresponding value set binding. This allows one to automatically construct a QDM-based QRDA, given a QDM-based eMeasure.The further constraint on a CDA template through value set binding results in a new CDA template. To retain flexibility in defining new QDM-based eMeasures without the need to update this guide, we introduce the notion of “dynamic CDA template creation”. The actual CDA template ID in a QRDA instance contains the templateId from the library (in templateId/@root), dynamically concatenated with the value set id from the eMeasure (in templateId/@extension).Figure SEQ Figure \* ARABIC 21: TemplateId construction in a QRDA Category I instanceQRDA TemplateQRDA TemplateCDA Template LibraryQuality Data TypeQDSNQF QDMPattern LibraryQuality Data TypeQuality Data TypePatterneMeasurePatternPatternPatternPatternQuality Data TypeTypeQuality Data TypePatternQuality Data ElementValue SetQuality Data ElementQDS ElementQDS ElementQuality Data Element Data CriteriaPopulation CriteriaDenominatorNumeratorInitial Patient PopulationQuality Data TypeQDSNQF QDMPattern LibraryQuality Data TypeQuality Data TypePatterneMeasurePatternPatternPatternPatternQuality Data TypeTypeQuality Data TypePatternQuality Data ElementValue SetQuality Data ElementQDS ElementQDS ElementQuality Data Element Data CriteriaPopulation CriteriaDenominatorNumeratorInitial Patient PopulationQRDA TemplateQRDA TemplateQRDA TemplateCDA Template LibraryQRDA Category I instance<substanceAdministration …> <templateId root="…CDA Template ID from library…" extension="…Value Set ID from eMeasure…"/> … </substanceAdministration>This guide describes how to construct a QDM-based QRDA for any QDM-based eMeasure rather than give prescriptive rules for QRDA construction on an eMeasure by eMeasure basis.QDM-Based QRDA Category I Construction RulesThis section provides guidelines on when to create QRDAs and what data to include.How Many QRDAs Should be Created?A QDM-based QRDA Category I instance contains data on a single patient for one or more QDM-based eMeasures. Each eMeasure for which data is included shall be referenced in the QRDA Measure Section, as described in the Measure Section QDM.As a result of this rule, it is very important to include date/time stamps for the data objects (e.g., to know that a particular medication was administered during a particular encounter). This guide, therefore, further constrains those CDA templates used elsewhere, such as in the Implementation Guide for CDA Release 2.0 Consolidated CDA Templates (US Realm), December 2011.Generate a QRDA for Which Patients?A QRDA should be created for each patient meeting the Initial Patient Population (IPP) criteria of the referenced eMeasure(s). No QRDA should be created for patients that fail to meet the IPP criteria.Where a QRDA references multiple measures, the patient shall have met the IPP criteria for each of them. For instance, at a hospital is reporting on three myocardial infarction measures (AMI-1, AMI-2, AMI-3), if a patient meets the IPP for AMI-1 and AMI-2, but not for AMI-3, then the QRDA for that patient will only reference AMI-1 and AMI-2, and will only carry data for those referenced eMeasures.Often times, a program implementing QRDA will provide prescriptive guidelines that define the exact triggers for sending a QRDA. Where such prescriptive guidelines exist, they take precedent over the more general guidance provided here.How Many Data Should be Sent?4572008826500A QDM-based QRDA adheres to a "scoop and filter" philosophy, whereby data from an EHR are scooped up and filtered, and the remaining content is packaged into the instance.When the recipient of the instance has access to no other EHR data, it is important that the instance include data elements relevant to computing eMeasure criteria, as well as the other data elements defined in an eMeasure – for stratification, for risk adjustment, etc. Every data element present in the EHR that is used within the referenced eMeasure(s), not just those needed to compute criteria, shall be included in the QRDA.1346835640207000The EHR may have more data than are relevant to the referenced eMeasure(s and more data than are needed to compute the criteria. For instance, a patient who has been in the Intensive Care Unit undergoing continuous blood pressure monitoring will have many blood pressure observations. A QDM-based QRDA adheres to a "smoking gun" philosophy where, at a minimum, the conclusive evidence needed to confirm that a criterion was met shall be included in the instance.At the very least, the QRDA should include:All data elements that confirm IPP inclusion for each referenced eMeasure (since by definition, the patient has met IPP criteria for each referenced eMeasure)Smoking gun data that offers confirmatory proof, where a patient has met a criterionAll relevant data elements present in the EHR For disjunctive criteria (e.g., where a criterion can be satisfied by either of two data elements), include all the relevant data elements that are present in the EHRStratification variables, supplemental data elements, risk adjustment variables, and any other data element specified in the referenced eMeasure(s)A program implementing QRDA will often provide prescriptive guidelines that define additional data, outside the smoking gun, that may or must be sent (such as the complete problem or medication list). Where such prescriptive guidelines exist, those take precedent over the more general guidance provided here. In other words, the "smoking gun" heuristic ensures that the bare minimum is present in the QRDA, and does not preclude inclusion of additional data.What if There are No Data in the EHR?Other than IPP data elements, which by definition will be known, other data elements may not be present in the EHR. Following from the scoop and filter philosophy, a QDM-based QRDA will not contain data elements that aren't present in the source system. For instance, if an eMeasure has a criterion "patient is in the Numerator if they have blue eyes" and the patient doesn't have eye color captured in the source system, then the corresponding QRDA will not contain an eye color observation for that patient.Each eMeasure will address exactly how it factors in missing data when calculating criteria. For instance, one measure may assume that absence of evidence equals evidence of absence (e.g., patient doesn't have eye color in the EHR, therefore is not in the Numerator), whereas another measure may differentiate between data that is known to be true, data that is known to be false, and data that isn't known. Where an eMeasure requires positive evidence of absence (e.g., "no known allergies"), that eMeasure will include a corresponding data element in its logic. For data elements of an eMeasure, other than those needed to compute the IPP, that are not present in the EHR, the corresponding QRDA will contain nothing.Generating a QDM-Based QRDA Category I Instance from a QDM-Based eMeasureThis guide does not give prescriptive rules for QRDA construction on an eMeasure by eMeasure basis, but rather, describes how to construct a QDM-based QRDA for any QDM-based eMeasure. This section walks through the QRDA generation process in detail, to illustrate how to automatically construct a QDM-based QRDA for one or more QDM-based eMeasures.There are many ways to generate a QDM-based QRDA. This section is illustrative, focusing on how to use an eMeasure to figure out what templates need to be included in the QRDA and how they are to be instantiated. This section does not address other important aspects of QRDA generation, such as how to extract relevant data from the EHR.When a QRDA references multiple measures, the patient shall have met the IPP criteria for each of them. If a provider wants to report on three myocardial infarction measures (AMI-1, AMI-2, AMI-3) for a population of patients and if a patient meets the IPP for AMI-1 and AMI-2, but not for AMI-3, then the QRDA for that patient will only reference AMI-1 and AMI-2 and will only carry data for those referenced eMeasures.Steps in constructing a QDM-based QRDA for a given patient in this scenario:Identify those eMeasures to be included in the QRDA. The patient shall have met the IPP for each of them. List each of these eMeasures in the Measure Section QDM.For each eMeasure in the QRDA Measure Section, take the union of Quality Data Elements. Include all data elements, including those needed to calculate population criteria, those needed for stratification, those needed for risk adjustment, etc. This list may have the same Quality Data Type multiple times, each associated with a different value set. In other words, take the union of Quality Data Elements (Quality Data Type + value set). You'll wind up with a table, looking something like this:Table SEQ Table \* ARABIC 2: Union of Quality Data Types from eMeasures of InterestQuality Data ElementQuality Data Type Pattern IDValue Set NameValue Set IDDiagnosis, Active: Pregnancy2.16.840.1.113883.3.560.1.2Pregnancy Grouping Value Set2.16.840.1.113883.3.600.0001.18Medication, Administered: Aspirin2.16.840.1.113883.3.560.1.14Aspirin RxNorm Value Set2.16.840.1.113883.3.117.??Medication, Administered: Beta Blocker2.16.840.1.113883.3.560.1.14Beta Blocker RxNorm Value Set2.16.840.1.113883.3.117.35…For each Quality Data Element identified, identify the corresponding CDA template from this guide. The appendix contains a REF _Ref321343789 \h QDM HQMF Pattern to CDA Mapping Table, from HQMF Quality Data Type Pattern ID to corresponding CDA template id.Table SEQ Table \* ARABIC 3: QDM HQMF Pattern to CDA Mapping TableQuality Data ElementQuality Data TypePattern IDValue Set NameValue Set IDCDA Template Library IDDiagnosis, Active: Pregnancy2.16.840.1.113883.3.560.1.2Pregnancy Grouping Value Set2.16.840.1.113883.3.600.0001.182.16.840.1.113883.10.20.24.3.11Medication, Administered: Aspirin2.16.840.1.113883.3.560.1.14Aspirin RxNorm Value Set2.16.840.1.113883.3.117.??2.16.840.1.113883.10.20.12.6.42Medication, Administered: Beta Blocker2.16.840.1.113883.3.560.1.14Beta Blocker RxNorm Value Set2.16.840.1.113883.3.117.352.16.840.1.113883.10.20.12.6.42…When adding data elements into the QRDA, recall that the templateId/@root is to be populated with the CDA template ID, and the templateId/@extension is to be populated with the value set ID, as shown in the following figure.Figure SEQ Figure \* ARABIC 22: Fully formed templateId in a QRDA Category I instanceQDM-Based QRDA Category I Instance ValidationThe dynamic approach to QDM-based QRDA Category I instance generation, coupled with the construction rules, has implications for instance validation. While the typical Schematron-based validation used in many CDA implementation guides will be applicable here (e.g., if an entry asserts a templateId, then validate that the instance conforms to that template), other types of validation are also possible by the fact that the QRDA references relevant eMeasures. Types of validation that can be performed on a QDM-based QRDA Category I instance include:Test that where a templateId is asserted, the instance conforms to that template.Test that the structural aspects of the instance conform to templateId/@root.Test that the vocabulary aspects of the instance conform to templateId/@extension.Test that for a referenced eMeasure, the IPP Quality Data Elements are present, and are not NULL. Additional Quality Data Elements from the referenced eMeasure may or may not be present. However it would be possible to produce a report that shows which data elements for a given eMeasure aren’t present.Test whether the QRDA contains more data than is required by the referenced eMeasures. This type of test might be necessary, for instance, by federal agencies precluded from receiving data above and beyond that which is absolutely required by an eMeasure.A program implementing QRDA may provide prescriptive guidelines that define validation criteria. Where such prescriptive guidelines exist, they take precedent over the more general guidance provided here.Clinical-Document-Level TemplatesUS Realm Header[Closed for comments; published December 2011][ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.1(open)]This template describes constraints that apply to the header for all documents that assert the US Realm Header templateId. Documents can further constrain the US Realm Header by asserting a document-specific templateId.SHALL contain exactly one [1..1] realmCode/@code="US" (CONF:5249).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" (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).can either be a locally defined name or the display name corresponding to clinicalDocument/code (CONF:5255).SHALL contain exactly one [1..1] effectiveTime (CONF:5256).Signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA (CONF:9995).This effectiveTime SHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3) (CONF:5257).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).Table SEQ Table \* ARABIC 4: Basic Confidentiality Kind Value SetValue Set: HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC 2010-04-21Code System(s):Confidentiality Code 2.16.840.1.113883.5.25CodeCode SystemPrint NameN Confidentiality CodeNormalRConfidentiality CodeRestricted VConfidentiality CodeVery Restricted Table SEQ Table \* ARABIC 5: Language Value Set (excerpt)Value Set: Language 2.16.840.1.113883.1.11.11526 DYNAMICCode System(s):Internet Society Language 2.16.840.1.113883.1.11.11526Description:A value set of codes defined by Internet RFC 4646 (replacing RFC 3066). Please see ISO 639 language code set maintained by Library of Congress for enumeration of language codes CodeCode SystemPrint NameenInternet Society LanguageenglishfrInternet Society LanguagefrencharInternet Society Languagearabicen-USInternet Society LanguageEnglish, USes-USInternet Society LanguageSpanish, US…Figure SEQ Figure \* ARABIC 23: US realm header example<realmCode code="US"/><typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/><!-- US General Header Template --><templateId root="2.16.840.1.113883.10.20.22.1.1"/><!-- History and Physical Template --><templateId root="2.16.840.1.113883.10.20.22.1.3"/> <id extension="999021" root="2.16.840.1.113883.19"/> <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34117-2" displayName="History and Physical Note"/> <title>Good Health History &amp; Physical</title> <effectiveTime value="20050329171504+0500"/><confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/><languageCode code="en-US" displayName="English, US" codeSystem="2.16.840.1.113883.1.11.11526" codeSystemName="Internet Society Language"/><setId extension="111199021" root="2.16.840.1.113883.19"/><versionNumber value="1"/>Figure SEQ Figure \* ARABIC 24: effectiveTime with timezone example<!-- the syntax is "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]" where digits can be omitted the right side to express less precision. --><effectiveTime value=”201107061227-08”/><!-- July 6, 2011, 12:27, 8 hours before UTC -->RecordTargetThe recordTarget records the patient whose health information is described by the clinical document; it must contain at least one patientRole element.SHALL 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 @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:5375).PatientThis patientRole SHALL contain exactly one [1..1] patient (CONF:5283).This patient SHALL contain exactly one [1..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 HL7 Marital Status 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 HL7 Religious Affiliation 2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:5317).This patient MAY contain zero or one [0..1] raceCode, which SHALL be selected from ValueSet Race 2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:5322).This patient MAY contain zero or more [0..*] sdtc:raceCode, which SHALL be selected from ValueSet Race 2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:7263).This patient MAY contain zero or one [0..1] ethnicGroupCode, which SHALL be selected from ValueSet HITSP Ethnicity Value Set 2.16.840.1.113883.1.11.15836 DYNAMIC (CONF:5323).GuardianThis patient MAY contain zero or more [0..*] guardian (CONF:5325).Such guardians, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC (CONF:5326).Such guardians, 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).Such guardians, if present, MAY contain zero or more [0..*] telecom (CONF:5382).Such telecoms, if present, SHOULD contain @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7993).Such guardians, 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 Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:10414).BirthplaceThis patient MAY contain zero or one [0..1] birthplace (CONF:5395).This birthplace, if present, SHALL contain exactly one [1..1] place (CONF:5396).This place SHALL contain exactly one [1..1] addr (CONF:5397).If country is US, this addr SHALL contain exactly one [1..1] state, which SHALL be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC (CONF:5402).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).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).LanguageCommunicationThis patient SHOULD contain zero or more [0..*] languageCommunication (CONF:5406).Such languageCommunications, 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).Such languageCommunications, if present, MAY contain zero or one [0..1] modeCode, which SHALL be selected from ValueSet HL7 LanguageAbilityMode 2.16.840.1.113883.1.11.12249 DYNAMIC (CONF:5409).Such languageCommunications, 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).Such languageCommunications, if present, MAY contain zero or one [0..1] preferenceInd (CONF:5414).ProviderOrganizationThis patientRole MAY contain zero or one [0..1] providerOrganization (CONF:5416).This providerOrganization, if present, SHALL contain one or more [1..*] id (CONF:5417).The id SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:9996)This providerOrganization, if present, SHALL contain one or more one [1..*] name (CONF:5419).This providerOrganization, if present, SHALL contain at least one [1..*] telecom (CONF:5420).Such telecoms SHOULD contain @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:7994).This 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).RecordTarget Value SetsTable SEQ Table \* ARABIC 6: Telecom Use (US Realm Header) Value SetValue Set: Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMICCode System(s):AddressUse 2.16.840.1.113883.5.1119CodeCode SystemPrint NameHPAddressUseprimary homeWPAddressUsework placeMCAddressUsemobile contactHVAddressUsevacation homeTable SEQ Table \* ARABIC 7: Administrative Gender (HL7) Value SetValue Set: Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMICCode System(s): AdministrativeGender 2.16.840.1.113883.5.1CodeCode SystemPrint NameFAdministrativeGenderFemaleMAdministrativeGenderMaleUNAdministrativeGenderUndifferentiatedTable SEQ Table \* ARABIC 8: Marital Status Value SetValue Set: HL7 Marital Status 2.16.840.1.113883.1.11.12212 DYNAMICCode System(s):MaritalStatus 2.16.840.1.113883.5.2CodeCode SystemPrint NameA MaritalStatusAnnulled D MaritalStatusDivorced I MaritalStatusInterlocutory L MaritalStatusLegally Separated M MaritalStatusMarried P MaritalStatusPolygamous S MaritalStatusNever Married T MaritalStatusDomestic partner W MaritalStatusWidowed Table SEQ Table \* ARABIC 9: Religious Affiliation Value Set (excerpt)Value Set: HL7 Religious Affiliation 2.16.840.1.113883.1.11.19185 DYNAMICCode System(s):ReligiousAffiliation 2.16.840.1.113883.5.1076 Description:A value set of codes that reflect spiritual faith affiliation CodeCode SystemPrint Name1026ReligiousAffiliationJudaism1020ReligiousAffiliationHinduism1041ReligiousAffiliationRoman Catholic Church…Table SEQ Table \* ARABIC 10: Race Value Set (excerpt)Value Set: Race 2.16.840.1.113883.1.11.14914 DYNAMICCode System(s):Race and Ethnicity - CDC 2.16.840.1.113883.6.238Description:A value set of codes for Classifying data based upon race.Race is always reported at the discretion of the person for whom this attribute is reported, and reporting must be completed according to Federal guidelines for race reporting. Any code descending from the Race concept (1000-9) in that terminology may be used in the exchange CodeCode SystemPrint Name2058-6Race and Ethnicity- CDCAfrican American1004-1Race and Ethnicity- CDCAmerican Indian2101-4Race and Ethnicity- CDCFijian2106-3Race and Ethnicity- CDCWhite…Table SEQ Table \* ARABIC 11: Ethnicity Value SetValue Set: HITSP Ethnicity Value Set 2.16.840.1.113883.1.11.15836 DYNAMICCode System(s):Race and Ethnicity - CDC 2.16.840.1.113883.6.238CodeCode SystemPrint Name2135-2Race and Ethnicity Code SetsHispanic or Latino2186-5Race and Ethnicity Code SetsNot Hispanic or LatinoTable SEQ Table \* ARABIC 12: Personal Relationship Role Type Value Set (excerpt)Value Set: Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMICCode System(s):RoleCode 2.16.840.1.113883.5.111Description:A Personal Relationship records the role of a person in relation to another person. This value set is to be used when recording the relationships between different people who are not necessarily related by family ties, but also includes family relationships. CodeCode SystemPrint NameHUSBRoleCodehusbandWIFERoleCodewifeFRNDRoleCodefriendSISINLAWRoleCodesister-in-law…Table SEQ Table \* ARABIC 13: State Value Set (excerpt)Value Set: StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMICCode System(s):FIPS 5-2 (State) 2.16.840.1.113883.6.92Description:Codes for the Identification of the States, the District of Columbia and the Outlying Areas of the United States, and Associated Areas Publication # 5-2, May, 1987 CodeCode SystemPrint NameALFIPS 5-2 (State Alpha Codes)AlabamaAKFIPS 5-2 (State Alpha Codes)AlaskaAZFIPS 5-2 (State Alpha Codes)ArizonaARFIPS 5-2 (State Alpha Codes)Arkansas…Table SEQ Table \* ARABIC 14: Postal Code Value Set (excerpt)Value Set: PostalCodeValueSet 2.16.840.1.113883.3.88.12.80.2 DYNAMICCode System(s):US Postal Codes 2.16.840.1.113883.6.231Description:A value set of codes postal (ZIP) Code of an address in the United States. CodeCode SystemPrint Name19009US Postal CodesBryn Athyn, PA92869-1736US Postal CodesOrange, CA32830-8413US Postal CodesLake Buena Vista, FL …Table SEQ Table \* ARABIC 15: Country Value Set (excerpt)Value Set: CountryValueSet 2.16.840.1.113883.3.88.12.80.63 DYNAMICCode System(s):ISO 3166-1 Country Codes: 1.0.3166.1Description:A value set of codes for the representation of names of countries, territories and areas of geographical interest.Note: This table provides the ISO 3166-1 code elements available in the alpha-2 code of ISO's country code standard SystemPrint NameAWISO 3166-1 Country CodesArubaILISO 3166-1 Country CodesIsraelKZISO 3166-1 Country CodesKazakhstanUSISO 3166-1 Country CodesUnited States…Table SEQ Table \* ARABIC 16: Language Ability Value SetValue Set: HL7 LanguageAbilityMode 2.16.840.1.113883.1.11.12249 DYNAMICCode System(s):LanguageAbilityMode 2.16.840.1.113883.5.60Description:A value representing the method of expression of the language.CodeCode SystemPrint NameESGN LanguageAbilityModeExpressed signed ESP LanguageAbilityModeExpressed spoken EWR LanguageAbilityModeExpressed written RSGN LanguageAbilityModeReceived signed RSP LanguageAbilityModeReceived spoken RWR LanguageAbilityModeReceived written Table SEQ Table \* ARABIC 17: Language Ability Proficiency Value SetValue Set: LanguageAbilityProficiency 2.16.840.1.113883.1.11.12199 DYNAMICCode System(s):LanguageAbilityProficiency 2.16.840.1.113883.5.61Description:A value representing the level of proficiency in a language.CodeCode SystemPrint NameELanguageAbilityProficiencyExcellentFLanguageAbilityProficiencyFairGLanguageAbilityProficiencyGoodPLanguageAbilityProficiencyPoorRecordTarget ExampleFigure SEQ Figure \* ARABIC 25: recordTarget example<recordTarget> <patientRole> <id extension="12345" root="2.16.840.1.113883.19"/> <!-- Fake ID using HL7 example OID. --> <id extension="111-00-1234" root="2.16.840.1.113883.4.1"/> <!-- Fake Social Security Number using the actual SSN OID. --> <addr use="HP"> <!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 --> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 --> </addr> <telecom value="tel:(781)555-1212" use="HP"/> <!-- HP is "primary home" from AddressUse 2.16.840.1.113883.5.1119 --> <patient> <name use="L"> <!-- L is "Legal" from EntityNameUse 2.16.840.1.113883.5.45 --> <prefix>Mr.</prefix> <given>Adam</given> <given qualifier="CL">Frankie</given> <!-- CL is "Call me" from EntityNamePartQualifier 2.16.840.1.113883.5.43 --> <family>Everyman</family> </name> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/> <birthTime value="19541125"/> <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/> <religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystemName="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 &amp; Ethnicity - CDC"/> <ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC"/> <guardian> <code code="GRFTH" displayName="Grandfather" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"/> <addr use="HP"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</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>US</country> </addr> </place> </birthplace> <languageCommunication> <languageCode code="fr-CN"/> <modeCode code="RWR" displayName="Receive Written" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/> <preferenceInd value="true"/> </languageCommunication> </patient> <providerOrganization> <id root="2.16.840.1.113883.19"/> <name>Good Health Clinic</name> <telecom use="WP" value="tel:(781)555-1212"/> <addr> <streetAddressLine>21 North Ave</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> </providerOrganization> </patientRole></recordTarget>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).This time 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:5446).Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:5448).This assignedAuthor SHALL contain at least one [1..*] id (CONF:5449).The id SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:9941).This assignedAuthor SHOULD 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:9942).This assignedAuthor SHALL contain at least one [1..*]addr (CONF:5452).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:10416).This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:5428).Such telecoms SHOULD contain @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 SHALL contain exactly one [1..1] assignedPerson or assignedAuthoringDevice (CONF:5430).If present this assignedPerson SHALL contain at least one [1..*] US RealmPerson Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:5431).If present this assignedAuthoringDevice SHALL contain at least one [1..1] manufacturerModelName (CONF:9936).If present this assignedAuthoringDevice SHALL contain at least 1..1 softwareName(CONF:9999).Figure SEQ Figure \* ARABIC 26: Person author example<author> <time value="20050329224411+0500"/> <assignedAuthor> <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>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor></author>Figure SEQ Figure \* ARABIC 27: Device author example<author> <time value="20050329224411+0500"/> <assignedAuthor> <id extension="KP00017dev" root="2.16.840.1.113883.19.5"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedAuthoringDevice> <manufacturerModelName>Good Health Medical Device</manufacturerModelName > <softwareName>Good Health Report Generator</softwareName > </ assignedAuthoringDevice > </assignedAuthor></author>DataEntererThe 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).MAY contain zero or one [0..1] dataEnterer (CONF:5441).This dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:5442).This assignedEntity SHALL contain at least one [1..*] id (CONF:5443).SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:9943).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).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 @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).Figure SEQ Figure \* ARABIC 28: dataEnterer example<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>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity></dataEnterer>InformantThe 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. 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:8001).SHALL contain exactly one [1..1] assignedEntity OR exactly one [1..1] relatedEntity (CONF:8002).SHOULD contain zero or more [0..*] 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 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).SHOULD 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).SHALL contain exactly one [1..1] assignedPerson OR exactly one [1..1] relatedPerson (CONF:8221).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).Figure SEQ Figure \* ARABIC 29: Informant with assignedEntity example<informant> <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>US</country> </addr> <telecom value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity></informant>CustodianThe custodian element represents the organization 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.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)The id SHOULD include zero or one [0..1] id where id/@root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:10000).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 @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 at least one [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).Figure SEQ Figure \* ARABIC 30: Custodian example<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>US</country> </addr> </representedCustodianOrganization> </assignedCustodian></custodian>InformationRecipientThe 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:5565).Such informationRecipients, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:5566).This intendedRecipient MAY contain zero or one [0..1] informationRecipient (CONF:5567).This 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).This receivedOrganization, if present, SHALL contain exactly one [1..1] name (CONF:5578).Figure SEQ Figure \* ARABIC 31: informationRecipient example<informationRecipient> <intendedRecipient> <informationRecipient> <name> <given>Henry</given> <family>Seven</family> </name> </informationRecipient> <receivedOrganization> <name>Good Health Clinic</name> </receivedOrganization> </intendedRecipient></informationRecipient>LegalAuthenticatorThe 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, clinical documents may be released before legal authentication. This implies that 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. 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 of time SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3) (CONF:5581).This 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) (CONF:5584).This legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:5585).This assignedEntity SHALL contain at least one [1..*] id (CONF:5586).SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:9948).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:9949)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 @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).Figure SEQ Figure \* ARABIC 32: legalAuthenticator example<legalAuthenticator> <time value="20050329224411+0500"/> <signatureCode code="S"/> <assignedEntity> <id extension="KP00017" root="2.16.840.1.113883.19"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity></legalAuthenticator>AuthenticatorThe authenticator identifies a participant or participants who attested to the accuracy of the information in the document.MAY contain zero or more [0..*] authenticator (CONF:5607).Such authenticators, if present, SHALL contain exactly one [1..1] time (CONF:5608).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:5634).Such authenticators, 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) (CONF:5611).Such authenticators, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:5612).This assignedEntity SHALL contain at least one [1..*] id (CONF:5613).SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:9950).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:9951)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 @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).Figure SEQ Figure \* ARABIC 33: Authenticator example<authenticator> <time value="20050329224411+0500"/> <signatureCode code="S"/> <assignedEntity> <id extension="KP00017" root="2.16.840.1.113883.19"/> <addr> <streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555)555-1003"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity></authenticator>Participant (Support)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 particpants (e.g., emergency contact and next-of-kin)MAY contain zero or more [0..*] participant (CONF:10003).Such participants, if present, MAY contain [0..1] time (CONF:10004).This time 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:10005).Such participants, if present, SHALL have an associatedPerson or scopingOrganization element under participant/associatedEntity. (CONF:10006).Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet INDRoleclassCodes 2.16.840.1.113883.11.20.9.33 STATIC 2011-09-30. (CONF: 10007).Table SEQ Table \* ARABIC 18: IND Role classCode Value SetValue Set: INDRoleclassCodes 2.16.840.1.113883.11.20.9.33 STATIC 2011-09-30Code System(s):RoleClass 2.16.840.1.113883.5.110CodeCode SystemPrint NamePRSRoleClasspersonal relationshipNOKRoleClassnext of kinCAREGIVERRoleClasscaregiverAGNTRoleClassagentGUARRoleClassguarantorECONRoleClassemergency contactFigure SEQ Figure \* ARABIC 34: Participant example for a supporting person<participant typeCode='IND'> <time xsi:type="IVL_TS"> <low value="19590101"/> <high value="20111025"/> </time> <associatedEntity classCode='NOK'> <code code='MTH' codeSystem='2.16.840.1.113883.5.111'/> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom value='tel:(555)555-2006' use='WP'/> <associatedPerson> <name> <prefix>Mrs.</prefix> <given>Martha</given> <family>Mum</family> </name> </associatedPerson> </associatedEntity></participant>InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document.MAY contain zero or more [0..*] inFulfillmentOf (CONF:9952).Such inFulfillmentOf elements, if present, SHALL contain exactly one [1..1] order (CONF:9953).This order SHALL contain at least one [1..*] id (CONF:9954).Authorization/consentThe header can record information about the patient’s consent.The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. The template is not intended for ‘Privacy Consent’. This specification does not address how privacy consents are represented.When consent is recorded, it SHALL be represented as ClinicalDocument/authorization/consent. (CONF:9960).Figure SEQ Figure \* ARABIC 35: Consent example <authorization typeCode="AUTH"> <consent classCode="CONS" moodCode="EVN"> <id root="629deb70-5306-11df-9879-0800200c9a66" /> <code codeSystem=" 2.16.840.1.113883.6.1" codeSystemName="LOINC" code="64292-6" displayName="Release of information consent"/> <statusCode code="completed"/> </consent> </authorizationcomponentOfThe componentOf element is used to wrap the encompassing encounter for this document. The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent occurred.MAY contain zero or more [0..1] componentOf (CONF:9955)This componentOf element, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:9956)SHALL contain at least one [1..*] id (CONF:9959).SHALL contain exactly one [1..1] effectiveTime (CONF:9958).This effectiveTime SHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3) (CONF:10131).US Realm Address (AD.US.FIELDED)[Closed for comments; published December 2011][addr: 2.16.840.1.113883.10.20.22.5.2(open)]The US Realm Clinical Document Address datatype flavor is used by US Realm Clinical Document Header for the patient or any other person or organization mentioned within it.SHALL NOT have mixed content except for white space(CONF:7296).SHOULD contain @use, which SHALL be selected from ValueSet PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 (CONF:7290).SHALL contain at least one and not more than four [1..4] streetAddressLine (CONF:7291).SHALL contain exactly one [1..1] city (CONF:7292).SHOULD contain exactly one [1..1] state, which SHOULD be selected from 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, its 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).SHOULD contain exactly one [1..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, its 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).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).Table SEQ Table \* ARABIC 19: PostalAddressUse Value SetValue Set: PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01Code System(s):AddressUse 2.16.840.1.113883.5.1119CodeCode SystemPrint NameBADAddressUsebad addressCONFAddressUseconfidentialDIRAddressUsedirectHAddressUsehome addressHPAddressUseprimary homeHVAddressUsevacation homePHYSAddressUsephysical visit addressPSTAddressUsepostal addressPUBAddressUsepublicTMPAddressUsetemporaryWPAddressUsework placeUS Realm Date and Time (DT.US.FIELDED)[effectiveTime: 2.16.840.1.113883.10.20.22.5.3(open)]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.This data type uses the same rules as US Realm Date and Time (DTM.US.FIELDED), but is used with the effectiveTime element.SHALL be precise to the day (CONF:10078).SHOULD be precise to the minute (CONF:10079).MAY be precise to the second (CONF:10080).If more precise than day, SHOULD include time-zone offset (CONF:10081).US Realm Date and Time (DTM.US.FIELDED)[time: 2.16.840.1.113883.10.20.22.5.4(open)]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.This data type uses the same rules as US Realm Date and Time (DT.US.FIELDED), but is used with the time element.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: 2.16.840.1.113883.10.20.22.5.1(open)]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 ().SHALL NOT have mixed content except for white space (CONF:7278).MAY contain @use, which SHALL be selected from ValueSet EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01 (CONF:7154).MAY contain zero or more [0..*] prefix (CONF:7155).Such prefixs, if present, MAY contain @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7156).SHALL contain at least one [1..*] given (CONF:7157).The second occurrence of given (given[2]) if provided, SHALL include middle name or middle initial (CONF:7163).Such givens MAY contain @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7158).SHALL contain exactly one [1..1] family (CONF:7159).This family MAY contain @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7160).MAY contain zero or one [0..1] suffix (CONF:7161).This suffix, if present, MAY contain @qualifier, which SHALL be selected from ValueSet EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:7162).Table SEQ Table \* ARABIC 20: EntityNameUse Value SetValue Set: EntityNameUse 2.16.840.1.113883.1.11.15913 STATIC 2005-05-01Code System(s):EntityNameUse 2.16.840.1.113883.5.45CodeCode SystemPrint NameAEntityNameUseArtist/StageABCEntityNameUseAlphabeticASGNEntityNameUseAssignedCEntityNameUseLicenseIEntityNameUseIndigenous/TribalIDEEntityNameUseIdeographicLEntityNameUseLegalPEntityNameUsePseudonymPHONEntityNameUsePhoneticREntityNameUseReligiousSNDXEntityNameUseSoundexSRCHEntityNameUseSearchSYLEntityNameUseSyllabicTable SEQ Table \* ARABIC 21: EntityPersonNamePartQualifier Value SetValue Set: EntityPersonNamePartQualifier 2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30Code System(s):EntityNamePartQualifier 2.16.840.1.113883.5.43CodeCode SystemPrint NameACEntityNamePartQualifieracademicADEntityNamePartQualifieradoptedBREntityNamePartQualifierbirthCLEntityNamePartQualifiercallmeINEntityNamePartQualifierinitialNBEntityNamePartQualifiernobilityPREntityNamePartQualifierprofessionalSPEntityNamePartQualifierspouseTITLEEntityNamePartQualifiertitleVVEntityNamePartQualifiervoorvoegselUS Realm Person Name (PN.US.FIELDED)[name: 2.16.840.1.113883.10.20.22.5.1.1(open)]The US Realm Clinical Document Person Name datatype flavor is a set of reusable constraints that can be used for Persons.SHALL 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).QRDA Category I Framework Header Constraints[ClinicalDocument: templateId 2.16.840.1.113883.10.20.24.1.1 (open)]Table SEQ Table \* ARABIC1: QRDA Category I Framework ContextsUsed By:Contains Entries:Measure SectionPatient Data SectionReporting Parameters SectionThis template describes constraints that apply to the Quality Reporting Document Architecture (QRDA) Document Category I report framework. Document-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and identify contained section-level templates. The document-level template contains the following information:?Description and explanatory narrative.?Template metadata (e.g., templateId, etc.)?Header constraints: this includes a reference to the US Realm Clinical Document?Required section-level templates ClinicalDocument/template IDConforms to US Realm Header template (2.16.840.1.113883.10.20.22.1.1).SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.10.20.24.1.1" (CONF:12910).ClinicalDocument/codeSHALL contain exactly one [1..1] code="55182-0" Quality Measure Report (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:12911).ClinicalDocument/titleSHALL contain exactly one [1..1] title (CONF:12912).RecordTargetThe QRDA Category I document contains measure data for a single patient. Only one recordTarget is allowed.SHALL contain exactly one [1..1] recordTarget (CONF:12913).ClinicalDocument/participantsThe QRDA document requires a legalAuthenticator and specifies what the custodianOrganization represents in quality reporting. There are no additional participant constraints in QRDA beyond the US Realm Header.LegalAuthenticatorSHALL contain exactly one [1..1] legalAuthenticator (CONF:13817).CustodianSHALL contain exactly one [1..1] custodian (CONF:12914).This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:12915).This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:12916).This assignedCustodian SHALL represent the organization that owns and reports the data (CONF:12917).Table SEQ Table \* ARABIC 22: Participant ScenariosScenarioAuthorCustodianInformantLegal AuthenticatorQRDA is wholly constructed automatically by deviceDeviceOrganization that owns and Reports the data (e.g., hospital)NAA designated person in the organization (may be assigned to the report automatically)QRDA is partially constructed automatically by device, partially constructed by quality managerDevice;Quality ManagerOrganization that owns and Reports the data (e.g., hospital)NAA designated person in the organization (such as the Quality Manager)QRDA is constructed manually (e.g., by an organization that doesn’t have an EHR)Quality ManagerOrganization that owns and Reports the data (e.g., hospital)NAA designated person in the organization (such as the Quality Manger)QRDA Category I Framework Body ConstraintsA QRDA Document contains a Measure section, a Reporting Parameters Section and a Patient Data Section.SHALL contain exactly one [1..1] component (CONF:12918).This component SHALL contain exactly one [1..1] structuredBody (CONF:12919).This structuredBody SHALL contain exactly one [1..1] Measure Section (templateId:2.16.840.1.113883.10.20.24.2.2) (CONF:12920).This structuredBody SHALL contain exactly one [1..1] Reporting Parameters Section (templateId:2.16.840.1.113883.10.20.17.2.1) (CONF:12923).This structuredBody SHALL contain exactly one [1..1] Patient Data Section (templateId:2.16.840.1.113883.10.20.17.2.4) (CONF:12924).QDM-Based QRDA[ClinicalDocument: templateId 2.16.840.1.113883.10.20.24.1.2 (open)]Table SEQ Table \* ARABIC3: QDM-Based QRDA ContextsUsed By:Contains Entries:Measure Section QDMPatient Data Section QDMReporting Parameters SectionA QDM-based QRDA is a QRDA where the patient data entry level templates are derived from the National Quality Forum (NQF) Quality Data Model. A QDM-based QRDA defines explicitly how an HQMF NQF eMeasure is referenced.Conforms to QRDA Category I Framework template (2.16.840.1.113883.10.20.24.1.1).SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.10.20.24.1.2" (CONF:12972).SHALL contain exactly one [1..1] Measure Section QDM (templateId:2.16.840.1.113883.10.20.24.2.3) (CONF:12973).SHALL contain exactly one [1..1] Reporting Parameters Section (templateId:2.16.840.1.113883.10.20.17.2.1) (CONF:12974).SHALL contain exactly one [1..1] Patient Data Section QDM (templateId:2.16.840.1.113883.10.20.24.2.1) (CONF:12975).Section-Level TemplatesThis section contains the section-level templates. Section-level templates are always included in a document with a structured body.Each section-level template contains the following:Template metadata (e.g., templateId, etc.)Description and explanatory narrativeLOINC section codeSection titleEntry-level template names and Ids for referenced templates.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 narrative is wholly derived from the structured entries.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.Measure Section[section: templateId 2.16.840.1.113883.10.20.24.2.2 (open)]Table SEQ Table \* ARABIC23: Measure Section ContextsUsed By:Contains Entries:QRDA Category I Framework (required)Measure ReferenceThis section contains information about the measure or measures being reported. It must contain entries with identifiers of all the measures so that corresponding QRDA data element entry templates to be instantiated in the Patient Data Section are identified.SHALL contain exactly one [1..1] templateId (CONF:12801).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.2.2" (CONF:12802).SHALL contain exactly one [1..1] code with @xsi:type="CD"="55186-1" Measure Section (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:12798).SHALL contain exactly one [1..1] title="Measure Section" (CONF:12799).SHALL contain exactly one [1..1] text (CONF:12800).SHALL contain exactly one [1..1] Measure Reference (templateId:2.16.840.1.113883.10.20.24.3.98) (CONF:13003).Measure Section QDM[section: templateId 2.16.840.1.113883.10.20.24.2.3 (closed)]Table SEQ Table \* ARABIC24: Measure Section QDM ContextsUsed By:Contains Entries:QDM-Based QRDA (required)eMeasure Reference QDMThis section contains information about the eMeasure or eMeasures being reported. It must contain entries with the identifiers of all the eMeasures so that corresponding QRDA QDM data element entry templates to be instantiated in the Patient Data Section are identified. Each eMeasure for which QRDA QDM data elements are being sent must reference the eMeasures act/id. Other eMeasure identifiers that could be referenced are the eMeasure Identifier (Measure Authoring Tool), eMeasure Version Number, eMeasure Title and the NQF Number.Conforms to Measure Section template (2.16.840.1.113883.10.20.24.2.2).SHALL contain exactly one [1..1] templateId (CONF:12803).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.2.3" (CONF:12804).SHALL contain exactly one [1..1] entry (CONF:12978).This entry SHALL contain exactly one [1..1] eMeasure Reference QDM (templateId:2.16.840.1.113883.10.20.24.3.97) (CONF:13193).Patient Data Section[section: templateId 2.16.840.1.113883.10.20.17.2.4 (open)]Table SEQ Table \* ARABIC25: Patient Data Section ContextsUsed By:Contains Entries:QRDA Category I Framework (required)The patient data section contains clinically significant patient data and may contain patient data elements and measure-specific grouping data elements as defined by particular measure(s).SHALL contain exactly one [1..1] templateId (CONF:12794).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.17.2.4" (CONF:12795).SHALL contain exactly one [1..1] code with @xsi:type="CD"="55188-7" Patient data (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:3865).SHALL contain exactly one [1..1] title="Patient Data" (CONF:3866).SHALL contain exactly one [1..1] text (CONF:3867).Patient Data Section QDM[section: templateId 2.16.840.1.113883.10.20.24.2.1 (open)]Table SEQ Table \* ARABIC26: Patient Data Section QDM ContextsUsed By:Contains Entries:DRAFT POSTED 4/4/2012 NOTE: The clinical Statement QDM pattern QRDA entry templates listed here are the only ones considered ready for ballot. Other QDM pattern QRDA entry templates in this guide may change before ballotQDM-Based QRDA (required)Care GoalCommunication from Patient to ProviderCommunication from Provider to PatientCommunication from Provider to ProviderDevice Adverse EventDevice AllergyDevice AppliedDevice IntoleranceDevice OrderDevice RecommendedDiagnosis ActiveDiagnosis InactiveDiagnosis ResolvedDiagnostic Study Adverse EventDiagnostic Study IntoleranceEncounter ActiveEncounter OrderEncounter RecommendedFunctional Status OrderFunctional Status PerformedFunctional Status RecommendedFunctional Status ResultLaboratory Test OrderLaboratory Test PerformedLaboratory Test RecommendedLaboratory Test ResultPatient Care ExperiencePhysical Exam FindingPhysical Exam PerformedPhysical Exam RecommendedProcedure OrderProcedure PerformedProcedure RecommendedProcedure ResultProvider Care ExperienceSymptom ActiveSymptom InactiveSymptom ResolvedThis section contains entries that conform to the QDM approach to QRDA. Contained entries must have a template ID extension that is the same as the QDM valueSet ID associated with the QDM Data element in the measure being reported. All entries must also have time element.Conforms to Patient Data Section template (2.16.840.1.113883.10.20.17.2.4).SHALL contain exactly one [1..1] templateId (CONF:12796).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.2.1" (CONF:12797).MAY contain zero or more [0..*] entry (CONF:12833) such that itSHALL contain exactly one [1..1] Care Goal (templateId:2.16.840.1.113883.10.20.24.3.1) (CONF:13081).MAY contain zero or more [0..*] entry (CONF:12871) such that itSHALL contain exactly one [1..1] Communication from Patient to Provider (templateId:2.16.840.1.113883.10.20.24.3.2) (CONF:13261).MAY contain zero or more [0..*] entry (CONF:12875) such that itSHALL contain exactly one [1..1] Device Adverse Event (templateId:2.16.840.1.113883.10.20.24.3.5) (CONF:13135).MAY contain zero or more [0..*] entry (CONF:12902) such that itSHALL contain exactly one [1..1] Device Intolerance (templateId:2.16.840.1.113883.10.20.24.3.8) (CONF:13136).MAY contain zero or more [0..*] entry (CONF:12904) such that itSHALL contain exactly one [1..1] Device Order (templateId:2.16.840.1.113883.10.20.24.3.9) (CONF:13137).MAY contain zero or more [0..*] entry (CONF:12906) such that itSHALL contain exactly one [1..1] Device Recommended (templateId:2.16.840.1.113883.10.20.24.3.10) (CONF:13138).MAY contain zero or more [0..*] entry (CONF:12908) such that itSHALL contain exactly one [1..1] Diagnosis Active (templateId:2.16.840.1.113883.10.20.24.3.11) (CONF:13139).MAY contain zero or more [0..*] entry (CONF:12976) such that itSHALL contain exactly one [1..1] Diagnosis Inactive (templateId:2.16.840.1.113883.10.20.24.3.13) (CONF:13140).MAY contain zero or more [0..*] entry (CONF:13015) such that itSHALL contain exactly one [1..1] Diagnosis Resolved (templateId:2.16.840.1.113883.10.20.24.3.14) (CONF:13141).MAY contain zero or more [0..*] entry (CONF:13017) such that itSHALL contain exactly one [1..1] Diagnostic Study Adverse Event (templateId:2.16.840.1.113883.10.20.24.3.15) (CONF:13142).MAY contain zero or more [0..*] entry (CONF:13019) such that itSHALL contain exactly one [1..1] Diagnostic Study Intolerance (templateId:2.16.840.1.113883.10.20.24.3.16) (CONF:13143).MAY contain zero or more [0..*] entry (CONF:13021) such that itSHALL contain exactly one [1..1] Encounter Active (templateId:2.16.840.1.113883.10.20.24.3.21) (CONF:13144).MAY contain zero or more [0..*] entry (CONF:13034) such that itSHALL contain exactly one [1..1] Encounter Order (templateId:2.16.840.1.113883.10.20.24.3.22) (CONF:13145).MAY contain zero or more [0..*] entry (CONF:13146) such that itSHALL contain exactly one [1..1] Encounter Recommended (templateId:2.16.840.1.113883.10.20.24.3.24) (CONF:13147).MAY contain zero or more [0..*] entry (CONF:13148) such that itSHALL contain exactly one [1..1] Functional Status Order (templateId:2.16.840.1.113883.10.20.24.3.25) (CONF:13149).MAY contain zero or more [0..*] entry (CONF:13150) such that itSHALL contain exactly one [1..1] Functional Status Performed (templateId:2.16.840.1.113883.10.20.24.3.26) (CONF:13151).MAY contain zero or more [0..*] entry (CONF:13152) such that itSHALL contain exactly one [1..1] Functional Status Recommended (templateId:2.16.840.1.113883.10.20.24.3.27) (CONF:13153).MAY contain zero or more [0..*] entry (CONF:13154) such that itSHALL contain exactly one [1..1] Laboratory Test Order (templateId:2.16.840.1.113883.10.20.24.3.37) (CONF:13155).MAY contain zero or more [0..*] entry (CONF:13156) such that itSHALL contain exactly one [1..1] Laboratory Test Performed (templateId:2.16.840.1.113883.10.20.24.3.38) (CONF:13157).MAY contain zero or more [0..*] entry (CONF:13160) such that itSHALL contain exactly one [1..1] Laboratory Test Result (templateId:2.16.840.1.113883.10.20.24.3.40) (CONF:13161).MAY contain zero or more [0..*] entry (CONF:13162) such that itSHALL contain exactly one [1..1] Procedure Order (templateId:2.16.840.1.113883.10.20.24.3.63) (CONF:13163).MAY contain zero or more [0..*] entry (CONF:13164) such that itSHALL contain exactly one [1..1] Procedure Performed (templateId:2.16.840.1.113883.10.20.24.3.64) (CONF:13165).MAY contain zero or more [0..*] entry (CONF:13166) such that itSHALL contain exactly one [1..1] Procedure Recommended (templateId:2.16.840.1.113883.10.20.24.3.65) (CONF:13167).MAY contain zero or more [0..*] entry (CONF:13168) such that itSHALL contain exactly one [1..1] Procedure Result (templateId:2.16.840.1.113883.10.20.24.3.66) (CONF:13169).MAY contain zero or more [0..*] entry (CONF:13170) such that itSHALL contain exactly one [1..1] Provider Care Experience (templateId:2.16.840.1.113883.10.20.24.3.67) (CONF:13171).MAY contain zero or more [0..*] entry (CONF:13172) such that itSHALL contain exactly one [1..1] Symptom Active (templateId:2.16.840.1.113883.10.20.24.3.76) (CONF:13173).MAY contain zero or more [0..*] entry (CONF:13174) such that itSHALL contain exactly one [1..1] Symptom Inactive (templateId:2.16.840.1.113883.10.20.24.3.78) (CONF:13175).MAY contain zero or more [0..*] entry (CONF:13176) such that itSHALL contain exactly one [1..1] Symptom Resolved (templateId:2.16.840.1.113883.10.20.24.3.79) (CONF:13177).MAY contain zero or more [0..*] entry (CONF:13245) such that itSHALL contain exactly one [1..1] Patient Care Experience (templateId:2.16.840.1.113883.10.20.24.3.48) (CONF:13246).MAY contain zero or more [0..*] entry (CONF:13247) such that itSHALL contain exactly one [1..1] Physical Exam Finding (templateId:2.16.840.1.113883.10.20.24.3.57) (CONF:13248).MAY contain zero or more [0..*] entry (CONF:13249) such that itSHALL contain exactly one [1..1] Physical Exam Performed (templateId:2.16.840.1.113883.10.20.24.3.59) (CONF:13250).MAY contain zero or more [0..*] entry (CONF:13262) such that itSHALL contain exactly one [1..1] Communication from Provider to Patient (templateId:2.16.840.1.113883.10.20.24.3.3) (CONF:13263).MAY contain zero or more [0..*] entry (CONF:13264) such that itSHALL contain exactly one [1..1] Communication from Provider to Provider (templateId:2.16.840.1.113883.10.20.24.3.4) (CONF:13265).MAY contain zero or more [0..*] entry (CONF:13266) such that itSHALL contain exactly one [1..1] Device Allergy (templateId:2.16.840.1.113883.10.20.24.3.6) (CONF:13267).MAY contain zero or more [0..*] entry (CONF:13268) such that itSHALL contain exactly one [1..1] Device Applied (templateId:2.16.840.1.113883.10.20.24.3.7) (CONF:13269).MAY contain zero or more [0..*] entry (CONF:13270) such that itSHALL contain exactly one [1..1] Functional Status Result (templateId:2.16.840.1.113883.10.20.24.3.28) (CONF:13271).MAY contain zero or more [0..*] entry (CONF:13272) such that itSHALL contain exactly one [1..1] Laboratory Test Recommended (templateId:2.16.840.1.113883.10.20.24.3.39) (CONF:13273).MAY contain zero or more [0..*] entry (CONF:13290) such that itSHALL contain exactly one [1..1] Patient Care Experience (templateId:2.16.840.1.113883.10.20.24.3.48) (CONF:13291).MAY contain zero or more [0..*] entry (CONF:13294) such that itSHALL contain exactly one [1..1] Physical Exam Recommended (templateId:2.16.840.1.113883.10.20.24.3.60) (CONF:13295).Reporting Parameters Section[section: templateId 2.16.840.1.113883.10.20.17.2.1 (open)]Table SEQ Table \* ARABIC27: Reporting Parameters Section ContextsUsed By:Contains Entries:QRDA Category I Framework (required)QDM-Based QRDA (required)Reporting Parameters ActThe Reporting Parameters Section provides information about the reporting time interval, and may contain other information that provides context for the patient data being reported. The receiving organization may tell the reporting hospitals what information they want in this section.SHALL contain exactly one [1..1] code with @xsi:type="CD"="55187-9" Reporting Parameters (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:4141).SHALL contain exactly one [1..1] title="Reporting Parameters" (CONF:4142).SHALL contain exactly one [1..1] text (CONF:4143).SHALL contain exactly one [1..1] templateId/@root="2.16.840.1.113883.10.20.17.2.1" (CONF:3276).SHALL contain exactly one [1..1] entry (CONF:3277) such that itSHALL contain exactly one [1..1] @typeCode="DRIV" Is derived from (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:3278).SHALL contain exactly one [1..1] Reporting Parameters Act (templateId:2.16.840.1.113883.10.20.17.3.8) (CONF:3279).Entry-Level TemplatesAge Observation[Closed for comments; published December 2011][observation: templateId 2.16.840.1.113883.10.20.22.4.31 (open)]Table SEQ Table \* ARABIC28: Age Observation ContextsUsed By:Contains Entries:Problem Observation (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").Table SEQ Table \* ARABIC29: Age Observation Constraints OverviewNameXPathCard.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) = EVNtemplateId1..1SHALLSET<II>7899@root1..1SHALL104872.16.840.1.113883.10.20.22.4.31code1..1SHALLCE76152.16.840.1.113883.6.96 (SNOMED-CT) = 445518008statusCode/@code1..1SHALLCS76162.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLPQ7617@unit1..1SHALL76182.16.840.1.113883.11.20.9.21 (AgePQ_UCUM)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7613).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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 with @xsi:type="CE"="445518008" Age At Onset (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:7615).SHALL contain exactly one [1..1] statusCode/@code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7616).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).Communication from Patient to Provider[act: templateId 2.16.840.1.113883.10.20.24.3.2 (open)]Table SEQ Table \* ARABIC30: Communication from Patient to Provider ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceThe receipt of response from a patient with respect to any aspect of the care provided. A time/date stamp is required.Notes: This is the QRDA template corresponds to the QDM data type Communication: From Patient to Provider.Table SEQ Table \* ARABIC31: Communication from Patient to Provider Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.2']@classCode1..1SHALLActClassObservation114842.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALLx_ActMoodDocumentObservation114852.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11486@root1..1SHALL114872.16.840.1.113883.10.20.24.3.2id1..*SHALL11619statusCode1..1SHALL116202.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11622participant1..1SHALL11631@typeCode1..1SHALL116322.16.840.1.113883.5.90 (HL7ParticipationType) = IRCPparticipantRole1..1SHALL11633@classCode1..1SHALL120982.16.840.1.113883.5.110 (RoleClass) = ASSIGNEDcode1..1SHALL116512.16.840.1.113883.6.96 (SNOMED-CT) = 158965000participant1..1SHALL11835@typeCode1..1SHALL120992.16.840.1.113883.5.90 (HL7ParticipationType) = AUTparticipantRole1..1SHALL11836@classCode1..1SHALL121002.16.840.1.113883.5.110 (RoleClass) = PATentryRelationship0..1MAY11638observation1..1SHALL11639entryRelationship0..1MAY11640observation1..1SHALL11641SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11484).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11485).SHALL contain exactly one [1..1] templateId (CONF:11486) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.2" (CONF:11487).SHALL contain at least one [1..*] id (CONF:11619).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from CodeSystem ActStatus (2.16.840.1.113883.5.14)="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11620).SHALL contain exactly one [1..1] effectiveTime (CONF:11622).SHALL contain exactly one [1..1] participant (CONF:11631) such that itSHALL contain exactly one [1..1] @typeCode="IRCP" information recipient (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11632).SHALL contain exactly one [1..1] participantRole (CONF:11633).This participantRole SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12098).This participantRole SHALL contain exactly one [1..1] code="158965000" medical practitioner (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11651).SHALL contain exactly one [1..1] participant (CONF:11835) such that itSHALL contain exactly one [1..1] @typeCode="AUT" author (originator) (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12099).SHALL contain exactly one [1..1] participantRole (CONF:11836).This participantRole SHALL contain exactly one [1..1] @classCode="PAT" patient (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12100).MAY contain zero or one [0..1] entryRelationship (CONF:11638) such that itSHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11639).MAY contain zero or one [0..1] entryRelationship (CONF:11640) such that itSHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11641).Communication from Provider to Patient[act: templateId 2.16.840.1.113883.10.20.24.3.3 (open)]Table SEQ Table \* ARABIC32: Communication from Provider to Patient ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceThe provision of any communication to the patient. (e.g., results, findings, plans for care, medical advice, instructions, educational resources, appointments, result).Notes: This is the corresponding QRDA template to the QRDA pattern Communication, From Provider to Patient.Table SEQ Table \* ARABIC33: Communication from Provider to Patient Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.3']@classCode1..1SHALL118402.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL118412.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11842@root1..1SHALL118432.16.840.1.113883.10.20.24.3.3@extension1..1SHALL11844id1..*SHALL11845statusCode1..1SHALL118462.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11847participant1..1SHALL11850@typeCode1..1SHALL118512.16.840.1.113883.5.90 (HL7ParticipationType) = AUTparticipantRole1..1SHALL11852@classCode1..1SHALL121012.16.840.1.113883.5.110 (RoleClass) = ASSIGNEDcode1..1SHALL118532.16.840.1.113883.6.96 (SNOMED-CT) = 158965000participant1..1SHALL11856@typeCode1..1SHALL118572.16.840.1.113883.5.90 (HL7ParticipationType) = IRCPparticipantRole1..1SHALL11858@classCode1..1SHALL121022.16.840.1.113883.5.110 (RoleClass) = PATentryRelationship0..1MAY11848observation1..1SHALL11849entryRelationship0..1MAY11854observation1..1SHALL11855SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11840).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11841).SHALL contain exactly one [1..1] templateId (CONF:11842) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.3" (CONF:11843).SHALL contain exactly one [1..1] @extension (CONF:11844).SHALL contain at least one [1..*] id (CONF:11845).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11846).SHALL contain exactly one [1..1] effectiveTime (CONF:11847).SHALL contain exactly one [1..1] participant (CONF:11850) such that itSHALL contain exactly one [1..1] @typeCode="AUT" author (originator) (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11851).SHALL contain exactly one [1..1] participantRole (CONF:11852).This participantRole SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12101).This participantRole SHALL contain exactly one [1..1] code="158965000" Medical Practitioner (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11853).SHALL contain exactly one [1..1] participant (CONF:11856) such that itSHALL contain exactly one [1..1] @typeCode="IRCP" information recipient (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11857).SHALL contain exactly one [1..1] participantRole (CONF:11858).This participantRole SHALL contain exactly one [1..1] @classCode="PAT" patient (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12102).MAY contain zero or one [0..1] entryRelationship (CONF:11848) such that itSHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11849).MAY contain zero or one [0..1] entryRelationship (CONF:11854) such that itSHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11855).Communication from Provider to Provider[act: templateId 2.16.840.1.113883.10.20.24.3.4 (open)]Table SEQ Table \* ARABIC34: Communication from Provider to Provider ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceThe provision of any communication from one clinician to another regarding findings, assessments, plans of care, consultative advice, instructions, educational resources, etc.Notes: This is the corresponding QRDA template to the QDM pattern Communication, From Provider to Provider.Table SEQ Table \* ARABIC35: Communication from Provider to Provider Constraints OverviewNameXPathCard.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..1SHALL118192.16.840.1.113883.10.20.24.3.4@extension1..1SHALL11820id1..*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) = 158965000participant1..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) = 158965000entryRelationship0..1MAY11831observation1..1SHALL11832entryRelationship0..1MAY11833observation1..1SHALL11834SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11816).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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 exactly one [1..1] @extension (CONF:11820).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) (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) (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) (CONF:12096).This participantRole SHALL contain exactly one [1..1] code="158965000" Medical Practitioner (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (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) (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) (CONF:12097).This participantRole SHALL contain exactly one [1..1] code="158965000" Medical Practitioner (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (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).Device Adverse Event[observation: templateId 2.16.840.1.113883.10.20.24.3.5 (open)]Table SEQ Table \* ARABIC36: Device Adverse Event ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReactionA device adverse event is an unexpected or dangerous reaction to a device. Serious adverse events are those that are fatal, life-threatening, permanently/significantly disabling, those that require or prolong hospitalization, and those that require intervention to prevent permanent impairment or damage. A time/date stamp is required as are notations indicating whether item is patient reported and/or provider verified.Table SEQ Table \* ARABIC37: Device Adverse Event Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.5']@classCode1..1SHALL121042.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL121052.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL121062.16.840.1.113883.10.20.24.3.5@extension1..1SHALL12131id1..*SHALL12107code1..1SHALL121082.16.840.1.113883.5.4 (ActCode) = ASSERTIONstatusCode1..1SHALL121092.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12110value1..1SHALLCD12111@code1..1SHALL121892.16.840.1.113883.6.96 (SNOMED-CT) = 281647001participant1..1SHALL121122.16.840.1.113883.5.90 (HL7ParticipationType)@typeCode1..1SHALL121132.16.840.1.113883.5.90 (HL7ParticipationType) = PRDparticipantRole1..1SHALL12114@classCode1..1SHALL121152.16.840.1.113883.5.110 (RoleClass) = MANUplayingDevice1..1SHALL12116@classCode1..1SHALL121172.16.840.1.113883.5.90 (HL7ParticipationType) = DEVcode1..1SHALL12118entryRelationship1..1SHALL12119@typeCode1..1SHALL121222.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL12123trueobservation1..1SHALL12124entryRelationship1..1SHALL12120@typeCode1..1SHALL121252.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12126entryRelationship1..1SHALL12121@typeCode1..1SHALL121272.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12128SHALL contain exactly one [1..1] @classCode="OBS" observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12104).SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12105).SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.10.20.24.3.5" (CONF:12106) such that itSHALL contain exactly one [1..1] @extension (CONF:12131).SHALL contain at least one [1..*] id (CONF:12107).SHALL contain exactly one [1..1] code="ASSERTION" (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:12108).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12109).SHALL contain exactly one [1..1] effectiveTime (CONF:12110).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12111).This value SHALL contain exactly one [1..1] @code, which SHALL be selected from CodeSystem SNOMED-CT (2.16.840.1.113883.6.96)="281647001" adverse reaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12189).SHALL contain exactly one [1..1] participant (CONF:12112) such that itSHALL contain exactly one [1..1] @typeCode="PRD" product (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12113).SHALL contain exactly one [1..1] participantRole (CONF:12114).This participantRole SHALL contain exactly one [1..1] @classCode="MANU" manufactured product (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12115).This participantRole SHALL contain exactly one [1..1] playingDevice (CONF:12116).This playingDevice SHALL contain exactly one [1..1] @classCode="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12117).This playingDevice SHALL contain exactly one [1..1] code (CONF:12118).SHALL contain exactly one [1..1] entryRelationship (CONF:12119) such that itSHALL contain exactly one [1..1] @typeCode="MFST" is manifestation of (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12122).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:12123).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:12124).SHALL contain exactly one [1..1] entryRelationship (CONF:12120) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12125).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12126).SHALL contain exactly one [1..1] entryRelationship (CONF:12121) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12127).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12128).Device Allergy[observation: templateId 2.16.840.1.113883.10.20.24.3.6 (open)]Table SEQ Table \* ARABIC38: Device Allergy ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReactionA device allergy is an immunologically mediated reaction that exhibits specificity and recurrence on re-exposure to the offending device (e.g., implanted device). A time/date stamp is required as are notations indicating whether the item is patient reported and/or provider verified.Table SEQ Table \* ARABIC39: Device Allergy Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.6']@classCode1..1SHALL121322.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL121332.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL121342.16.840.1.113883.10.20.24.3.6@extension1..1SHALL12135id1..*SHALL12136code1..1SHALL121372.16.840.1.113883.5.4 (ActCode) = ASSERTIONstatusCode1..1SHALL121382.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12139value1..1SHALLCD12140@code1..1SHALL121882.16.840.1.113883.6.96 (SNOMED-CT) = 106190000participant1..1SHALL121412.16.840.1.113883.5.90 (HL7ParticipationType)@typeCode1..1SHALL121422.16.840.1.113883.5.90 (HL7ParticipationType) = PRDparticipantRole1..1SHALL12143@classCode1..1SHALL121442.16.840.1.113883.5.110 (RoleClass) = MANUplayingDevice1..1SHALL12145@classCode1..1SHALL121462.16.840.1.113883.5.90 (HL7ParticipationType) = DEVcode1..1SHALL12147entryRelationship1..1SHALL12148@typeCode1..1SHALL121492.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL12150trueobservation1..1SHALL12151entryRelationship0..1MAY12152@typeCode1..1SHALL121532.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12154entryRelationship0..1MAY12155@typeCode1..1SHALL121562.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12157SHALL contain exactly one [1..1] @classCode="OBS" observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12132).SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12133).SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.10.20.24.3.6" (CONF:12134) such that itSHALL contain exactly one [1..1] @extension (CONF:12135).SHALL contain at least one [1..*] id (CONF:12136).SHALL contain exactly one [1..1] code="ASSERTION" (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:12137).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12138).SHALL contain exactly one [1..1] effectiveTime (CONF:12139).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12140).This value SHALL contain exactly one [1..1] @code, which SHALL be selected from CodeSystem SNOMED-CT (2.16.840.1.113883.6.96)="106190000" allergy (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12188).SHALL contain exactly one [1..1] participant (CONF:12141) such that itSHALL contain exactly one [1..1] @typeCode="PRD" product (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12142).SHALL contain exactly one [1..1] participantRole (CONF:12143).This participantRole SHALL contain exactly one [1..1] @classCode="MANU" manufactured product (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12144).This participantRole SHALL contain exactly one [1..1] playingDevice (CONF:12145).This playingDevice SHALL contain exactly one [1..1] @classCode="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12146).This playingDevice SHALL contain exactly one [1..1] code (CONF:12147).SHALL contain exactly one [1..1] entryRelationship (CONF:12148) such that itSHALL contain exactly one [1..1] @typeCode="MFST" is manifestation of (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12149).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:12150).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:12151).MAY contain zero or one [0..1] entryRelationship (CONF:12152) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12153).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12154).MAY contain zero or one [0..1] entryRelationship (CONF:12155) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12156).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12157).Device Intolerance[observation: templateId 2.16.840.1.113883.10.20.24.3.8 (open)]Table SEQ Table \* ARABIC40: Device Intolerance ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceDevice intolerance is a reaction in specific patients representing a low threshold to the normal actions of a device. Intolerance is generally based on patient report and perception of his or her ability to tolerate a device that was properly applied. A time/date stamp is required as arenotations indicating whether the item is patient reported and/or provider verified.Notes: This is the corresponding QRDA template for the QDM pattern Device, Intolerance.Table SEQ Table \* ARABIC41: Device Intolerance Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.8']@classCode1..1SHALL121602.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL121612.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL121622.16.840.1.113883.10.20.24.3.8@extension1..1SHALL12163id1..*SHALL12164code1..1SHALL121652.16.840.1.113883.6.96 (SNOMED-CT) = 29544009statusCode1..1SHALL121662.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12167value1..1SHALL12342participant1..1SHALL121702.16.840.1.113883.5.90 (HL7ParticipationType)@typeCode1..1SHALL121712.16.840.1.113883.5.90 (HL7ParticipationType) = PRDparticipantRole1..1SHALL12172@classCode1..1SHALL121732.16.840.1.113883.5.110 (RoleClass) = MANUplayingDevice1..1SHALL12174@classCode1..1SHALL121752.16.840.1.113883.5.90 (HL7ParticipationType) = DEVcode1..1SHALL12176entryRelationship0..1MAY12181@typeCode1..1SHALL121822.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12183entryRelationship0..1MAY12184@typeCode1..1SHALL121852.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12186SHALL contain exactly one [1..1] @classCode="OBS" observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12160).SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12161).SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.10.20.24.3.8" (CONF:12162) such that itSHALL contain exactly one [1..1] @extension (CONF:12163).SHALL contain at least one [1..*] id (CONF:12164).SHALL contain exactly one [1..1] code="29544009" intolerance (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12165).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12166).SHALL contain exactly one [1..1] effectiveTime (CONF:12167).SHALL contain exactly one [1..1] value (CONF:12342).SHALL contain exactly one [1..1] participant (CONF:12170) such that itSHALL contain exactly one [1..1] @typeCode="PRD" product (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12171).SHALL contain exactly one [1..1] participantRole (CONF:12172).This participantRole SHALL contain exactly one [1..1] @classCode="MANU" manufactured product (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12173).This participantRole SHALL contain exactly one [1..1] playingDevice (CONF:12174).This playingDevice SHALL contain exactly one [1..1] @classCode="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12175).This playingDevice SHALL contain exactly one [1..1] code (CONF:12176).MAY contain zero or one [0..1] entryRelationship (CONF:12181) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12182).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12183).MAY contain zero or one [0..1] entryRelationship (CONF:12184) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12185).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12186).Diagnostic Study Adverse Event[observation: templateId 2.16.840.1.113883.10.20.24.3.15 (open)]Table SEQ Table \* ARABIC42: Diagnostic Study Adverse Event ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProcedure PerformedProvider PreferenceReactionThis clinical statement represents an adverse event caused by a diagnostic study.An adverse event is an unexpected or dangerous reaction to a device, diagnostic study, intervention, laboratory test, procedure, or substance. Serious adverse events are those that are fatal, life-threatening, permanently or significantly disabling, or require or prolonging hospitalization.A diagnostic study is any kind of medical test performed as a specific test or series of steps to aid in diagnosing or detecting disease (e.g., to establish a diagnosis, measure the progress or recovery from disease, to confirm that a person is free from disease).Table SEQ Table \* ARABIC43: Diagnostic Study Adverse Event Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.15']@classCode1..1SHALL117672.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL117682.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11769@root1..1SHALL117702.16.840.1.113883.10.20.24.3.15id1..1SHALL11771code1..1SHALL11772@code1..1SHALL117732.16.840.1.113883.6.96 (SNOMED-CT) = 281647001statusCode1..1SHALL11774@code1..1SHALL117752.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11776low1..1SHALL11777high0..1SHOULD11778entryRelationship1..1SHALL11779@typeCode1..1SHALL117802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUS@inversionInd1..1SHALL11781trueprocedure1..1SHALL11782entryRelationship0..1SHOULD11783@typeCode1..1SHALL117842.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL11785trueobservation1..1SHALL11786entryRelationship0..1MAY11787@typeCode1..1SHALL117882.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11789entryRelationship0..1MAY11790@typeCode1..1SHALL117912.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11792SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11767).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11768).SHALL contain exactly one [1..1] templateId (CONF:11769).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.15" (CONF:11770).SHALL contain exactly one [1..1] id (CONF:11771).SHALL contain exactly one [1..1] code (CONF:11772).This code SHALL contain exactly one [1..1] @code="281647001" adverse reaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11773).SHALL contain exactly one [1..1] statusCode (CONF:11774).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11775).SHALL contain exactly one [1..1] effectiveTime (CONF:11776).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11777).This effectiveTime SHOULD contain zero or one [0..1] high (CONF:11778).SHALL contain exactly one [1..1] entryRelationship (CONF:11779) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11780).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11781).SHALL contain exactly one [1..1] Procedure Performed (templateId:2.16.840.1.113883.10.20.24.3.64) (CONF:11782).SHOULD contain zero or one [0..1] entryRelationship (CONF:11783) such that itSHALL contain exactly one [1..1] @typeCode="MFST" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11784).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11785).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:11786).MAY contain zero or one [0..1] entryRelationship (CONF:11787) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11788).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11789).MAY contain zero or one [0..1] entryRelationship (CONF:11790) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11791).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11792).Diagnostic Study Intolerance[observation: templateId 2.16.840.1.113883.10.20.24.3.16 (open)]Table SEQ Table \* ARABIC44: Diagnostic Study Intolerance ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProcedure PerformedProvider PreferenceReactionThis clinical statement template represents an intolerance to a diagnostic study perceived and reported by the patient. Table SEQ Table \* ARABIC45: Diagnostic Study Intolerance Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.16']@classCode1..1SHALL117332.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL117342.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11735@root1..1SHALL117362.16.840.1.113883.10.20.24.3.16id1..1SHALL11737code1..1SHALL11738@code1..1SHALL117392.16.840.1.113883.3.560 (National Quality Forum (NQF)) = INTOL-XstatusCode1..1SHALL11740@code1..1SHALL117412.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11742low1..1SHALL11743high0..1SHOULD11744entryRelationship1..1SHALL11745@typeCode1..1SHALL117462.16.840.1.113883.5.90 (HL7ParticipationType) = CAUS@inversionInd1..1SHALL11747trueprocedure1..1SHALL11748entryRelationship0..1SHOULD11749@typeCode1..1SHALL117502.16.840.1.113883.5.90 (HL7ParticipationType) = MFST@inversionInd1..1SHALL11751trueobservation1..1SHALL11752entryRelationship0..1MAY11753@typeCode1..1SHALL117542.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL11755entryRelationship0..1MAY11756@typeCode1..1SHALL117572.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL11758SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11733).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11734).SHALL contain exactly one [1..1] templateId (CONF:11735).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.16" (CONF:11736).SHALL contain exactly one [1..1] id (CONF:11737).SHALL contain exactly one [1..1] code (CONF:11738).This code SHALL contain exactly one [1..1] @code="INTOL-X" intolerance (CodeSystem: National Quality Forum (NQF) 2.16.840.1.113883.3.560) (CONF:11739).SHALL contain exactly one [1..1] statusCode (CONF:11740).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11741).SHALL contain exactly one [1..1] effectiveTime (CONF:11742).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11743).This effectiveTime SHOULD contain zero or one [0..1] high (CONF:11744).SHALL contain exactly one [1..1] entryRelationship (CONF:11745) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11746).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11747).SHALL contain exactly one [1..1] Procedure Performed (templateId:2.16.840.1.113883.10.20.24.3.64) (CONF:11748).SHOULD contain zero or one [0..1] entryRelationship (CONF:11749) such that itSHALL contain exactly one [1..1] @typeCode="MFST" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11750).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11751).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:11752).MAY contain zero or one [0..1] entryRelationship (CONF:11753) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11754).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11755).MAY contain zero or one [0..1] entryRelationship (CONF:11756) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11757).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11758).Drug Vehicle[Closed for comments; published December 2011][participantRole: templateId 2.16.840.1.113883.10.20.22.4.24 (open)]Table SEQ Table \* ARABIC46: Drug Vehicle ContextsUsed By:Contains Entries:Medication Activity (optional)This template represents the vehicle (e.g. saline, dextrose) for administering a medication.Table SEQ Table \* ARABIC47: Drug Vehicle Constraints OverviewNameXPathCard.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) = MANUtemplateId1..1SHALLSET<II>7495@root1..1SHALL104932.16.840.1.113883.10.20.22.4.24code1..1SHALLCE74912.16.840.1.113883.6.96 (SNOMED-CT) = 412307009playingEntity1..1SHALL7492code1..1SHALLCE7493name0..1MAYPN7494SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (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 with @xsi:type="CE"="412307009" Drug Vehicle (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:7491).SHALL contain exactly one [1..1] playingEntity (CONF:7492).This playingEntity SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:7493).This playingEntity/code is used to supply a coded term for the drug vehicle (CONF:10086).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).eMeasure Reference QDM[organizer: templateId 2.16.840.1.113883.10.20.24.3.97 (open)]Table SEQ Table \* ARABIC48: eMeasure Reference QDM ContextsUsed By:Contains Entries:Measure Section QDM (required)This template defines the way that a QDM eMeasure should be referenced in a QDM based QRDA.Table SEQ Table \* ARABIC49: eMeasure Reference QDM Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.24.3.97']@classCode1..1SHALLCS128052.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALLCS128062.16.840.1.113883.5.1001 (ActMood) = EVNstatusCode1..1SHALL128072.16.840.1.113883.5.14 (ActStatus) = completedreference1..*SHALL12808@typeCode1..1SHALLCS128092.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRexternalDocument1..1SHALL128102.16.840.1.113883.5.6 (HL7ActClass) = DOCid1..1SHALL12811@root1..1SHALL12812id0..1SHOULD12856@root1..1SHALL128572.16.840.1.113883.3.560.1@extension1..1SHALL12858id0..1SHOULD12860@root1..1SHALL12861TempMATtoolrootOID@extension1..1SHALL12862code0..1SHOULD128642.16.840.1.113883.6.1 (LOINC) = 57024-2text0..1SHOULD12865setId0..1SHOULD12867versionNumber0..1SHOULD12869SHALL contain exactly one [1..1] @classCode="CLUSTER" cluster (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12805).SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12806).SHALL contain exactly one [1..1] statusCode="completed" completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12807).SHALL contain at least one [1..*] reference (CONF:12808) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12809).SHALL contain exactly one [1..1] externalDocument="DOC" Document (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12810).This externalDocument SHALL contain exactly one [1..1] id (CONF:12811) such that itSHALL contain exactly one [1..1] @root (CONF:12812).This ID is equal to the version specific identifier for eMeasure QualityMeasureDocument/id. It is a GUID (CONF:12813).This externalDocument SHOULD contain zero or one [0..1] id (CONF:12856) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.3.560.1" (CONF:12857).SHALL contain exactly one [1..1] @extension (CONF:12858).The root is an NQF OID for an eMeasure Number and the extension is the eMeasure's unique NQF number (CONF:12859).This externalDocument SHOULD contain zero or one [0..1] id (CONF:12860) such that itSHALL contain exactly one [1..1] @root="TempMATtoolrootOID" (CONF:12861).SHALL contain exactly one [1..1] @extension (CONF:12862).The extension represents the eMeasure Measure Authoring Tool Identifier (CONF:12863).This externalDocument SHOULD contain zero or one [0..1] code="57024-2" Health Quality Measure Document (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:12864).This externalDocument SHOULD contain zero or one [0..1] text (CONF:12865).This text is the title of the eMeasure (CONF:12866).This externalDocument SHOULD contain zero or one [0..1] setId (CONF:12867).This setId is equal to the QualityMeasureDocument/setId which is the eMeasure version neutral id (CONF:12868).This externalDocument SHOULD contain zero or one [0..1] versionNumber (CONF:12869).The version number is equal to the sequential eMeasure Version number (CONF:12870).Encounter Activities[Closed for comments; published December 2011][encounter: templateId 2.16.840.1.113883.10.20.22.4.49 (open)]Table SEQ Table \* ARABIC50: Encounter Activities ContextsUsed By:Contains Entries:IndicationService Delivery LocationThis clinical statement describes the interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.Table SEQ Table \* ARABIC51: Encounter Activities Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Encounter Activitiesencounter[templateId/@root = '2.16.840.1.113883.10.20.22.4.49']@classCode1..1SHALL87102.16.840.1.113883.5.6 (HL7ActClass) = ENC@moodCode1..1SHALL87112.16.840.1.113883.5.6 (HL7ActClass) = EVNtemplateId1..1SHALLSET<II>8712@root1..1SHALL104942.16.840.1.113883.10.20.22.4.49encounterIDid1..*SHALLII8713encounterTypecode0..1SHOULDCE87142.16.840.1.113883.3.88.12.80.32 (EncounterTypeCode)originalText0..1SHOULDED8719encounterFreeTextTypereference/@value0..1SHOULD8720encounterDateTimeeffectiveTime1..1SHALLTS or IVL<TS>8715performer0..*MAY8725encounterProviderassignedEntity1..1SHALL8726code0..1MAYCE8727facilityLocationparticipant0..*MAY8738@typeCode1..1SHALL87402.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCreasonForVisitentryRelationship0..*MAY8722@typeCode1..1SHALL87232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONSHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8710).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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" (CONF:10494).SHALL contain at least one [1..*] id (CONF:8713).SHOULD contain zero or one [0..1] code with @xsi:type="CE", where the @code 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/@value (CONF:8720).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:8721).SHALL contain exactly one [1..1] effectiveTime (CONF:8715).MAY have a 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. 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 dischargeDispositionCode element (CONF:9929).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 with @xsi:type="CE" (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) (CONF:8740).SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:8739).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) (CONF:8723).SHALL contain exactly one [1..1] Indication (templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:8724).Encounter Active[encounter: templateId 2.16.840.1.113883.10.20.24.3.21 (open)]Table SEQ Table \* ARABIC52: Encounter Active ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Facility LocationPatient PreferenceProvider PreferenceReasonThis clinical statement describes an active interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.Table SEQ Table \* ARABIC53: Encounter Active Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueencounter[templateId/@root = '2.16.840.1.113883.10.20.24.3.21']templateId1..1SHALL11888@root1..1SHALL118892.16.840.1.113883.10.20.24.3.21@extension1..1SHALL11897code1..1SHALL11894statusCode1..1SHALL11895@code1..1SHALL118962.16.840.1.113883.5.14 (ActStatus) = activeeffectiveTime1..1SHALL11898low1..1SHALL11899high1..1SHALL11900participant0..1MAY13388entryRelationship0..1MAY11901@typeCode1..1SHALL119022.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11903entryRelationship0..1MAY11904@typeCode1..1SHALL119052.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11906entryRelationship0..1MAY11907@typeCode1..1SHALL119082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11909Conforms to Encounter Activities template (2.16.840.1.113883.10.20.22.4.49).SHALL contain exactly one [1..1] templateId (CONF:11888) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.21" (CONF:11889).SHALL contain exactly one [1..1] @extension (CONF:11897).SHALL contain exactly one [1..1] code (CONF:11894).SHALL contain exactly one [1..1] statusCode (CONF:11895).This statusCode SHALL contain exactly one [1..1] @code="active" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11896).SHALL contain exactly one [1..1] effectiveTime (CONF:11898).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11899).This effectiveTime SHALL contain exactly one [1..1] high (CONF:11900).MAY contain zero or one [0..1] Facility Location (templateId:2.16.840.1.113883.10.20.24.3.100) (CONF:13388).MAY contain zero or one [0..1] entryRelationship (CONF:11901) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11902).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11903).MAY contain zero or one [0..1] entryRelationship (CONF:11904) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11905).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11906).MAY contain zero or one [0..1] entryRelationship (CONF:11907) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11908).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11909).Encounter Performed[encounter: templateId 2.16.840.1.113883.10.20.24.3.23 (open)]Table SEQ Table \* ARABIC54: Encounter Performed ContextsUsed By:Contains Entries:Facility LocationPatient PreferenceProvider PreferenceReasonTransfer FromTransfer ToThis clinical statement describes the interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.Table SEQ Table \* ARABIC55: Encounter Performed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueencounter[templateId/@root = '2.16.840.1.113883.10.20.24.3.23']templateId1..1SHALL11861@root1..1SHALL118622.16.840.1.113883.10.20.24.3.23@extension1..1SHALL11863code1..1SHALL11864statusCode1..1SHALL11874@code1..1SHALL118752.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11876low1..1SHALL11877high1..1SHALL11878participant0..1MAY13025participant0..1MAYParticipant213386participant0..1MAYParticipant213387entryRelationship0..1MAY11865@typeCode1..1SHALL118662.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11867entryRelationship0..1MAY11868@typeCode1..1SHALL118692.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11870entryRelationship0..1MAY11871@typeCode1..1SHALL118722.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11873Conforms to Encounter Activities template (2.16.840.1.113883.10.20.22.4.49).SHALL contain exactly one [1..1] templateId (CONF:11861) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.23" (CONF:11862).SHALL contain exactly one [1..1] @extension (CONF:11863).SHALL contain exactly one [1..1] code (CONF:11864).SHALL contain exactly one [1..1] statusCode (CONF:11874).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11875).SHALL contain exactly one [1..1] effectiveTime (CONF:11876).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11877).This effectiveTime SHALL contain exactly one [1..1] high (CONF:11878).MAY contain zero or one [0..1] Facility Location (templateId:2.16.840.1.113883.10.20.24.3.100) (CONF:13025).MAY contain zero or one [0..1] Transfer From (templateId:2.16.840.1.113883.10.20.24.3.81) (CONF:13386).MAY contain zero or one [0..1] Transfer To (templateId:2.16.840.1.113883.10.20.24.3.82) (CONF:13387).MAY contain zero or one [0..1] entryRelationship (CONF:11865) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11866).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11867).MAY contain zero or one [0..1] entryRelationship (CONF:11868) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11869).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11870).MAY contain zero or one [0..1] entryRelationship (CONF:11871) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11872).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11873).Functional Status Performed[observation: templateId 2.16.840.1.113883.10.20.24.3.26 (open)]Table SEQ Table \* ARABIC56: Functional Status Performed ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonA functional status assessment has been completed. The expected performer and recorder of the assessment will vary with the measure. Table SEQ Table \* ARABIC57: Functional Status Performed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.26']@classCode1..1SHALL127512.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL127522.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12753@root1..1SHALL127542.16.840.1.113883.10.20.24.3.26@extension1..1SHALL12755id1..*SHALL12756code1..1SHALL12757statusCode1..1SHALL12758@code1..1SHALL127592.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12760low1..1SHALL12761high1..1SHALL12762methodCode0..1MAY12763entryRelationship0..1MAY12765@typeCode1..1SHALL127662.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12767entryRelationship0..1MAY12768@typeCode1..1SHALL127692.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12770entryRelationship0..1MAY12771@typeCode1..1SHALL127722.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12773SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12751).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12752).SHALL contain exactly one [1..1] templateId (CONF:12753) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.26" (CONF:12754).SHALL contain exactly one [1..1] @extension (CONF:12755).SHALL contain at least one [1..*] id (CONF:12756).SHALL contain exactly one [1..1] code (CONF:12757).SHALL contain exactly one [1..1] statusCode (CONF:12758).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12759).SHALL contain exactly one [1..1] effectiveTime (CONF:12760).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12761).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12762).MAY contain zero or one [0..1] methodCode (CONF:12763).MAY contain zero or one [0..1] entryRelationship (CONF:12765) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12766).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12767).MAY contain zero or one [0..1] entryRelationship (CONF:12768) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12769).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12770).MAY contain zero or one [0..1] entryRelationship (CONF:12771) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12772).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12773).Health Status Observation[Closed for comments; published December 2011][observation: templateId 2.16.840.1.113883.10.20.22.4.5 (closed)]Table SEQ Table \* ARABIC58: Health Status Observation ContextsUsed By:Contains Entries:Problem Observation (optional)The Health Status Observation records information about the current health status of the patient.Table SEQ Table \* ARABIC59: Health Status Observation Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.5']@classCode1..1SHALL90572.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL90722.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALLCE90732.16.840.1.113883.6.1 (LOINC) = 11323-3text0..1SHOULDED9270reference/@value0..1SHOULD9271statusCode1..1SHALLCS90742.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD90752.16.840.1.113883.3.88.12.80.68 (HITSPProblemStatus)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:9057).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:9072).SHALL contain exactly one [1..1] code with @xsi:type="CE"="11323-3" Health status (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:9073).SHOULD contain zero or one [0..1] text (CONF:9270).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:9271).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:9272).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:9074).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHALL be selected from ValueSet HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:9075).Immunization Medication Information[Closed for comments; published December 2011][manufacturedProduct: templateId 2.16.840.1.113883.10.20.22.4.54 (open)]Table SEQ Table \* ARABIC60: Immunization Medication Information ContextsUsed By:Contains Entries:Medication Dispense (optional)Medication Supply Order (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: SEQ Table \* ARABIC61: Immunization Medication Information Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Immunization Medication InformationmanufacturedProduct[templateId/@root = '2.16.840.1.113883.10.20.22.4.54']@classCode1..1SHALL90022.16.840.1.113883.5.110 (RoleClass) = MANUtemplateId1..1SHALLSET<II>9004@root1..1SHALL104992.16.840.1.113883.10.20.22.4.54id0..*MAYII9005manufacturedMaterial1..1SHALL9006codedProductNamecode1..1SHALLCE90072.16.840.1.113883.3.88.12.80.22 (Vaccine Administered Value Set)freeTextProductNameoriginalText0..1SHOULDED9008reference/@value0..1SHOULD9009translation0..*MAYSET<PQR>9011lotNumberlotNumberText0..1SHOULDST9014drugManufacturermanufacturerOrganization0..1SHOULD9012SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (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 with @xsi:type="CE", where the @code 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/@value (CONF:9009).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:9010).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:9013).This manufacturedMaterial SHOULD contain zero or one [0..1] lotNumberText (CONF:9014).SHOULD contain zero or one [0..1] manufacturerOrganization (CONF:9012).Incision Datetime[observation: templateId 2.16.840.1.113883.10.20.24.3.89 (open)]Table SEQ Table \* ARABIC62: Incision Datetime ContextsUsed By:Contains Entries:Procedure Performed (optional)Notes: Need to find a description for this template.Table SEQ Table \* ARABIC63: Incision Datetime Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.89']@classCode1..1SHALLActClassObservation114002.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALLx_ActMoodDocumentObservation114012.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLII11402@root1..1SHALLuid114032.16.840.1.113883.10.20.24.3.89code1..1SHALL11404@code1..1SHALLcs114052.16.840.1.113883.6.96 (SNOMED-CT) = 34896006qualifier1..1SHALLCR11406name1..1SHALLCV114072.16.840.1.113883.6.96 (SNOMED-CT) = 118575009value1..1SHALLCD114082.16.840.1.113883.6.96 (SNOMED-CT) = 398201009value1..1SHALLANY11409SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11400).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11401).SHALL contain exactly one [1..1] templateId (CONF:11402) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.89" (CONF:11403).SHALL contain exactly one [1..1] code (CONF:11404).This code SHALL contain exactly one [1..1] @code="34896006" incision (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11405).This code SHALL contain exactly one [1..1] qualifier (CONF:11406).This qualifier SHALL contain exactly one [1..1] name="118575009" datetime (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11407).This qualifier SHALL contain exactly one [1..1] value with @xsi:type="CD"="398201009" start datetime (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11408).SHALL contain exactly one [1..1] value with @xsi:type="ANY" (CONF:11409).Indication[Closed for comments; published December 2011][observation: templateId 2.16.840.1.113883.10.20.22.4.19 (open)]Table SEQ Table \* ARABIC64: Indication ContextsUsed By:Contains Entries:Medication Activity (optional)Procedure Activity Procedure (optional)Procedure Activity Observation (optional)Procedure Activity Act (optional)Encounter Activities (optional)The Indication Observation documents the rationale for an activity. It can do this with the id element to reference a problem recorded elsewhere in the document or with a code and value to record the problem type and problem within the Indication. For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section.Table SEQ Table \* ARABIC65: Indication Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.19']@classCode1..1SHALL74802.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL74812.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLSET<II>7482@root1..1SHALL105022.16.840.1.113883.10.20.22.4.19id1..1SHALLII7483code0..1SHOULDCE74842.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)statusCode1..1SHALLCS74872.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime0..1SHOULDTS or IVL<TS>7488value0..1SHOULDCD7489code0..1SHOULD79912.16.840.1.113883.3.88.12.3221.7.4 (Problem)@nullFlavor0..1MAY10088SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7480).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (CONF:10502).SHALL contain exactly one [1..1] id (CONF:7483).Set the observation/id equal to an ID on the problem list to signify that problem as an indication (CONF:9321).SHOULD contain zero or one [0..1] code with @xsi:type="CE", where the @code SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2011-07-01 (CONF:7484).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7487).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 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:7991).The code, if present, MAY contain zero or one [0..1] @nullFlavor (CONF:10088).If the diagnosis is unkown 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:10089).Instructions[Closed for comments; published December 2011][act: templateId 2.16.840.1.113883.10.20.22.4.20 (open)]Table SEQ Table \* ARABIC66: Instructions ContextsUsed By:Contains Entries:Medication Supply Order (optional)Medication Activity (optional)Procedure Activity Procedure (optional)Procedure Activity Observation (optional)Procedure Activity Act (optional)The Instructions 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.Table SEQ Table \* ARABIC67: Instructions Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.22.4.20']@classCode1..1SHALL73912.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL73922.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALLSET<II>7393@root1..1SHALL105032.16.840.1.113883.10.20.22.4.20code1..1SHALLCE73942.16.840.1.113883.11.20.9.34 (Patient Education)text0..1SHOULDED7395reference/@value0..1SHOULD7397statusCode1..1SHALLCS73962.16.840.1.113883.5.14 (ActStatus) = completedSHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7391).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (CONF:10503).SHALL contain exactly one [1..1] code with @xsi:type="CE", where the @code SHOULD be selected from ValueSet Patient Education 2.16.840.1.113883.11.20.9.34 DYNAMIC (CONF:7394).SHOULD contain zero or one [0..1] text (CONF:7395).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7397).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:7398).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7396).Intervention Adverse Event[observation: templateId 2.16.840.1.113883.10.20.24.3.29 (open)]Table SEQ Table \* ARABIC68: Intervention Adverse Event ContextsUsed By:Contains Entries:Intervention PerformedPatient PreferenceProvider PreferenceReactionAn Intervention Adverse Event is an unexpected or dangerous reaction to an intervention. Serious adverse events are those that are fatal, life-threatening, permanently/significantly disabling, those that require or prolong hospitalization, and those that require intervention to prevent permanent impairment or damage. Table SEQ Table \* ARABIC69: Intervention Adverse Event Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.29']@classCode1..1SHALL135382.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL135392.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL13540@root1..1SHALL135412.16.840.1.113883.10.20.24.3.29id1..1SHALL13542code1..1SHALL13543@code1..1SHALL135442.16.840.1.113883.6.96 (SNOMED-CT) = 281647001statusCode1..1SHALL135452.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL13546low1..1SHALL13547high0..1SHOULD13548entryRelationship1..1SHALL13549@typeCode1..1SHALL135502.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUS@inversionInd1..1SHALL13551trueact1..1SHALL13563entryRelationship0..1SHOULD13553@typeCode1..1SHALL135542.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL13555trueobservation1..1SHALL13556entryRelationship0..1MAY13557@typeCode1..1SHALL135582.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL13559entryRelationship0..1MAY13560@typeCode1..1SHALL135612.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL13562SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13538).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13539).SHALL contain exactly one [1..1] templateId (CONF:13540).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.29" (CONF:13541).SHALL contain exactly one [1..1] id (CONF:13542).SHALL contain exactly one [1..1] code (CONF:13543).This code SHALL contain exactly one [1..1] @code="281647001" Adverse reaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:13544).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13545).SHALL contain exactly one [1..1] effectiveTime (CONF:13546).This effectiveTime SHALL contain exactly one [1..1] low (CONF:13547).This effectiveTime SHOULD contain zero or one [0..1] high (CONF:13548).SHALL contain exactly one [1..1] entryRelationship (CONF:13549) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13550).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:13551).SHALL contain exactly one [1..1] Intervention Performed (templateId:2.16.840.1.113883.10.20.24.3.32) (CONF:13563).SHOULD contain zero or one [0..1] entryRelationship (CONF:13553) such that itSHALL contain exactly one [1..1] @typeCode="MFST" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13554).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:13555).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:13556).MAY contain zero or one [0..1] entryRelationship (CONF:13557) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13558).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:13559).MAY contain zero or one [0..1] entryRelationship (CONF:13560) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13561).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:13562).Intervention Intolerance[observation: templateId 2.16.840.1.113883.10.20.24.3.30 (open)]Table SEQ Table \* ARABIC70: Intervention Intolerance ContextsUsed By:Contains Entries:Intervention PerformedPatient PreferenceProvider PreferenceReactionThis clinical statement template represents an intolerance to an intervention generally perceived and reported by the patient.Table SEQ Table \* ARABIC71: Intervention Intolerance Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.30']@classCode1..1SHALL136572.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL136582.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL13659@root1..1SHALL136602.16.840.1.113883.10.20.24.3.30id1..1SHALL13661code1..1SHALL13662@code1..1SHALL136632.16.840.1.113883.3.560 (National Quality Forum (NQF)) = INTOL-XstatusCode1..1SHALL13664@code1..1SHALL136652.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL13666low1..1SHALL13667high0..1SHOULD13668entryRelationship0..1SHOULD13669@typeCode1..1SHALL136702.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL13671trueobservation1..1SHALL13672entryRelationship0..1MAY13673@typeCode1..1SHALL136742.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL13675entryRelationship0..1MAY13676@typeCode1..1SHALL136772.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL13678entryRelationship1..1SHALL13679@typeCode1..1SHALL136802.16.840.1.113883.5.90 (HL7ParticipationType) = CAUS@inversionInd1..1SHALL13681trueact1..1SHALL13683SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13657).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13658).SHALL contain exactly one [1..1] templateId (CONF:13659).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.30" (CONF:13660).SHALL contain exactly one [1..1] id (CONF:13661).SHALL contain exactly one [1..1] code (CONF:13662).This code SHALL contain exactly one [1..1] @code="INTOL-X" intolerance (CodeSystem: National Quality Forum (NQF) 2.16.840.1.113883.3.560) (CONF:13663).SHALL contain exactly one [1..1] statusCode (CONF:13664).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13665).SHALL contain exactly one [1..1] effectiveTime (CONF:13666).This effectiveTime SHALL contain exactly one [1..1] low (CONF:13667).This effectiveTime SHOULD contain zero or one [0..1] high (CONF:13668).SHOULD contain zero or one [0..1] entryRelationship (CONF:13669) such that itSHALL contain exactly one [1..1] @typeCode="MFST" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13670).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:13671).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:13672).MAY contain zero or one [0..1] entryRelationship (CONF:13673) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:13674).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:13675).MAY contain zero or one [0..1] entryRelationship (CONF:13676) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:13677).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:13678).SHALL contain exactly one [1..1] entryRelationship (CONF:13679) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:13680).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:13681).SHALL contain exactly one [1..1] Intervention Performed (templateId:2.16.840.1.113883.10.20.24.3.32) (CONF:13683).Laboratory Test Adverse Event[observation: templateId 2.16.840.1.113883.10.20.24.3.35 (open)]Table SEQ Table \* ARABIC72: Laboratory Test Adverse Event ContextsUsed By:Contains Entries:Laboratory Test PerformedPatient PreferenceProvider PreferenceReactionThis clinical statement represents an adverse event caused by a lab test. An adverse event is an unexpected or dangerous reaction to procedure. Serious adverse events are those that are fatal, life-threatening, permanently or significantly disabling, or require or prolonging hospitalization.A lab test is a study in the clinical laboratory (traditionally chemistry, hematology, microbiology, serology, urinalysis, blood bank) that has been performed. A time/date stamp is required. Table SEQ Table \* ARABIC73: Laboratory Test Adverse Event Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.35']@classCode1..1SHALL131942.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL131952.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL13196@root1..1SHALL13197id1..1SHALL13198code1..1SHALL13199@code1..1SHALL132002.16.840.1.113883.6.96 (SNOMED-CT) = 281647001statusCode1..1SHALL13201@code1..1SHALL132022.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL13203low1..1SHALL13204high0..1SHOULD13205entryRelationship1..1SHALL13206@typeCode1..1SHALL132072.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUS@inversionInd1..1SHALL13208trueobservation1..1SHALL13209entryRelationship0..1MAYEntryRelationship13210@typeCode1..1SHALL132112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL13212entryRelationship0..1MAYEntryRelationship13213@typeCode1..1SHALL132142.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL13215entryRelationship0..1SHOULDEntryRelationship13216@typeCode1..1SHALL132172.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL13218trueobservation1..1SHALL13219SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13194).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13195).SHALL contain exactly one [1..1] templateId (CONF:13196).This templateId SHALL contain exactly one [1..1] @root (CONF:13197).SHALL contain exactly one [1..1] id (CONF:13198).SHALL contain exactly one [1..1] code (CONF:13199).This code SHALL contain exactly one [1..1] @code="281647001" Adverse Reaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:13200).SHALL contain exactly one [1..1] statusCode (CONF:13201).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13202).SHALL contain exactly one [1..1] effectiveTime (CONF:13203).This effectiveTime SHALL contain exactly one [1..1] low (CONF:13204).This effectiveTime SHOULD contain zero or one [0..1] high (CONF:13205).SHALL contain exactly one [1..1] entryRelationship (CONF:13206) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13207).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:13208).SHALL contain exactly one [1..1] Laboratory Test Performed (templateId:2.16.840.1.113883.10.20.24.3.38) (CONF:13209).MAY contain zero or one [0..1] entryRelationship (CONF:13210) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13211).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:13212).MAY contain zero or one [0..1] entryRelationship (CONF:13213) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13214).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:13215).SHOULD contain zero or one [0..1] entryRelationship (CONF:13216) such that itSHALL contain exactly one [1..1] @typeCode="MFST" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13217).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:13218).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:13219).Laboratory Test Intolerance[observation: templateId 2.16.840.1.113883.10.20.24.3.36 (open)]Table SEQ Table \* ARABIC74: Laboratory Test Intolerance ContextsTable SEQ Table \* ARABIC75: Laboratory Test Intolerance Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.36']Laboratory Test Performed[observation: templateId 2.16.840.1.113883.10.20.24.3.38 (open)]Table SEQ Table \* ARABIC76: Laboratory Test Performed ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Laboratory Test Adverse Event (required)Patient PreferenceProvider PreferenceReasonA study in the clinical laboratory (traditionally chemistry, hematology, microbiology, serology, urinalysis, blood bank) has been performed. A time/date stamp is required. A laboratory test is a medical procedure that involves testing a sample of blood, urine, or other substance from the body. Tests can help determine a diagnosis, plan treatment, check to see if t reatment is working, or monitor the disease over time. Laboratory tests may be performed on specimens not derived from patients (electrolytes or contents of water or consumed fluids, cultures of environment, pets, other animals). The states will remain the same.Table SEQ Table \* ARABIC77: Laboratory Test Performed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.38']@classCode1..1SHALL117052.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL117062.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11721@root1..1SHALL117222.16.840.1.113883.10.20.24.3.38@extension1..1SHALL11723id1..*SHALL11707code1..1SHALL11708statusCode1..1SHALL11709@code1..1SHALL117102.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11711low1..1SHALL11712high1..1SHALL11713methodCode0..1MAY11714entryRelationship0..1MAY11718@typeCode1..1SHALL117192.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11720entryRelationship0..1MAY11724@typeCode1..1SHALL117252.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11726entryRelationship0..1MAY11727@typeCode1..1SHALL117282.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11729SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11705).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11706).SHALL contain exactly one [1..1] templateId (CONF:11721) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.38" (CONF:11722).SHALL contain exactly one [1..1] @extension (CONF:11723).SHALL contain at least one [1..*] id (CONF:11707).SHALL contain exactly one [1..1] code (CONF:11708).SHALL contain exactly one [1..1] statusCode (CONF:11709).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11710).SHALL contain exactly one [1..1] effectiveTime (CONF:11711).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11712).This effectiveTime SHALL contain exactly one [1..1] high (CONF:11713).MAY contain zero or one [0..1] methodCode (CONF:11714).MAY contain zero or one [0..1] entryRelationship (CONF:11718) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11719).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11720).MAY contain zero or one [0..1] entryRelationship (CONF:11724) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11725).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11726).MAY contain zero or one [0..1] entryRelationship (CONF:11727) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11728).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11729).Measure Reference[organizer: templateId 2.16.840.1.113883.10.20.24.3.98 (open)]Table SEQ Table \* ARABIC78: Measure Reference ContextsUsed By:Contains Entries:Measure Section (required)Table SEQ Table \* ARABIC79: Measure Reference Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueorganizer[templateId/@root = '2.16.840.1.113883.10.20.24.3.98']@classCode1..1SHALLCS129792.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER@moodCode1..1SHALLCS129802.16.840.1.113883.5.1001 (ActMood) = EVNstatusCode1..1SHALL129812.16.840.1.113883.5.14 (ActStatus) = completedreference1..1SHALL12982@typeCode1..1SHALLCS129832.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRexternalDocument1..1SHALL129842.16.840.1.113883.5.6 (HL7ActClass) = DOCid1..1SHALL12985@root1..1SHALL12986text0..1SHOULD12997SHALL contain exactly one [1..1] @classCode="CLUSTER" cluster (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12979).SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12980).SHALL contain exactly one [1..1] statusCode="completed" completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12981).SHALL contain exactly one [1..1] reference (CONF:12982) such that itSHALL contain exactly one [1..1] @typeCode="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12983).SHALL contain exactly one [1..1] externalDocument="DOC" Document (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12984).This externalDocument SHALL contain exactly one [1..1] id (CONF:12985) such that itSHALL contain exactly one [1..1] @root (CONF:12986).This ID references the ID of the Quality Measure (CONF:12987).This externalDocument SHOULD contain zero or one [0..1] text (CONF:12997).This text is the title of the eMeasure (CONF:12998).Medication Activity[Closed for comments; published December 2011][substanceAdministration: templateId 2.16.840.1.113883.10.20.22.4.16 (open)]Table SEQ Table \* ARABIC80: Medication Activity ContextsUsed By:Contains Entries:Reaction Observation (optional)Procedure Activity Procedure (optional)Procedure Activity Observation (optional)Procedure Activity Act (optional)Medication Administered (required)Drug VehicleIndicationInstructionsMedication DispenseMedication InformationMedication Supply OrderPrecondition for Substance AdministrationReaction ObservationA 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. Medication activities in "EVN" mood reflect actual use.Medication timing is complex. This template requires that there be a substanceAdministration/effectiveTime valued with a time interval, representing the start and stop dates. Additional effectiveTime elements are optional, and can be used to represent frequency and other aspects of more detailed dosing regimens.Table SEQ Table \* ARABIC81: Medication Activity Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Medication ActivitysubstanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.22.4.16']@classCode1..1SHALL74962.16.840.1.113883.5.6 (HL7ActClass) = SBADM@moodCode1..1SHALL74972.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALLSET<II>7499@root1..1SHALL10504id1..*SHALLII7500deliveryMethodcode0..1MAYCD7506freeTextSigtext0..1SHOULDED7501reference/@value0..1SHOULD7502statusCode1..1SHALLCS7507effectiveTime1..1SHALLTS or IVL<TS>7508@xsi:type1..1SHALL9104IVL_TSindicateMedicationStartedlow1..1SHALLTS7511indicateMedicationStoppedhigh1..1SHALLTS7512administrationTimingeffectiveTime0..1SHOULDTS or IVL<TS>7513@operator1..1SHALL9106ArepeatNumber0..1MAYIVL<INT>7555routerouteCode0..1MAYCE75142.16.840.1.113883.3.88.12.3221.8.7 (Medication Route FDA Value Set)siteapproachSiteCode0..1MAYSET<CD>75152.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)dosedoseQuantity0..1SHOULDIVL<PQ>7516@unit0..1SHOULD75262.16.840.1.113883.1.11.12839 (UCUM Units of Measure (case sensitive))rateQuantity0..1MAYIVL<PQ>7517@unit1..1SHALL75252.16.840.1.113883.1.11.12839 (UCUM Units of Measure (case sensitive))doseRestrictionmaxDoseQuantity0..1MAYRTO<PQ, PQ>7518productFormadministrationUnitCode0..1MAYCE75192.16.840.1.113883.3.88.12.3221.8.11 (Medication Product Form)medicationInformationconsumable1..1SHALL7520performer0..1MAY7522vehicleparticipant0..*MAY7523@typeCode1..1SHALL75242.16.840.1.113883.5.90 (HL7ParticipationType) = CSMindicationentryRelationship0..*MAY7536@typeCode1..1SHALL75372.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONpatientInstructionsentryRelationship0..1MAY7539@typeCode1..1SHALL75402.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL7542trueorderInformationentryRelationship0..1MAY7543@typeCode1..1SHALL75472.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRfulfillmentInstructionsentryRelationship0..1MAY7549@typeCode1..1SHALL75532.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRreactionentryRelationship0..1MAY7552@typeCode1..1SHALL75442.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUSprecondition0..*MAY7546@typeCode1..1SHALL75502.16.840.1.113883.5.1002 (HL7ActRelationshipType) = PRCNSHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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 (CONF:10504).SHALL contain at least one [1..*] id (CONF:7500).MAY contain zero or one [0..1] code with @xsi:type="CD" (CONF:7506).SHOULD contain zero or one [0..1] text (CONF:7501).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7502).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:7503).SHALL contain exactly one [1..1] statusCode (CONF:7507).SHALL contain exactly one [1..1] effectiveTime (CONF:7508) such that itSHALL contain exactly one [1..1] @xsi:type, where the @code="IVL_TS" (CONF:9104).SHALL contain exactly one [1..1] low (CONF:7511).SHALL contain exactly one [1..1] high (CONF:7512).SHOULD contain zero or one [0..1] effectiveTime (CONF:7513) such that itSHALL contain exactly one [1..1] @xsi:type=”PIVL_TS” or “EIVL_TS” (CONF:9105).SHALL contain exactly one [1..1] @operator="A" (CONF:9106).MAY contain zero or one [0..1] repeatNumber (CONF:7555).A.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 (CONF:7556).In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series (CONF:9485).MAY contain zero or one [0..1] routeCode, where the @code 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).Pre-coordinated consumable: If the consumable code is a precoordinated 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") (CONF:10118).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:7533).The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:7526).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 UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:7525).Medication Activity SHOULD include doseQuantity OR rateQuantity (CONF:7529).MAY contain zero or one [0..1] maxDoseQuantity (CONF:7518).MAY contain zero or one [0..1] administrationUnitCode, where the @code SHALL be selected from ValueSet Medication Product Form 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 (templateId:2.16.840.1.113883.10.20.22.4.23) (CONF:7521).MAY contain zero or one [0..1] performer (CONF:7522).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) (CONF:7524).SHALL contain exactly one [1..1] Drug Vehicle (templateId:2.16.840.1.113883.10.20.22.4.24) (CONF:7535).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) (CONF:7537).SHALL contain exactly one [1..1] Indication (templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:7538).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) (CONF:7540).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7542).SHALL contain exactly one [1..1] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:7541).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) (CONF:7547).SHALL contain exactly one [1..1] Medication Supply Order (templateId:2.16.840.1.113883.10.20.22.4.17) (CONF:7545).MAY contain zero or one [0..1] entryRelationship (CONF:7549) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:7553).SHALL contain exactly one [1..1] Medication Dispense (templateId:2.16.840.1.113883.10.20.22.4.18) (CONF:7554).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) (CONF:7544).SHALL contain exactly one [1..1] Reaction Observation (templateId:2.16.840.1.113883.10.20.22.4.9) (CONF:7548).MAY contain zero or more [0..*] precondition (CONF:7546) such that itSHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:7550).SHALL contain exactly one [1..1] Precondition for Substance Administration (templateId:2.16.840.1.113883.10.20.22.4.25) (CONF:7551).Medication Active[substanceAdministration: templateId 2.16.840.1.113883.10.20.24.3.41 (open)]Table SEQ Table \* ARABIC82: Medication Active ContextsUsed By:Contains Entries:Patient PreferenceProvider PreferenceMedications currently taken by a patient. A time/date stamp is required. Table SEQ Table \* ARABIC83: Medication Active Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValuesubstanceAdministration[templateId/@root = '2.16.840.1.113883.10.20.24.3.41']@moodCode1..1SHALL120812.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12082@root1..1SHALL120832.16.840.1.113883.10.20.24.3.41@extension1..1SHALL12084code1..1SHALL12205statusCode1..1SHALL12412@code1..1SHALL124132.16.840.1.113883.5.14 (ActStatus) = activeentryRelationship0..1MAY12085@typeCode1..1SHALL120862.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12087entryRelationship0..1MAY12088@typeCode1..1SHALL120892.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12090Conforms to Medication Activity template (2.16.840.1.113883.10.20.22.4.16).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12081).SHALL contain exactly one [1..1] templateId (CONF:12082) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.41" (CONF:12083).SHALL contain exactly one [1..1] @extension (CONF:12084).SHALL contain exactly one [1..1] code (CONF:12205).SHALL contain exactly one [1..1] statusCode (CONF:12412).This statusCode SHALL contain exactly one [1..1] @code="active" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12413).MAY contain zero or one [0..1] entryRelationship (CONF:12085) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12086).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12087).MAY contain zero or one [0..1] entryRelationship (CONF:12088) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12089).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12090).Medication Administered[act: templateId 2.16.840.1.113883.10.20.24.3.42 (open)]Table SEQ Table \* ARABIC84: Medication Administered ContextsUsed By:Contains Entries:Medication ActivityPatient PreferenceProvider PreferenceA record by the care provider that a medication actually was administered. Appropriate time/date stamps for all medication administration are generated. Table SEQ Table \* ARABIC85: Medication Administered Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.42']@classCode1..1SHALL124442.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL124452.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12446@root0..1MAY124472.16.840.1.113883.10.20.24.3.42@extension1..1SHALL12451id1..*SHALL12448code1..1SHALL12449@code1..1SHALL124502.16.840.1.113883.6.1 (LOINC) = 18610-6statusCode1..1SHALL12452@code1..1SHALL132412.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12453entryRelationship1..1SHALL12454@typeCode1..1SHALL124552.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPsubstanceAdministration1..1SHALL12456@moodCode1..1SHALL124572.16.840.1.113883.5.1001 (ActMood) = EVNentryRelationship0..1MAY12458@typeCode1..1SHALL124592.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12460entryRelationship0..1MAY12461@typeCode1..1SHALL124622.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12463SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12444).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12445).SHALL contain exactly one [1..1] templateId (CONF:12446) such that itMAY contain zero or one [0..1] @root="2.16.840.1.113883.10.20.24.3.42" (CONF:12447).SHALL contain exactly one [1..1] @extension (CONF:12451).SHALL contain at least one [1..*] id (CONF:12448).SHALL contain exactly one [1..1] code (CONF:12449).This code SHALL contain exactly one [1..1] @code="18610-6" Medication administered (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:12450).SHALL contain exactly one [1..1] statusCode (CONF:12452).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13241).SHALL contain exactly one [1..1] effectiveTime (CONF:12453).SHALL contain exactly one [1..1] entryRelationship (CONF:12454) such that itSHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12455).SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:12456).This substanceAdministration SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12457).MAY contain zero or one [0..1] entryRelationship (CONF:12458) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12459).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12460).MAY contain zero or one [0..1] entryRelationship (CONF:12461) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12462).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12463).Medication Dispense[supply: templateId 2.16.840.1.113883.10.20.22.4.18 (open)]Table SEQ Table \* ARABIC88: Medication Dispense ContextsUsed By:Contains Entries:Medication Activity (optional)Immunization Medication InformationMedication InformationMedication Supply OrderThis template records the act of supplying medications (i.e., dispensing).Table SEQ Table \* ARABIC89: Medication Dispense Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Medication Dispensesupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.18']@classCode1..1SHALL74512.16.840.1.113883.5.6 (HL7ActClass) = SPLY@moodCode1..1SHALL74522.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLSET<II>7453@root1..1SHALL105052.16.840.1.113883.10.20.22.4.18prescriptionNumberid1..*SHALLII7454statusCode1..1SHALLCS74552.16.840.1.113883.3.88.12.80.64 (Medication Fill Status)dispenseDateeffectiveTime0..1SHOULDTS or IVL<TS>7456fillNumberrepeatNumber0..1SHOULDIVL<INT>7457quantityDispensedquantity0..1SHOULDPQ7458product0..1MAY7459product0..1MAY9331performer0..1MAY7461providerassignedEntity1..1SHALL7467addr0..1SHOULDSET<AD>7468orderInformationentryRelationship0..1MAY7473@typeCode1..1SHALL74742.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRSHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7451).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (CONF:10505).SHALL contain at least one [1..*] id (CONF:7454).SHALL contain exactly one [1..1] statusCode, where the @code 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:7466).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 (templateId:2.16.840.1.113883.10.20.22.4.23) (CONF:7460).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:9332).A supply act SHALL contain one product/Medication Information or one product/Immunization Medication Information template (CONF:9333).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) (CONF:7474).SHALL contain exactly one [1..1] Medication Supply Order (templateId:2.16.840.1.113883.10.20.22.4.17) (CONF:7476).Medication Information[manufacturedProduct: templateId 2.16.840.1.113883.10.20.22.4.23 (open)]Table SEQ Table \* ARABIC90: Medication Information ContextsUsed By:Contains Entries:Medication Supply Order (optional)Medication Dispense (optional)Medication Activity (required)The medication can be recorded as a precoordinated product strength, product form, or product concentration (e.g. "metoprolol 25mg tablet", "amoxicillin 400mg/5mL suspension"); or not pre-coordinated (e.g. "metoprolol product").Table SEQ Table \* ARABIC91: Medication Information Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Medication InformationmanufacturedProduct[templateId/@root = '2.16.840.1.113883.10.20.22.4.23']@classCode1..1SHALL74082.16.840.1.113883.5.110 (RoleClass) = MANUtemplateId1..1SHALLSET<II>7409@root1..1SHALL105062.16.840.1.113883.10.20.22.4.23id0..*MAYII7410manufacturedMaterial1..1SHALL7411codedProductNamecode1..1SHALLCE74122.16.840.1.113883.3.88.12.80.17 (Medication Clinical Drug)freeTextProductNameoriginalText0..1SHOULDED7413reference/@value0..1SHOULD7417codedBrandNametranslation0..*MAYSET<PQR>7414drugManufacturermanufacturerOrganization0..1MAY7416SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (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" (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 with @xsi:type="CE", where the @code SHALL be selected from ValueSet Medication Clinical Drug 2.16.840.1.113883.3.88.12.80.17 DYNAMIC (CONF:7412).This code SHOULD contain zero or one [0..1] originalText (CONF:7413).The originalText, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7417).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:7418).This code MAY contain zero or more [0..*] translation (CONF:7414).Translations can be used to represent generic product name, packaged product code, etc (CONF:7420).MAY contain zero or one [0..1] manufacturerOrganization (CONF:7416).Medication Supply Order[supply: templateId 2.16.840.1.113883.10.20.22.4.17 (open)]Table SEQ Table \* ARABIC92: Medication Supply Order ContextsUsed By:Contains Entries:Medication Dispense (optional)Medication Activity (optional)Immunization Medication InformationInstructionsMedication InformationThis template records the intent to supply a patient with medications.Table SEQ Table \* ARABIC93: Medication Supply Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Medication Supply Ordersupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.17']@classCode1..1SHALL74272.16.840.1.113883.5.6 (HL7ActClass) = SPLY@moodCode1..1SHALL74282.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALLSET<II>7429@root1..1SHALL105072.16.840.1.113883.10.20.22.4.17orderNumberid1..*SHALLII7430statusCode1..1SHALLCS7432orderExpirationDateTimeeffectiveTime/high0..1SHOULDTS7433fillsrepeatNumber0..1SHOULDIVL<INT>7434quantityOrderedquantity0..1SHOULDPQ7436product0..1MAY7439product0..1MAY9334orderingProviderauthor0..1MAY7438patientInstructionsentryRelationship0..1MAY7442@typeCode1..1SHALL74442.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL7445trueSHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7427).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (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/high (CONF:7433).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:7435).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 (templateId:2.16.840.1.113883.10.20.22.4.23) (CONF:7437).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:9335).A supply act SHALL contain one product/Medication Information or one product/Immunization Medication Information template (CONF:9336).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) (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] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:7443).Ordinality[observation: templateId 2.16.840.1.113883.10.20.24.3.86 (open)]Table SEQ Table \* ARABIC94: Ordinality ContextsUsed By:Contains Entries:Procedure Performed (optional)Procedure Recommended (optional)Procedure Result (optional)Diagnosis Active (optional)Diagnosis Inactive (optional)Diagnosis Resolved (optional)Symptom Active (optional)Symptom Inactive (optional)Symptom Resolved (optional)Symptom Assessed (optional)Procedure Order (optional)The scale in which objects are ordered in terms of their qualitative value, as opposed to a ranking performed strictly numerically or quantitatively. For example, a clinical quality measure may only be interested in including patients with a principal diagnosis of congestive heart failure to evaluate care during a hospitalization. The measure developer can specify Diagnosis active: congestive heart failure with the attribute ordinality: principal. Table SEQ Table \* ARABIC95: Ordinality Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.86']@classCode1..1SHALLActClassObservation112692.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALLx_ActMoodDocumentObservation112702.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLII112712.16.840.1.113883.10.20.24.3.86code1..1SHALL11272@code1..1SHALLcs112732.16.840.1.113883.6.96 (SNOMED-CT) = 117363000value1..1SHALLANY11276SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11269).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11270).SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.10.20.24.3.86" (CONF:11271).SHALL contain exactly one [1..1] code (CONF:11272).This code SHALL contain exactly one [1..1] @code="117363000" ordinality (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11273).SHALL contain exactly one [1..1] value with @xsi:type="ANY" (CONF:11276).Patient Care Experience[observation: templateId 2.16.840.1.113883.10.20.24.3.48 (open)]Table SEQ Table \* ARABIC96: Patient Care Experience ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceInformation collected from patients about their perception of the care they received.Notes: This is the corresponding QRDA template for the QDM pattern Patient Care Experience. No consolidated CDA templates seem can be reused.Table SEQ Table \* ARABIC97: Patient Care Experience Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.48']@classCode1..1SHALL124642.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL124652.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12466@root1..1SHALL124672.16.840.1.113883.10.20.24.3.48@extension1..1SHALL12468id1..*SHALL12469code1..1SHALL12470@code1..1SHALL130372.16.840.1.113883.6.96 (SNOMED-CT) = 406193000statusCode1..1SHALL124712.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12472value1..1SHALLCD13038entryRelationship0..1MAY12473@typeCode1..1SHALL124742.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL12475entryRelationship0..1MAY12476@typeCode1..1SHALL124772.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL12478SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6)="OBS" observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12464).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12465).SHALL contain exactly one [1..1] templateId (CONF:12466) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.48" (CONF:12467).SHALL contain exactly one [1..1] @extension (CONF:12468).SHALL contain at least one [1..*] id (CONF:12469).SHALL contain exactly one [1..1] code (CONF:12470).This code SHALL contain exactly one [1..1] @code="406193000" patient satisfaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:13037).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from CodeSystem ActStatus (2.16.840.1.113883.5.14)="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12471).SHALL contain exactly one [1..1] effectiveTime (CONF:12472).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:13038).MAY contain zero or one [0..1] entryRelationship (CONF:12473) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="RSON" has reason (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12474).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12475).MAY contain zero or one [0..1] entryRelationship (CONF:12476) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="RSON" has reason (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12477).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12478).Patient Characteristic Clinical Trial Participant[procedure: templateId 2.16.840.1.113883.10.20.24.3.51 (open)]Table SEQ Table \* ARABIC98: Patient Characteristic Clinical Trial Participant ContextsUsed By:Contains Entries:ReasonIndicates that the patient is a clinical trial participant.Notes: This is the corresponding QRDA template for the QDM pattern Patient Characteristic Clinical Trial Participant.Table SEQ Table \* ARABIC99: Patient Characteristic Clinical Trial Participant Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.24.3.51']@classCode1..1SHALL130432.16.840.1.113883.5.6 (HL7ActClass) = PROC@moodCode1..1SHALL125262.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12537@root1..1SHALL125382.16.840.1.113883.10.20.24.3.51@extension1..1SHALL12539id1..*SHALL12528code1..1SHALL130412.16.840.1.113883.6.96 (SNOMED-CT) = 110465008statusCode1..1SHALL130422.16.840.1.113883.5.14 (ActStatus) = activeeffectiveTime1..1SHALL12536entryRelationship0..1MAY12531@typeCode1..1SHALL125322.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12533SHALL contain exactly one [1..1] @classCode="PROC" procedure (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13043).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12526).SHALL contain exactly one [1..1] templateId (CONF:12537) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.51" (CONF:12538).SHALL contain exactly one [1..1] @extension (CONF:12539).SHALL contain at least one [1..*] id (CONF:12528).SHALL contain exactly one [1..1] code="110465008" clinical trial (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:13041).SHALL contain exactly one [1..1] statusCode="active" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13042).SHALL contain exactly one [1..1] effectiveTime (CONF:12536).MAY contain zero or one [0..1] entryRelationship (CONF:12531) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12532).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12533).Patient Characteristic Expired[observation: templateId 2.16.840.1.113883.10.20.24.3.54 (open)]Table SEQ Table \* ARABIC100: Patient Characteristic Expired ContextsUsed By:Contains Entries:ReasonIndication of patient is expired.Notes: This is the corresponding QRDA template to the QDM pattern Patient Characteristic Expired.Table SEQ Table \* ARABIC101: Patient Characteristic Expired Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.54']@classCode1..1SHALL125122.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL125132.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12540@root1..1SHALL125412.16.840.1.113883.10.20.24.3.54@extension1..1SHALL12542id1..*SHALL12515code1..1SHALL12516@code1..1SHALL125172.16.840.1.113883.6.96 (SNOMED-CT) = 419099009statusCode1..1SHALL125212.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12522value1..1SHALLCD12520entryRelationship0..1MAY12519@typeCode1..1SHALL125232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12524SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6)="OBS" observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12512).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12513).SHALL contain exactly one [1..1] templateId (CONF:12540) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.54" (CONF:12541).SHALL contain exactly one [1..1] @extension (CONF:12542).SHALL contain at least one [1..*] id (CONF:12515).SHALL contain exactly one [1..1] code (CONF:12516).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from CodeSystem SNOMED-CT (2.16.840.1.113883.6.96)="419099009" expired (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12517).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from CodeSystem ActStatus (2.16.840.1.113883.5.14)="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12521).SHALL contain exactly one [1..1] effectiveTime (CONF:12522).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12520).MAY contain zero or one [0..1] entryRelationship (CONF:12519) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12523).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12524).Patient Characteristic Payer[observation: templateId 2.16.840.1.113883.10.20.24.3.55 (open)]The payer type for the patient.Notes: This is the corresponding QRDA template for the QDM pattern Patient Characteristic Payer.Table SEQ Table \* ARABIC102: Patient Characteristic Payer Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.55']@classCode1..1SHALL125712.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL125602.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12561@root1..1SHALL125622.16.840.1.113883.10.20.24.3.55@extension1..1SHALL12563id1..*SHALL12564code1..1SHALL12565@code1..1SHALL125662.16.840.1.113883.6.1 (LOINC) = 48768-6statusCode1..1SHALL125672.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12568value1..1SHALLCD12569SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6)="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12571).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12560).SHALL contain exactly one [1..1] templateId (CONF:12561) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.55" (CONF:12562).SHALL contain exactly one [1..1] @extension (CONF:12563).SHALL contain at least one [1..*] id (CONF:12564).SHALL contain exactly one [1..1] code (CONF:12565).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from CodeSystem LOINC (2.16.840.1.113883.6.1)="48768-6" payer (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:12566).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from CodeSystem ActStatus (2.16.840.1.113883.5.14)="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12567).SHALL contain exactly one [1..1] effectiveTime (CONF:12568).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12569).Patient Preference[observation: templateId 2.16.840.1.113883.10.20.24.3.83 (open)]Table SEQ Table \* ARABIC103: Patient Preference ContextsUsed By:Contains Entries:Care Goal (optional)Procedure Adverse Event (optional)Procedure Intolerance (optional)Procedure Performed (optional)Procedure Recommended (optional)Procedure Order (optional)Communication from Patient to Provider (optional)Procedure Result (optional)Laboratory Test Performed (optional)Diagnostic Study Intolerance (optional)Diagnostic Study Adverse Event (optional)Laboratory Test Recommended (optional)Communication from Provider to Provider (optional)Communication from Provider to Patient (optional)Encounter Performed (optional)Encounter Active (optional)Encounter Recommended (optional)Encounter Order (optional)Laboratory Test Order (optional)Diagnosis Active (optional)Diagnosis Inactive (optional)Diagnosis Resolved (optional)Medication Active (optional)Device Adverse Event (required)Device Allergy (optional)Device Intolerance (optional)Symptom Active (optional)Symptom Inactive (optional)Symptom Resolved (optional)Device Order (optional)Device Recommended (optional)Device Applied (optional)Medication Administered (optional)Patient Care Experience (optional)Provider Care Experience (required)Risk Category Assessment (optional)Physical Exam Performed (optional)Physical Exam Recommended (optional)Physical Exam Order (optional)Physical Exam Finding (optional)Laboratory Test Result (optional)Functional Status Performed (optional)Functional Status Order (optional)Functional Status Recommended (optional)Functional Status Result (optional)Symptom Assessed (optional)Diagnostic Study Performed (optional)Laboratory Test Adverse Event (optional)Intervention Adverse Event (optional)Intervention Performed (optional)Intervention Order (optional)Intervention Intolerance (optional)Intervention Recommended (optional)Intervention Result (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.Table SEQ Table \* ARABIC104: Patient Preference Constraints OverviewNameXPathCard.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..1SHALL111212.16.840.1.113883.10.20.24.3.83@extension1..1SHALL11122id1..1SHALL11355code1..1SHALL11123@code1..1SHALL111242.16.840.1.113883.5.8 (HL7 Act Accommodation Reason) = PATvalue1..1SHALLCD11125SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6)="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11118).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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).This templateId SHALL contain exactly one [1..1] @extension (CONF:11122).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: HL7 Act Accommodation Reason 2.16.840.1.113883.5.8) (CONF:11124).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11125).Plan of Care Activity Encounter[encounter: templateId 2.16.840.1.113883.10.20.22.4.40 (open)]This is the template for the Plan of Care Activity Encounter.Table SEQ Table \* ARABIC105: Plan of Care Activity Encounter Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueencounter[templateId/@root = '2.16.840.1.113883.10.20.22.4.40']@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..1SHALLSET<II>8566@root1..1SHALL105112.16.840.1.113883.10.20.22.4.40id1..*SHALLII8567SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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 2011-05-02 (CONF:8565).SHALL contain exactly one [1..1] templateId (CONF:8566) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.40" (CONF:10511).SHALL contain at least one [1..*] id (CONF:8567).Encounter Order[encounter: templateId 2.16.840.1.113883.10.20.24.3.22 (open)]Table SEQ Table \* ARABIC106: Encounter Order ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonService Delivery LocationThis template describes an order for an encounter.This clinical statement describes the ordered interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.Table SEQ Table \* ARABIC107: Encounter Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueencounter[templateId/@root = '2.16.840.1.113883.10.20.24.3.22']@moodCode1..1SHALL119322.16.840.1.113883.5.1001 (ActMood) = RQOtemplateId1..1SHALL11933@root1..1SHALL119342.16.840.1.113883.10.20.24.3.22@extension1..1SHALL11935code1..1SHALL11936statusCode1..1SHALL11937@code1..1SHALL119382.16.840.1.113883.5.14 (ActStatus) = newauthor1..1SHALL11939time1..1SHALL11940participant0..*MAY11941@typeCode1..1SHALL119422.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCparticipantRole1..1SHALL11943entryRelationship0..1MAY11944@typeCode1..1SHALL119452.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11946entryRelationship0..1MAY11947@typeCode1..1SHALL119482.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11949entryRelationship0..1MAY11950@typeCode1..1SHALL119512.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11952Conforms to Plan of Care Activity Encounter template (2.16.840.1.113883.10.20.22.4.40).SHALL contain exactly one [1..1] @moodCode="RQO" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11932).SHALL contain exactly one [1..1] templateId (CONF:11933) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.22" (CONF:11934).SHALL contain exactly one [1..1] @extension (CONF:11935).SHALL contain exactly one [1..1] code (CONF:11936).SHALL contain exactly one [1..1] statusCode (CONF:11937).This statusCode SHALL contain exactly one [1..1] @code="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11938).SHALL contain exactly one [1..1] author (CONF:11939).This author SHALL contain exactly one [1..1] time (CONF:11940).MAY contain zero or more [0..*] participant (CONF:11941).The participant, if present, SHALL contain exactly one [1..1] @typeCode="LOC" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11942).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:11943).MAY contain zero or one [0..1] entryRelationship (CONF:11944) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11945).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11946).MAY contain zero or one [0..1] entryRelationship (CONF:11947) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11948).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11949).MAY contain zero or one [0..1] entryRelationship (CONF:11950) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11951).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11952).Encounter Recommended[encounter: templateId 2.16.840.1.113883.10.20.24.3.24 (open)]Table SEQ Table \* ARABIC108: Encounter Recommended ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonService Delivery LocationThis clinical statement describes the intended interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.Table SEQ Table \* ARABIC109: Encounter Recommended Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueencounter[templateId/@root = '2.16.840.1.113883.10.20.24.3.24']@moodCode1..1SHALL119112.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL11912@root1..1SHALL119132.16.840.1.113883.10.20.24.3.24@extension1..1SHALL11914code1..1SHALL11915statusCode1..1SHALL11916@code1..1SHALL119172.16.840.1.113883.5.14 (ActStatus) = newauthor1..1SHALL11918time1..1SHALL11919participant0..1MAY11920@typeCode1..1SHALL119212.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCparticipantRole1..1SHALL11922entryRelationship0..1MAY11923@typeCode1..1SHALL119242.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11925entryRelationship0..1MAY11926@typeCode1..1SHALL119272.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11928entryRelationship0..1MAY11929@typeCode1..1SHALL119302.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11931Conforms to Plan of Care Activity Encounter template (2.16.840.1.113883.10.20.22.4.40).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11911).SHALL contain exactly one [1..1] templateId (CONF:11912) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.24" (CONF:11913).SHALL contain exactly one [1..1] @extension (CONF:11914).SHALL contain exactly one [1..1] code (CONF:11915).SHALL contain exactly one [1..1] statusCode (CONF:11916).This statusCode SHALL contain exactly one [1..1] @code="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11917).SHALL contain exactly one [1..1] author (CONF:11918).This author SHALL contain exactly one [1..1] time (CONF:11919).MAY contain zero or one [0..1] participant (CONF:11920).The participant, if present, SHALL contain exactly one [1..1] @typeCode="LOC" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11921).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:11922).MAY contain zero or one [0..1] entryRelationship (CONF:11923) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11924).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11925).MAY contain zero or one [0..1] entryRelationship (CONF:11926) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11927).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11928).MAY contain zero or one [0..1] entryRelationship (CONF:11929) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11930).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11931).Plan of Care Activity Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.44 (open)]This is the template for the Plan of Care Activity Observation.Table SEQ Table \* ARABIC110: Plan of Care Activity Observation Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.44']@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..1SHALLSET<II>8583@root1..1SHALL105122.16.840.1.113883.10.20.22.4.44id1..*SHALLII8584SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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 2011-05-03 (CONF:8582).SHALL contain exactly one [1..1] templateId (CONF:8583) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.44" (CONF:10512).SHALL contain at least one [1..*] id (CONF:8584).Care Goal[observation: templateId 2.16.840.1.113883.10.20.24.3.1 (open)]Table SEQ Table \* ARABIC111: Care Goal ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceA goal is a defined target or measure to be achieved in the process of patient care. A typical goal is expressed as an observation scheduled for some time in the future with a particular value. A goal can be found in the plan of care (care plan). The plan of care (care plan) is the structure used by all stakeholders, including the patient, to define the management actions for the various conditions, problems, or issues identified for the target of the plan. It is the structure through which the goals and care planning actions and processes can be organized, planned, communicated, and checked for completion. A time/date stamp is required.Table SEQ Table \* ARABIC112: Care Goal Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.1']@classCode1..1SHALL112452.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL112462.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11247@root1..1SHALL112482.16.840.1.113883.10.20.24.3.1@extension1..1SHALL11645code1..1SHALL11251@code1..1SHALL11252@codeSystem1..1SHALL11253statusCode1..1SHALL112542.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11255entryRelationship0..1MAY11258@typeCode1..1SHALL114232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11429entryRelationship0..1MAY11259@typeCode1..1SHALL114242.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11430entryRelationship0..1MAY116462.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL11647@classCode1..1SHALL116482.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL116492.16.840.1.113883.5.1001 (ActMood) = EVNvalue1..1SHALLCD11650Conforms to Plan of Care Activity Observation template (2.16.840.1.113883.10.20.22.4.44).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11245).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11246).SHALL contain exactly one [1..1] templateId (CONF:11247) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.1" (CONF:11248).SHALL contain exactly one [1..1] @extension (CONF:11645).SHALL contain exactly one [1..1] code (CONF:11251).This code SHALL contain exactly one [1..1] @code (CONF:11252).This code SHALL contain exactly one [1..1] @codeSystem (CONF:11253).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11254).SHALL contain exactly one [1..1] effectiveTime (CONF:11255).MAY contain zero or one [0..1] entryRelationship (CONF:11258) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11423).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11429).MAY contain zero or one [0..1] entryRelationship (CONF:11259) such that itSHALL contain exactly one [1..1] @typeCode="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11424).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11430).MAY contain zero or one [0..1] entryRelationship="REFR" refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11646) such that itSHALL contain exactly one [1..1] observation (CONF:11647).This observation SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11648).This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11649).This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11650).Functional Status Order[observation: templateId 2.16.840.1.113883.10.20.24.3.25 (open)]Table SEQ Table \* ARABIC113: Functional Status Order ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonA request to perform a functional status assessment.Functional status assessment is specific tools that evaluate an individual patient's actual physical or behavioral performance as an indicator of capabilities at a point in time. The functional status assessment can be used in measurement to determine change in physical or behavioral performance over time.Table SEQ Table \* ARABIC114: Functional Status Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.25']@moodCode1..1SHALL127742.16.840.1.113883.5.1001 (ActMood) = RQOtemplateId1..1SHALL12775@root1..1SHALL127762.16.840.1.113883.10.20.24.3.25@extension1..1SHALL12777code1..1SHALL12778statusCode1..1SHALL12779@code1..1SHALL127802.16.840.1.113883.5.14 (ActStatus) = newmethodCode0..*MAY12781author1..1SHALL12782time1..1SHALL12783entryRelationship0..1MAY12784@typeCode1..1SHALL127852.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12786entryRelationship0..1MAY12787@typeCode1..1SHALL127882.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12789entryRelationship0..1MAY12790@typeCode1..1SHALL127912.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12792Conforms to Plan of Care Activity Observation template (2.16.840.1.113883.10.20.22.4.44).SHALL contain exactly one [1..1] @moodCode="RQO" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12774).SHALL contain exactly one [1..1] templateId (CONF:12775) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.25" (CONF:12776).SHALL contain exactly one [1..1] @extension (CONF:12777).SHALL contain exactly one [1..1] code (CONF:12778).SHALL contain exactly one [1..1] statusCode (CONF:12779).This statusCode SHALL contain exactly one [1..1] @code="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12780).MAY contain zero or more [0..*] methodCode (CONF:12781).SHALL contain exactly one [1..1] author (CONF:12782) such that itSHALL contain exactly one [1..1] time (CONF:12783).MAY contain zero or one [0..1] entryRelationship (CONF:12784) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12785).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12786).MAY contain zero or one [0..1] entryRelationship (CONF:12787) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12788).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12789).MAY contain zero or one [0..1] entryRelationship (CONF:12790) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12791).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12792).Functional Status Recommended[observation: templateId 2.16.840.1.113883.10.20.24.3.27 (open)]Table SEQ Table \* ARABIC115: Functional Status Recommended ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonA recommendation to perform a functional status assessment.Functional status assessment is specific tools that evaluate an individual patient's actual physical or behavioral performance as an indicator of capabilities at a point in time. The functional status assessment can be used in measurement to determine change in physical or behavioral performance over time.Table SEQ Table \* ARABIC116: Functional Status Recommended Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.27']@moodCode1..1SHALL128142.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL12815@root1..1SHALL128162.16.840.1.113883.10.20.24.3.25@extension1..1SHALL12817code1..1SHALL12818statusCode1..1SHALL12819@code1..1SHALL128202.16.840.1.113883.5.14 (ActStatus) = newmethodCode0..*MAY12821author1..1SHALL12822time1..1SHALL12823entryRelationship0..1MAY12824@typeCode1..1SHALL128252.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12826entryRelationship0..1MAY12827@typeCode1..1SHALL128282.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12829entryRelationship0..1MAY12830@typeCode1..1SHALL128312.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12832Conforms to Plan of Care Activity Observation template (2.16.840.1.113883.10.20.22.4.44).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12814).SHALL contain exactly one [1..1] templateId (CONF:12815) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.25" (CONF:12816).SHALL contain exactly one [1..1] @extension (CONF:12817).SHALL contain exactly one [1..1] code (CONF:12818).SHALL contain exactly one [1..1] statusCode (CONF:12819).This statusCode SHALL contain exactly one [1..1] @code="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12820).MAY contain zero or more [0..*] methodCode (CONF:12821).SHALL contain exactly one [1..1] author (CONF:12822) such that itSHALL contain exactly one [1..1] time (CONF:12823).MAY contain zero or one [0..1] entryRelationship (CONF:12824) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12825).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12826).MAY contain zero or one [0..1] entryRelationship (CONF:12827) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12828).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12829).MAY contain zero or one [0..1] entryRelationship (CONF:12830) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12831).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12832).Laboratory Test Order[observation: templateId 2.16.840.1.113883.10.20.24.3.37 (open)]Table SEQ Table \* ARABIC117: Laboratory Test Order ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonThis template represents an order for a laboratory test.A laboratory test is a medical procedure that involves testing a sample of blood, urine, or other substance from the body. Tests can help determine a diagnosis, plan treatment, check to see if t reatment is working, or monitor the disease over time. Laboratory tests may be performed on specimens not derived from patients (electrolytes or contents of water or consumed fluids, cultures of environment, pets, other animals). The states will remain the same.Table SEQ Table \* ARABIC118: Laboratory Test Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.37']@moodCode1..1SHALL119532.16.840.1.113883.5.1001 (ActMood) = RQOtemplateId1..1SHALL11954@root1..1SHALL119552.16.840.1.113883.10.20.24.3.37@extension1..1SHALL11956code1..1SHALL11957statusCode1..1SHALL11958@code1..1SHALL119592.16.840.1.113883.5.14 (ActStatus) = completedmethodCode0..*MAY11960author1..1SHALL11961time1..1SHALL11962entryRelationship0..1MAY11963@typeCode1..1SHALL119642.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11965entryRelationship0..1MAYEntryRelationship11966@typeCode1..1SHALL119672.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11968entryRelationship0..1MAYEntryRelationship11969@typeCode1..1SHALL119702.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11971Conforms to Plan of Care Activity Observation template (2.16.840.1.113883.10.20.22.4.44).SHALL contain exactly one [1..1] @moodCode="RQO" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11953).SHALL contain exactly one [1..1] templateId (CONF:11954) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.37" (CONF:11955).SHALL contain exactly one [1..1] @extension (CONF:11956).SHALL contain exactly one [1..1] code (CONF:11957).SHALL contain exactly one [1..1] statusCode (CONF:11958).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11959).MAY contain zero or more [0..*] methodCode (CONF:11960).SHALL contain exactly one [1..1] author (CONF:11961) such that itSHALL contain exactly one [1..1] time (CONF:11962).MAY contain zero or one [0..1] entryRelationship (CONF:11963) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11964).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11965).MAY contain zero or one [0..1] entryRelationship (CONF:11966) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11967).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11968).MAY contain zero or one [0..1] entryRelationship (CONF:11969) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11970).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11971).Laboratory Test Recommended[observation: templateId 2.16.840.1.113883.10.20.24.3.39 (open)]Table SEQ Table \* ARABIC119: Laboratory Test Recommended ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonThis template represents a laboratory test that has been recommended.A laboratory test is a medical procedure that involves testing a sample of blood, urine, or other substance from the body. Tests can help determine a diagnosis, plan treatment, check to see if t reatment is working, or monitor the disease over time. Laboratory tests may be performed on specimens not derived from patients (electrolytes or contents of water or consumed fluids, cultures of environment, pets, other animals). The states will remain the same.Table SEQ Table \* ARABIC120: Laboratory Test Recommended Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.39']@moodCode1..1SHALL117932.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL11794@root1..1SHALL117952.16.840.1.113883.10.20.24.3.39@extension1..1SHALL11796code1..1SHALL11797statusCode1..1SHALL11798@code1..1SHALL117992.16.840.1.113883.5.14 (ActStatus) = completedmethodCode0..1MAY11803author1..1SHALL11814time1..1SHALL11815entryRelationship0..1MAY11804@typeCode1..1SHALL118052.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11806entryRelationship0..1MAY11807@typeCode1..1SHALL118082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11810entryRelationship0..1MAY11811@typeCode1..1SHALL118122.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11813Conforms to Plan of Care Activity Observation template (2.16.840.1.113883.10.20.22.4.44).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11793).SHALL contain exactly one [1..1] templateId (CONF:11794) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.39" (CONF:11795).SHALL contain exactly one [1..1] @extension (CONF:11796).SHALL contain exactly one [1..1] code (CONF:11797).SHALL contain exactly one [1..1] statusCode (CONF:11798).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11799).MAY contain zero or one [0..1] methodCode (CONF:11803).SHALL contain exactly one [1..1] author (CONF:11814).This author SHALL contain exactly one [1..1] time (CONF:11815).MAY contain zero or one [0..1] entryRelationship (CONF:11804) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11805).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11806).MAY contain zero or one [0..1] entryRelationship (CONF:11807) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11808).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11810).MAY contain zero or one [0..1] entryRelationship (CONF:11811) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11812).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11813).Physical Exam Order[observation: templateId 2.16.840.1.113883.10.20.24.3.58 (open)]Table SEQ Table \* ARABIC121: Physical Exam Order ContextsUsed By:Contains Entries:Patient PreferenceProvider PreferenceReasonA request by a physician or appropriately licensed care provider to order a physical exam for the patient. A time/date stamp is required. Table SEQ Table \* ARABIC122: Physical Exam Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.58']@moodCode1..1SHALL126852.16.840.1.113883.5.1001 (ActMood) = RQOtemplateId1..1SHALL12686@root1..1SHALL126872.16.840.1.113883.10.20.24.3.58@extension1..1SHALL12688code1..1SHALL12689@code1..1SHALL132422.16.840.1.113883.6.96 (SNOMED-CT) = 5880005statusCode1..1SHALL12690@code1..1SHALL126912.16.840.1.113883.5.14 (ActStatus) = newvalue1..1SHALL13254methodCode0..*MAY12692targetSiteCode0..*MAY12704author1..1SHALL12693time1..1SHALL12694entryRelationship0..1MAY12695@typeCode1..1SHALL126962.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12697entryRelationship0..1MAY12698@typeCode1..1SHALL126992.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12700entryRelationship0..1MAY12701@typeCode1..1SHALL127022.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12703Conforms to Plan of Care Activity Observation template (2.16.840.1.113883.10.20.22.4.44).SHALL contain exactly one [1..1] @moodCode="RQO" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12685).SHALL contain exactly one [1..1] templateId (CONF:12686) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.58" (CONF:12687).SHALL contain exactly one [1..1] @extension (CONF:12688).SHALL contain exactly one [1..1] code (CONF:12689).This code SHALL contain exactly one [1..1] @code="5880005" physical examination (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:13242).SHALL contain exactly one [1..1] statusCode (CONF:12690).This statusCode SHALL contain exactly one [1..1] @code="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12691).SHALL contain exactly one [1..1] value (CONF:13254).MAY contain zero or more [0..*] methodCode (CONF:12692).MAY contain zero or more [0..*] targetSiteCode (CONF:12704).SHALL contain exactly one [1..1] author (CONF:12693) such that itSHALL contain exactly one [1..1] time (CONF:12694).MAY contain zero or one [0..1] entryRelationship (CONF:12695) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12696).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12697).MAY contain zero or one [0..1] entryRelationship (CONF:12698) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12699).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12700).MAY contain zero or one [0..1] entryRelationship (CONF:12701) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12702).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12703).Physical Exam Recommended[observation: templateId 2.16.840.1.113883.10.20.24.3.60 (open)]Table SEQ Table \* ARABIC123: Physical Exam Recommended ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonA recommendation by a physician or appropriately licensed care provider for a physical exam to be performed on the patient. A time/date stamp is required. Table SEQ Table \* ARABIC124: Physical Exam Recommended Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.60']@moodCode1..1SHALL126652.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL12666@root1..1SHALL126672.16.840.1.113883.10.20.24.3.60@extension1..1SHALL12668code1..1SHALL12669@code1..1SHALL132742.16.840.1.113883.6.96 (SNOMED-CT) = 5880005statusCode1..1SHALL12670@code1..1SHALL126712.16.840.1.113883.5.14 (ActStatus) = newvalue1..1SHALL13275methodCode0..1MAY12672targetSiteCode0..1MAY12684author1..1SHALL12682time1..1SHALL12683entryRelationship0..1MAY12673@typeCode1..1SHALL126742.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12675entryRelationship0..1MAY12676@typeCode1..1SHALL126772.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12678entryRelationship0..1MAY12679@typeCode1..1SHALL126802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12681Conforms to Plan of Care Activity Observation template (2.16.840.1.113883.10.20.22.4.44).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12665).SHALL contain exactly one [1..1] templateId (CONF:12666) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.60" (CONF:12667).SHALL contain exactly one [1..1] @extension (CONF:12668).SHALL contain exactly one [1..1] code (CONF:12669).This code SHALL contain exactly one [1..1] @code="5880005" physical examination (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:13274).SHALL contain exactly one [1..1] statusCode (CONF:12670).This statusCode SHALL contain exactly one [1..1] @code="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12671).SHALL contain exactly one [1..1] value (CONF:13275).MAY contain zero or one [0..1] methodCode (CONF:12672).MAY contain zero or one [0..1] targetSiteCode (CONF:12684).SHALL contain exactly one [1..1] author (CONF:12682).This author SHALL contain exactly one [1..1] time (CONF:12683).MAY contain zero or one [0..1] entryRelationship (CONF:12673) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12674).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12675).MAY contain zero or one [0..1] entryRelationship (CONF:12676) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12677).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12678).MAY contain zero or one [0..1] entryRelationship (CONF:12679) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12680).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12681).Plan of Care Activity Procedure[procedure: templateId 2.16.840.1.113883.10.20.22.4.41 (open)]This is the template for the Plan of Care Activity Procedure.Table SEQ Table \* ARABIC125: Plan of Care Activity Procedure Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.41']@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..1SHALLSET<II>8570@root1..1SHALL105132.16.840.1.113883.10.20.22.4.41id1..*SHALLII8571SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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 2011-05-02 (CONF:8569).SHALL contain exactly one [1..1] templateId (CONF:8570) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.41" (CONF:10513).SHALL contain at least one [1..*] id (CONF:8571).Procedure Order[procedure: templateId 2.16.840.1.113883.10.20.24.3.63 (open)]Table SEQ Table \* ARABIC126: Procedure Order ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProvider PreferenceReasonThis clinical statement represents an order for a procedure.A procedure is a course of action intended to achieve a result in the care of persons with health problems. It is generally invasive and involves physical contact. A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses and/or providing treatment. Some of these procedures are not reimbursed. Note that procedure is distinct from intervention.Table SEQ Table \* ARABIC127: Procedure Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.24.3.63']@moodCode1..1SHALL110972.16.840.1.113883.5.1001 (ActMood) = RQOtemplateId1..1SHALL11098@root1..1SHALL110992.16.840.1.113883.10.20.24.3.63@extension1..1SHALL11100code1..1SHALL11101methodCode0..1MAY11606author1..1SHALL11595time1..1SHALL11596entryRelationship0..1MAY11610@typeCode1..1SHALL116112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11612entryRelationship0..1MAY11613@typeCode1..1SHALL116142.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11615entryRelationship0..1MAY11616@typeCode1..1SHALL116172.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11618entryRelationship0..1MAY13707@typeCode1..1SHALL137082.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL13709Conforms to Plan of Care Activity Procedure template (2.16.840.1.113883.10.20.22.4.41).SHALL contain exactly one [1..1] @moodCode="RQO" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11097).SHALL contain exactly one [1..1] templateId (CONF:11098) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.63" (CONF:11099).SHALL contain exactly one [1..1] @extension (CONF:11100).SHALL contain exactly one [1..1] code (CONF:11101).MAY contain zero or one [0..1] methodCode (CONF:11606).SHALL contain exactly one [1..1] author (CONF:11595).This author SHALL contain exactly one [1..1] time (CONF:11596).MAY contain zero or one [0..1] entryRelationship (CONF:11610) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11611).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11612).MAY contain zero or one [0..1] entryRelationship (CONF:11613) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11614).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11615).MAY contain zero or one [0..1] entryRelationship (CONF:11616) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11617).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11618).MAY contain zero or one [0..1] entryRelationship (CONF:13707) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13708).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:13709).Procedure Recommended[procedure: templateId 2.16.840.1.113883.10.20.24.3.65 (open)]Table SEQ Table \* ARABIC128: Procedure Recommended ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProvider PreferenceReasonThis clinical statement represents a recommendation for a procedure.A procedure is a course of action intended to achieve a result in the care of persons with health problems. It is generally invasive and involves physical contact. A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses and/or providing treatment. Some of these procedures are not reimbursed. Note that procedure is distinct from intervention.Table SEQ Table \* ARABIC129: Procedure Recommended Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.24.3.65']@moodCode1..1SHALL111032.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL11104@root1..1SHALL111052.16.840.1.113883.10.20.24.3.65@extension1..1SHALL11106code1..1SHALL11107statusCode1..1SHALL13239@code0..1MAY132402.16.840.1.113883.5.14 (ActStatus) = newmethodCode0..1MAY11560author1..1SHALL11581time1..1SHALL11582entryRelationship0..1MAY11561@typeCode1..1SHALL115622.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL11563entryRelationship0..1MAY11586@typeCode1..1SHALL115872.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11588entryRelationship0..1MAY11589@typeCode1..1SHALL115912.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONorganizer1..1SHALL11590entryRelationship0..1MAY11592@typeCode1..1SHALL115932.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11594Conforms to Plan of Care Activity Procedure template (2.16.840.1.113883.10.20.22.4.41).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11103).SHALL contain exactly one [1..1] templateId (CONF:11104) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.65" (CONF:11105).SHALL contain exactly one [1..1] @extension (CONF:11106).SHALL contain exactly one [1..1] code (CONF:11107).SHALL contain exactly one [1..1] statusCode (CONF:13239).This statusCode MAY contain zero or one [0..1] @code="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13240).MAY contain zero or one [0..1] methodCode (CONF:11560).SHALL contain exactly one [1..1] author (CONF:11581).This author SHALL contain exactly one [1..1] time (CONF:11582).MAY contain zero or one [0..1] entryRelationship (CONF:11561) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11562).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:11563).MAY contain zero or one [0..1] entryRelationship (CONF:11586) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11587).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11588).MAY contain zero or one [0..1] entryRelationship (CONF:11589) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11591).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11590).MAY contain zero or one [0..1] entryRelationship (CONF:11592) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11593).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11594).Plan of Care Activity Supply[supply: templateId 2.16.840.1.113883.10.20.22.4.43 (open)]This is the template for the Plan of Care Activity Supply.Table SEQ Table \* ARABIC130: Plan of Care Activity Supply Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.22.4.43']@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..1SHALLSET<II>8579@root1..1SHALL105152.16.840.1.113883.10.20.22.4.43id1..*SHALLII8580SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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 2011-05-03 (CONF:8578).SHALL contain exactly one [1..1] templateId (CONF:8579) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.43" (CONF:10515).SHALL contain at least one [1..*] id (CONF:8580).Device Order[supply: templateId 2.16.840.1.113883.10.20.24.3.9 (open)]Table SEQ Table \* ARABIC131: Device Order ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonEquipment designed to treat, monitor, or diagnose a patient's status is ordered. Notes: This is the corresponding QRDA template for the QDM pattern Device, Order.Table SEQ Table \* ARABIC132: Device Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.24.3.9']@moodCode1..1SHALL123432.16.840.1.113883.5.1001 (ActMood) = RQOtemplateId1..1SHALL12344@root1..1SHALL123452.16.840.1.113883.10.20.24.3.9@extension1..1SHALL12346statusCode1..1SHALL130352.16.840.1.113883.5.14 (ActStatus) = neweffectiveTime1..1SHALL12348participant1..1SHALL12349@typeCode1..1SHALL123502.16.840.1.113883.5.90 (HL7ParticipationType) = DEVparticipantRole1..1SHALL12351@classCode1..1SHALL123522.16.840.1.113883.5.110 (RoleClass) = MANUplayingDevice1..1SHALL12353@classCode1..1SHALL123542.16.840.1.113883.5.90 (HL7ParticipationType) = DEVcode1..1SHALL12355entryRelationship0..1MAY12356@typeCode1..1SHALL123592.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12360entryRelationship0..1MAY12357@typeCode1..1SHALL123612.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12362entryRelationship0..1MAY12358@nullFlavor1..1SHALL123632.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12364Conforms to Plan of Care Activity Supply template (2.16.840.1.113883.10.20.22.4.43).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="RQO" request (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12343).SHALL contain exactly one [1..1] templateId (CONF:12344) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.9" (CONF:12345).SHALL contain exactly one [1..1] @extension (CONF:12346).SHALL contain exactly one [1..1] statusCode="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13035).SHALL contain exactly one [1..1] effectiveTime (CONF:12348).SHALL contain exactly one [1..1] participant (CONF:12349) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12350).SHALL contain exactly one [1..1] participantRole (CONF:12351).This participantRole SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem RoleClass (2.16.840.1.113883.5.110)="MANU" manufactured product (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12352).This participantRole SHALL contain exactly one [1..1] playingDevice (CONF:12353).This playingDevice SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12354).This playingDevice SHALL contain exactly one [1..1] code (CONF:12355).MAY contain zero or one [0..1] entryRelationship (CONF:12356) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12359).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12360).MAY contain zero or one [0..1] entryRelationship (CONF:12357) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12361).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12362).MAY contain zero or one [0..1] entryRelationship (CONF:12358) such that itSHALL contain exactly one [1..1] @nullFlavor, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12363).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12364).Device Recommended[supply: templateId 2.16.840.1.113883.10.20.24.3.10 (open)]Table SEQ Table \* ARABIC133: Device Recommended ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonTo suggest a device that worthy of being used.Notes: This is the corresponding QRDA template for the QDM pattern Device, Recommended.Table SEQ Table \* ARABIC134: Device Recommended Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valuesupply[templateId/@root = '2.16.840.1.113883.10.20.24.3.10']@moodCode1..1SHALL123682.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL12369@root1..1SHALL123702.16.840.1.113883.10.20.24.3.10@extension1..1SHALL12371statusCode1..1SHALL130362.16.840.1.113883.5.14 (ActStatus) = neweffectiveTime1..1SHALL12373participant1..1SHALL12374@typeCode1..1SHALL123752.16.840.1.113883.5.90 (HL7ParticipationType) = DEVparticipantRole1..1SHALL12376@classCode1..1SHALL123772.16.840.1.113883.5.110 (RoleClass) = MANUplayingDevice1..1SHALL12378@classCode1..1SHALL123792.16.840.1.113883.5.90 (HL7ParticipationType) = DEVcode1..1SHALL12380entryRelationship0..1MAY12381@typeCode1..1SHALL123822.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12383entryRelationship0..1MAY12384@typeCode1..1SHALL123852.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12386entryRelationship0..1MAY12387@nullFlavor1..1SHALL123882.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12389Conforms to Plan of Care Activity Supply template (2.16.840.1.113883.10.20.22.4.43).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="INT" intent (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12368).SHALL contain exactly one [1..1] templateId (CONF:12369) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.10" (CONF:12370).SHALL contain exactly one [1..1] @extension (CONF:12371).SHALL contain exactly one [1..1] statusCode="new" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13036).SHALL contain exactly one [1..1] effectiveTime (CONF:12373).SHALL contain exactly one [1..1] participant (CONF:12374) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12375).SHALL contain exactly one [1..1] participantRole (CONF:12376).This participantRole SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem RoleClass (2.16.840.1.113883.5.110)="MANU" manufactured product (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12377).This participantRole SHALL contain exactly one [1..1] playingDevice (CONF:12378).This playingDevice SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12379).This playingDevice SHALL contain exactly one [1..1] code (CONF:12380).MAY contain zero or one [0..1] entryRelationship (CONF:12381) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12382).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12383).MAY contain zero or one [0..1] entryRelationship (CONF:12384) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12385).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12386).MAY contain zero or one [0..1] entryRelationship (CONF:12387) such that itSHALL contain exactly one [1..1] @nullFlavor, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12388).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12389).Precondition for Substance Administration[criterion: templateId 2.16.840.1.113883.10.20.22.4.25 (open)]Table SEQ Table \* ARABIC135: Precondition for Substance Administration ContextsUsed By:Contains Entries:Medication Activity (optional)A criterion for administration can be used to record that the medication is to be administered only when the associated criteria are met.Table SEQ Table \* ARABIC136: Precondition for Substance Administration Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valuecriterion[templateId/@root = '2.16.840.1.113883.10.20.22.4.25']templateId1..1SHALLSET<II>7372@root1..1SHALL105172.16.840.1.113883.10.20.22.4.25code0..1SHOULDCE7367text0..1MAYED7373value0..1SHOULDCD7369SHALL 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 with @xsi:type="CE" (CONF:7367).MAY contain zero or one [0..1] text (CONF:7373).SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:7369).Problem Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.4 (open)]Table SEQ Table \* ARABIC137: Problem Observation ContextsUsed By:Contains Entries:Age ObservationHealth Status ObservationProblem StatusA problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need.A Problem Observation is required to be wrapped in an act wrapper in locations such as the Problem Section, Allergies Section, and Hospital Discharge Diagnosis Section, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid "standalone" template instance in cases where a simple problem observation is to be sent.The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). NegationInd='true' is an acceptable way to make a clinical assertion that something did not occur, for example, "no diabetes".Table SEQ Table \* ARABIC138: Problem Observation Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Problem Observationobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.4']@classCode1..1SHALL9041@moodCode1..1SHALL90422.16.840.1.113883.5.1001 (ActMood) = EVN@negationInd0..1MAY10139id1..*SHALLII9043problemTypecode1..1SHALLCE90452.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)problemNametext0..1SHOULDED9185reference/@value0..1SHOULD9187statusCode1..1SHALLCS90492.16.840.1.113883.5.14 (ActStatus) = completedproblemDateeffectiveTime0..1SHOULDTS or IVL<TS>9050problemCodevalue1..1SHALLCD90582.16.840.1.113883.3.88.12.3221.7.4 (Problem)@nullFlavor0..1MAY10141ageAtOnsetentryRelationship0..1MAY9059@typeCode1..1SHALL90602.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL9069trueproblemStatusentryRelationship0..1MAY9063@typeCode1..1SHALL90682.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRentryRelationship0..1MAY9067@typeCode1..1SHALL90642.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRSHALL contain exactly one [1..1] @classCode (CONF:9041).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:9042).MAY contain zero or one [0..1] @negationInd (CONF:10139).NegationInd="true" SHALL be used to represent that the problem was not observed (CONF:10140).SHALL contain at least one [1..*] id (CONF:9043).SHALL contain exactly one [1..1] code with @xsi:type="CE", where the @code SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2011-07-01 (CONF:9045).SHOULD contain zero or one [0..1] text (CONF:9185).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:9187).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:9188).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:9049).SHOULD contain zero or one [0..1] effectiveTime (CONF:9050).The onset date SHALL be recorded in the low element of the effectiveTime element when known (CONF:9051).The resolution date SHALL be recorded in the high element of the effectiveTime element when known (CONF:9052).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 resolved (CONF:9053).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).This value MAY contain zero or one [0..1] @nullFlavor (CONF:10141).If the diagnosis is unkown 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:10142).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) (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:9066).MAY contain zero or one [0..1] entryRelationship (CONF:9063) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:9068).SHALL contain exactly one [1..1] Problem Status (templateId:2.16.840.1.113883.10.20.22.4.6) (CONF:9062).MAY contain zero or one [0..1] entryRelationship (CONF:9067) such that itSHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:9064).SHALL contain exactly one [1..1] Health Status Observation (templateId:2.16.840.1.113883.10.20.22.4.5) (CONF:9070).Diagnosis Active[observation: templateId 2.16.840.1.113883.10.20.24.3.11 (open)]Table SEQ Table \* ARABIC139: Diagnosis Active ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProblem Status ActiveProvider PreferenceReasonSeverity ObservationAn active diagnosis is a problem, diagnosis or condition that is currently monitored, tracked or is a factor that must be considered as part of the treatment plan in progress. A time/date stamp is required.Notes: Can't change value/qualifier cardinality to [0..1] due to a bug in the tool. Have raised JIRA issue. Susan/Diana - can you please change it in the export from 0..* to 0..1 - should be about the 6th conformance statement?Table SEQ Table \* ARABIC140: Diagnosis Active Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.11']@classCode1..1SHALL120122.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL11972@root1..1SHALL119732.16.840.1.113883.10.20.24.3.11@extension1..1SHALL11974code1..1SHALL11980@code1..1SHALL119952.16.840.1.113883.6.96 (SNOMED-CT) = 282291009effectiveTime1..1SHALL11983low1..1SHALL11984high1..1SHALL11985value1..1SHALLCD12008qualifier0..*MAY12009name1..1SHALL12010value1..1SHALL12011entryRelationship1..1SHALL11975@typeCode1..1SHALL119792.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12253entryRelationship0..1MAY11986@typeCode1..1SHALL119872.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11988entryRelationship0..1MAY11989@typeCode1..1SHALL119902.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11991entryRelationship0..1MAY11992@typeCode1..1SHALL119932.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11994entryRelationship0..1MAY11996@typeCode1..1SHALL119972.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL11998entryRelationship0..1MAY12013@typeCode1..1SHALL120142.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL12015Conforms to Problem Observation template (2.16.840.1.113883.10.20.22.4.4).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12012).SHALL contain exactly one [1..1] templateId (CONF:11972) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.11" (CONF:11973).SHALL contain exactly one [1..1] @extension (CONF:11974).SHALL contain exactly one [1..1] code (CONF:11980).This code SHALL contain exactly one [1..1] @code="282291009" diagnosis (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11995).SHALL contain exactly one [1..1] effectiveTime (CONF:11983).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11984).This effectiveTime SHALL contain exactly one [1..1] high (CONF:11985).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12008).This value MAY contain zero or more [0..*] qualifier (CONF:12009).The qualifier, if present, SHALL contain exactly one [1..1] name (CONF:12010).The qualifier, if present, SHALL contain exactly one [1..1] value (CONF:12011).SHALL contain exactly one [1..1] entryRelationship (CONF:11975) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11979).SHALL contain exactly one [1..1] Problem Status Active (templateId:2.16.840.1.113883.10.20.24.3.94) (CONF:12253).MAY contain zero or one [0..1] entryRelationship (CONF:11986) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11987).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11988).MAY contain zero or one [0..1] entryRelationship (CONF:11989) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11990).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11991).MAY contain zero or one [0..1] entryRelationship (CONF:11992) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11993).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11994).MAY contain zero or one [0..1] entryRelationship (CONF:11996) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11997).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:11998).MAY contain zero or one [0..1] entryRelationship (CONF:12013) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12014).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:12015).Diagnosis Inactive[observation: templateId 2.16.840.1.113883.10.20.24.3.13 (open)]Table SEQ Table \* ARABIC141: Diagnosis Inactive ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProblem Status InactiveProvider PreferenceReasonSeverity ObservationAn inactive diagnosis is a problem, diagnosis, or condition that has been present in the past and is currently not under active treatment or causing clinical manifestations, but may require treatment or monitoring in the future (e.g., a cancer diagnosis in remission). A date/time stamp is required. Table SEQ Table \* ARABIC142: Diagnosis Inactive Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.13']@classCode1..1SHALL120472.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL12016@root1..1SHALL120172.16.840.1.113883.10.20.24.3.13@extension1..1SHALL12018code1..1SHALL12024@code1..1SHALL120252.16.840.1.113883.6.96 (SNOMED-CT) = 282291009effectiveTime1..1SHALL12028low1..1SHALL12029high1..1SHALL12030value1..1SHALL12043entryRelationship1..1SHALL12019@typeCode1..1SHALL120232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12219entryRelationship0..1MAY12031@typeCode1..1SHALL120322.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12033entryRelationship0..1MAY12034@typeCode1..1SHALL120352.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12036entryRelationship0..1MAY12037@typeCode1..1SHALL120382.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12039entryRelationship0..1MAY12040@typeCode1..1SHALL120412.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12042entryRelationship0..1MAY12048@typeCode1..1SHALL120492.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL12050Conforms to Problem Observation template (2.16.840.1.113883.10.20.22.4.4).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12047).SHALL contain exactly one [1..1] templateId (CONF:12016) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.13" (CONF:12017).SHALL contain exactly one [1..1] @extension (CONF:12018).SHALL contain exactly one [1..1] code (CONF:12024).This code SHALL contain exactly one [1..1] @code="282291009" diagnosis (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12025).SHALL contain exactly one [1..1] effectiveTime (CONF:12028).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12029).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12030).SHALL contain exactly one [1..1] value (CONF:12043).SHALL contain exactly one [1..1] entryRelationship (CONF:12019) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12023).SHALL contain exactly one [1..1] Problem Status Inactive (templateId:2.16.840.1.113883.10.20.24.3.95) (CONF:12219).MAY contain zero or one [0..1] entryRelationship (CONF:12031) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12032).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12033).MAY contain zero or one [0..1] entryRelationship (CONF:12034) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12035).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12036).MAY contain zero or one [0..1] entryRelationship (CONF:12037) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12038).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12039).MAY contain zero or one [0..1] entryRelationship (CONF:12040) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12041).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:12042).MAY contain zero or one [0..1] entryRelationship (CONF:12048) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12049).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:12050).Diagnosis Resolved[observation: templateId 2.16.840.1.113883.10.20.24.3.14 (open)]Table SEQ Table \* ARABIC143: Diagnosis Resolved ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProblem Status ResolvedProvider PreferenceReasonSeverity ObservationA resolved diagnosis is a problem, diagnosis, or condition that no longer requires treatment and, by its nature is unlikely to recur. A date/time stamp is required.Table SEQ Table \* ARABIC144: Diagnosis Resolved Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.14']@classCode1..1SHALL120772.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL12051@root1..1SHALL120522.16.840.1.113883.10.20.24.3.14@extension1..1SHALL12053code1..1SHALL12059@code1..1SHALL120602.16.840.1.113883.6.96 (SNOMED-CT) = 282291009effectiveTime1..1SHALL12061low1..1SHALL12062high1..1SHALL12063value1..1SHALL12076entryRelationship1..1SHALL12054@typeCode1..1SHALL120582.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12313entryRelationship0..1MAY12064@typeCode1..1SHALL120652.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12066entryRelationship0..1MAY12067@typeCode1..1SHALL120682.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12069entryRelationship0..1MAY12070@typeCode1..1SHALL120712.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12072entryRelationship0..1MAY12073@typeCode1..1SHALL120742.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12075entryRelationship0..1MAY12078@typeCode1..1SHALL120792.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL12080Conforms to Problem Observation template (2.16.840.1.113883.10.20.22.4.4).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12077).SHALL contain exactly one [1..1] templateId (CONF:12051) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.14" (CONF:12052).SHALL contain exactly one [1..1] @extension (CONF:12053).SHALL contain exactly one [1..1] code (CONF:12059).This code SHALL contain exactly one [1..1] @code="282291009" diagnosis (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12060).SHALL contain exactly one [1..1] effectiveTime (CONF:12061).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12062).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12063).SHALL contain exactly one [1..1] value (CONF:12076).SHALL contain exactly one [1..1] entryRelationship (CONF:12054) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12058).SHALL contain exactly one [1..1] Problem Status Resolved (templateId:2.16.840.1.113883.10.20.24.3.96) (CONF:12313).MAY contain zero or one [0..1] entryRelationship (CONF:12064) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12065).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12066).MAY contain zero or one [0..1] entryRelationship (CONF:12067) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12068).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12069).MAY contain zero or one [0..1] entryRelationship (CONF:12070) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12071).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12072).MAY contain zero or one [0..1] entryRelationship (CONF:12073) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12074).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:12075).MAY contain zero or one [0..1] entryRelationship (CONF:12078) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12079).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:12080).Symptom Active[observation: templateId 2.16.840.1.113883.10.20.24.3.76 (open)]Table SEQ Table \* ARABIC145: Symptom Active ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProblem Status ActiveProvider PreferenceSeverity ObservationAn active symptom is a patient’s reported perception of departure from normal functioning that is present at the time indicated. A time/date stamp is required.Table SEQ Table \* ARABIC146: Symptom Active Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.76']@classCode1..1SHALL122812.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL12254@root1..1SHALL122552.16.840.1.113883.10.20.24.3.76@extension1..1SHALL12256code1..1SHALL12260@code1..1SHALL122612.16.840.1.113883.6.96 (SNOMED-CT) = 418799008effectiveTime1..1SHALL12262low1..1SHALL12263high1..1SHALL12264entryRelationship1..1SHALL12257@typeCode1..1SHALL122582.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12259entryRelationship0..1MAY12265@typeCode1..1SHALL122662.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12267entryRelationship0..1MAY12268@typeCode1..1SHALL122692.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12270entryRelationship0..1MAY12274@typeCode1..1SHALL122752.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12276entryRelationship0..1MAY12282@typeCode1..1SHALL122832.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL12284Conforms to Problem Observation template (2.16.840.1.113883.10.20.22.4.4).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12281).SHALL contain exactly one [1..1] templateId (CONF:12254) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.76" (CONF:12255).SHALL contain exactly one [1..1] @extension (CONF:12256).SHALL contain exactly one [1..1] code (CONF:12260).This code SHALL contain exactly one [1..1] @code="418799008" symptom (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12261).SHALL contain exactly one [1..1] effectiveTime (CONF:12262).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12263).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12264).SHALL contain exactly one [1..1] entryRelationship (CONF:12257) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12258).SHALL contain exactly one [1..1] Problem Status Active (templateId:2.16.840.1.113883.10.20.24.3.94) (CONF:12259).MAY contain zero or one [0..1] entryRelationship (CONF:12265) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12266).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12267).MAY contain zero or one [0..1] entryRelationship (CONF:12268) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12269).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12270).MAY contain zero or one [0..1] entryRelationship (CONF:12274) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12275).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:12276).MAY contain zero or one [0..1] entryRelationship (CONF:12282) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12283).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:12284).Symptom Assessed[observation: templateId 2.16.840.1.113883.10.20.24.3.77 (open)]Table SEQ Table \* ARABIC147: Symptom Assessed ContextsUsed By:Contains Entries:OrdinalityPatient PreferenceProvider PreferenceSeverity ObservationThe patient’s reported perception of departure from normal functioning is evaluated. A time/date stamp is required. Table SEQ Table \* ARABIC148: Symptom Assessed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.77']@classCode1..1SHALL128982.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL12877@root1..1SHALL128782.16.840.1.113883.10.20.24.3.77@extension1..1SHALL12879code1..1SHALL13132@code1..1SHALL131332.16.840.1.113883.6.96 (SNOMED-CT) = 418799008effectiveTime1..1SHALL13220entryRelationship0..1MAY12888@typeCode1..1SHALL128892.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12890entryRelationship0..1MAY12891@typeCode1..1SHALL128922.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12893entryRelationship0..1MAY12894@typeCode1..1SHALL128952.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12896entryRelationship0..1MAY12899@typeCode1..1SHALL129002.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL12901Conforms to Problem Observation template (2.16.840.1.113883.10.20.22.4.4).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12898).SHALL contain exactly one [1..1] templateId (CONF:12877) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.77" (CONF:12878).SHALL contain exactly one [1..1] @extension (CONF:12879).SHALL contain exactly one [1..1] code (CONF:13132).This code SHALL contain exactly one [1..1] @code="418799008" symptom (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:13133).SHALL contain exactly one [1..1] effectiveTime (CONF:13220).MAY contain zero or one [0..1] entryRelationship (CONF:12888) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12889).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12890).MAY contain zero or one [0..1] entryRelationship (CONF:12891) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12892).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12893).MAY contain zero or one [0..1] entryRelationship (CONF:12894) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12895).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:12896).MAY contain zero or one [0..1] entryRelationship (CONF:12899) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12900).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:12901).Symptom Inactive[observation: templateId 2.16.840.1.113883.10.20.24.3.78 (open)]Table SEQ Table \* ARABIC149: Symptom Inactive ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProblem Status InactiveProvider PreferenceSeverity ObservationAn inactive symptom is a symptom that has been present in the past and is currently not under active treatment or causing clinical manifestations, but may require treatment or monitoring in the future. A time/date stamp is required. Table SEQ Table \* ARABIC150: Symptom Inactive Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.78']@classCode1..1SHALL123092.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL12285@root1..1SHALL122862.16.840.1.113883.10.20.24.3.78@extension1..1SHALL12287code1..1SHALL12291@code1..1SHALL122922.16.840.1.113883.6.96 (SNOMED-CT) = 418799008effectiveTime1..1SHALL12293low1..1SHALL12294high1..1SHALL12295entryRelationship1..1SHALL12288@typeCode1..1SHALL122892.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12290entryRelationship0..1MAY12296@typeCode1..1SHALL122972.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12298entryRelationship0..1MAY12299@typeCode1..1SHALL123002.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12301entryRelationship0..1MAY12305@typeCode1..1SHALL123062.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12307entryRelationship0..1MAY12310@typeCode1..1SHALL123112.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL12312Conforms to Problem Observation template (2.16.840.1.113883.10.20.22.4.4).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12309).SHALL contain exactly one [1..1] templateId (CONF:12285) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.78" (CONF:12286).SHALL contain exactly one [1..1] @extension (CONF:12287).SHALL contain exactly one [1..1] code (CONF:12291).This code SHALL contain exactly one [1..1] @code="418799008" symptom (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12292).SHALL contain exactly one [1..1] effectiveTime (CONF:12293).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12294).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12295).SHALL contain exactly one [1..1] entryRelationship (CONF:12288) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12289).SHALL contain exactly one [1..1] Problem Status Inactive (templateId:2.16.840.1.113883.10.20.24.3.95) (CONF:12290).MAY contain zero or one [0..1] entryRelationship (CONF:12296) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12297).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12298).MAY contain zero or one [0..1] entryRelationship (CONF:12299) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12300).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12301).MAY contain zero or one [0..1] entryRelationship (CONF:12305) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12306).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:12307).MAY contain zero or one [0..1] entryRelationship (CONF:12310) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12311).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:12312).Symptom Resolved[observation: templateId 2.16.840.1.113883.10.20.24.3.79 (open)]Table SEQ Table \* ARABIC151: Symptom Resolved ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProblem Status ResolvedProvider PreferenceSeverity ObservationAn resolved symptom is a symptom that has been present in the past and is currently not expected to recur. A time/date stamp is required. Table SEQ Table \* ARABIC152: Symptom Resolved Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.79']@classCode1..1SHALL123382.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL12314@root1..1SHALL123152.16.840.1.113883.10.20.24.3.79@extension1..1SHALL12316code1..1SHALL12320@code1..1SHALL123212.16.840.1.113883.6.96 (SNOMED-CT) = 418799008effectiveTime1..1SHALL12322low1..1SHALL12323high1..1SHALL12324entryRelationship1..1SHALL12317@typeCode1..1SHALL123182.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12319entryRelationship0..1MAY12325@typeCode1..1SHALL123262.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12327entryRelationship0..1MAY12328@typeCode1..1SHALL123292.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12330entryRelationship0..1MAY12334@typeCode1..1SHALL123352.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL12336entryRelationship0..1MAY12339@typeCode1..1SHALL123402.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL12341Conforms to Problem Observation template (2.16.840.1.113883.10.20.22.4.4).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12338).SHALL contain exactly one [1..1] templateId (CONF:12314) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.79" (CONF:12315).SHALL contain exactly one [1..1] @extension (CONF:12316).SHALL contain exactly one [1..1] code (CONF:12320).This code SHALL contain exactly one [1..1] @code="418799008" symptom (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12321).SHALL contain exactly one [1..1] effectiveTime (CONF:12322).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12323).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12324).SHALL contain exactly one [1..1] entryRelationship (CONF:12317) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12318).SHALL contain exactly one [1..1] Problem Status Resolved (templateId:2.16.840.1.113883.10.20.24.3.96) (CONF:12319).MAY contain zero or one [0..1] entryRelationship (CONF:12325) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12326).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12327).MAY contain zero or one [0..1] entryRelationship (CONF:12328) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12329).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12330).MAY contain zero or one [0..1] entryRelationship (CONF:12334) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12335).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:12336).MAY contain zero or one [0..1] entryRelationship (CONF:12339) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12340).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:12341).Problem Status[observation: templateId 2.16.840.1.113883.10.20.22.4.6 (open)]Table SEQ Table \* ARABIC153: Problem Status ContextsUsed By:Contains Entries:Problem Observation (optional)The Problem Status records whether the indicated problem is active, inactive, or resolved.Table SEQ Table \* ARABIC154: Problem Status Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.6']@classCode1..1SHALL73572.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73582.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLSET<II>7359@root1..1SHALL105182.16.840.1.113883.10.20.22.4.6code1..1SHALLCE73612.16.840.1.113883.6.1 (LOINC) = 33999-4text0..1SHOULDED7362reference/@value0..1SHOULD7363statusCode1..1SHALLCS73642.16.840.1.113883.5.14 (ActStatus) = completedvalue1..1SHALLCD73652.16.840.1.113883.3.88.12.80.68 (HITSPProblemStatus)SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7357).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (CONF:10518).SHALL contain exactly one [1..1] code with @xsi:type="CE"="33999-4" Status (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:7361).SHOULD contain zero or one [0..1] text (CONF:7362).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7363).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:7375).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7364).SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHALL be selected from ValueSet HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:7365).Problem Status Active[observation: templateId 2.16.840.1.113883.10.20.24.3.94 (open)]Table SEQ Table \* ARABIC155: Problem Status Active ContextsUsed By:Contains Entries:Diagnosis Active (required)Symptom Active (required)Records that the indicated problem is active.Table SEQ Table \* ARABIC156: Problem Status Active Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.94']templateId1..1SHALL12212@root1..1SHALL122132.16.840.1.113883.10.20.24.3.94value1..1SHALLCD12207@code1..1SHALL122142.16.840.1.113883.6.96 (SNOMED-CT) = 55561003Conforms to Problem Status template (2.16.840.1.113883.10.20.22.4.6).SHALL contain exactly one [1..1] templateId (CONF:12212) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.94" (CONF:12213).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12207).This value SHALL contain exactly one [1..1] @code="55561003" active (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12214).Problem Status Inactive[observation: templateId 2.16.840.1.113883.10.20.24.3.95 (open)]Table SEQ Table \* ARABIC157: Problem Status Inactive ContextsUsed By:Contains Entries:Diagnosis Inactive (required)Symptom Inactive (required)Records that the indicated problem is inactive.Table SEQ Table \* ARABIC158: Problem Status Inactive Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.95']templateId1..1SHALL12209@root1..1SHALL122102.16.840.1.113883.10.20.24.3.95value1..1SHALLCD12208@code1..1SHALL122112.16.840.1.113883.6.96 (SNOMED-CT) = 73425007Conforms to Problem Status template (2.16.840.1.113883.10.20.22.4.6).SHALL contain exactly one [1..1] templateId (CONF:12209) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.95" (CONF:12210).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12208).This value SHALL contain exactly one [1..1] @code="73425007" inactive (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12211).Problem Status Resolved[observation: templateId 2.16.840.1.113883.10.20.24.3.96 (open)]Table SEQ Table \* ARABIC159: Problem Status Resolved ContextsUsed By:Contains Entries:Diagnosis Resolved (required)Symptom Resolved (required)Records that the indicated problem is resolved.Table SEQ Table \* ARABIC160: Problem Status Resolved Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.96']templateId1..1SHALL12217@root1..1SHALL122182.16.840.1.113883.10.20.24.3.96value1..1SHALLCD12215@code1..1SHALL122162.16.840.1.113883.6.96 (SNOMED-CT) = 413322009Conforms to Problem Status template (2.16.840.1.113883.10.20.22.4.6).SHALL contain exactly one [1..1] templateId (CONF:12217) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.96" (CONF:12218).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12215).This value SHALL contain exactly one [1..1] @code="413322009" resolved (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12216).Procedure Activity Act[act: templateId 2.16.840.1.113883.10.20.22.4.12 (open)]Table SEQ Table \* ARABIC161: Procedure Activity Act ContextsUsed By:Contains Entries:IndicationInstructionsMedication ActivityService 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 any procedure that cannot be 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.Table SEQ Table \* ARABIC162: Procedure Activity Act Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Procedure Activity Actact[templateId/@root = '2.16.840.1.113883.10.20.22.4.12']@classCode1..1SHALL82892.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL82902.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALLSET<II>8291@root1..1SHALL105192.16.840.1.113883.10.20.22.4.12procedureIdid1..*SHALLII8292procedureTypecode1..1SHALLCE8293procedureFreeTextTypeoriginalText0..1SHOULDED8295reference/@value0..1SHOULD8296statusCode1..1SHALLCS82982.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode)procedureDateTimeeffectiveTime0..1SHOULDTS or IVL<TS>8299priorityCode0..1MAYCE83002.16.840.1.113883.1.11.16866 (ActPriority)performer0..*SHOULD8301procedurePerformerassignedEntity1..1SHALL8302id1..*SHALLII8303addr1..1SHALLSET<AD>8304telecom1..1SHALLSET<TEL>8305representedOrganization0..1SHOULD8306id0..*SHOULDII8307name0..*MAYPN8308addr1..1SHALLSET<AD>8309telecom1..1SHALLSET<TEL>8310participant0..*MAY8311@typeCode1..1SHALL83122.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCentryRelationship0..*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..1SHALLII8320entryRelationship0..1MAY8322@typeCode1..1SHALL83232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL8324trueentryRelationship0..*MAY8326@typeCode1..1SHALL83272.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONentryRelationship0..1MAY8329@typeCode1..1SHALL83302.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPSHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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" (CONF:10519).SHALL contain at least one [1..*] id (CONF:8292).SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:8293).This code in a procedure activity observation 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:8294).This code SHOULD contain zero or one [0..1] originalText (CONF:8295).The originalText, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:8296).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:8297).SHALL contain exactly one [1..1] statusCode, where the @code 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, where the @code SHALL be selected from ValueSet ActPriority 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] addr (CONF:8309).The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:8310).MAY contain zero or more [0..*] participant (CONF:8311).The participant, if present, SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:8312).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:8313).MAY contain zero or more [0..*] entryRelationship (CONF:8314).The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:8315).The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8316).The entryRelationship, if present, 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) (CONF:8318).This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:8319).Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:8321).This encounter SHALL contain exactly one [1..1] id (CONF:8320).MAY contain zero or one [0..1] entryRelationship (CONF:8322).The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:8323).The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8324).The entryRelationship, if present, SHALL contain exactly one [1..1] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:8325).MAY contain zero or more [0..*] entryRelationship (CONF:8326).The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:8327).The entryRelationship, if present, SHALL contain exactly one [1..1] Indication (templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:8328).MAY contain zero or one [0..1] entryRelationship (CONF:8329).The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:8330).The entryRelationship, if present, SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:8331).Intervention Order[act: templateId 2.16.840.1.113883.10.20.24.3.31 (open)]Table SEQ Table \* ARABIC163: Intervention Order ContextsUsed By:Contains Entries:Patient PreferenceProvider PreferenceReasonA request by a physician or appropriately licensed care provider to an appropriate provider or facility to perform a service and/or other type of action necessary for care.Table SEQ Table \* ARABIC164: Intervention Order Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.31']@classCode1..1SHALL136562.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALLx_DocumentProcedureMood136362.16.840.1.113883.5.1001 (ActMood) = RQOtemplateId1..1SHALL13637@root1..1SHALL136382.16.840.1.113883.10.20.24.3.32@extension1..1SHALL13639code1..1SHALL13640effectiveTime1..1SHALL13653low1..1SHALL13654high1..1SHALL13655entryRelationship0..1MAY13644@typeCode1..1SHALL136452.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13646entryRelationship0..1MAY13647@typeCode1..1SHALL136482.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13649entryRelationship0..1MAY13650@typeCode1..1SHALL136512.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13652Conforms to Procedure Activity Act template (2.16.840.1.113883.10.20.22.4.12).SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13656).SHALL contain exactly one [1..1] @moodCode="RQO" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13636).SHALL contain exactly one [1..1] templateId (CONF:13637) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.32" (CONF:13638).SHALL contain exactly one [1..1] @extension (CONF:13639).SHALL contain exactly one [1..1] code (CONF:13640).SHALL contain exactly one [1..1] effectiveTime (CONF:13653).This effectiveTime SHALL contain exactly one [1..1] low (CONF:13654).This effectiveTime SHALL contain exactly one [1..1] high (CONF:13655).MAY contain zero or one [0..1] entryRelationship (CONF:13644) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13645).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:13646).MAY contain zero or one [0..1] entryRelationship (CONF:13647) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13648).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:13649).MAY contain zero or one [0..1] entryRelationship (CONF:13650) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13651).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:13652).Intervention Performed[act: templateId 2.16.840.1.113883.10.20.24.3.32 (open)]Table SEQ Table \* ARABIC165: Intervention Performed ContextsUsed By:Contains Entries:Intervention Adverse Event (required)Intervention Intolerance (required)Patient PreferenceProvider PreferenceReasonThis clinical statement template represents an intervention has been completed. An intervention is an influencing force or act that occurs in order to modify a given state of affairs. An intervention is any action carried out (by a healthcare provider or a consumer) to improve or maintain the health of a subject of care with the expectation of producing an outcome.Table SEQ Table \* ARABIC166: Intervention Performed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.32']@classCode1..1SHALL136352.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALLx_DocumentProcedureMood135902.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL13591@root1..1SHALL135922.16.840.1.113883.10.20.24.3.32@extension1..1SHALL13593code1..1SHALL13594effectiveTime1..1SHALL13611low1..1SHALL13612high1..1SHALL13613entryRelationship0..1MAY13598@typeCode1..1SHALL135992.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13600entryRelationship0..1MAY13601@typeCode1..1SHALL136022.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13603entryRelationship0..1MAY13604@typeCode1..1SHALL136052.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13606Conforms to Procedure Activity Act template (2.16.840.1.113883.10.20.22.4.12).SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13635).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13590).SHALL contain exactly one [1..1] templateId (CONF:13591) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.32" (CONF:13592).SHALL contain exactly one [1..1] @extension (CONF:13593).SHALL contain exactly one [1..1] code (CONF:13594).SHALL contain exactly one [1..1] effectiveTime (CONF:13611).This effectiveTime SHALL contain exactly one [1..1] low (CONF:13612).This effectiveTime SHALL contain exactly one [1..1] high (CONF:13613).MAY contain zero or one [0..1] entryRelationship (CONF:13598) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13599).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:13600).MAY contain zero or one [0..1] entryRelationship (CONF:13601) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13602).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:13603).MAY contain zero or one [0..1] entryRelationship (CONF:13604) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13605).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:13606).Intervention Recommended[act: templateId 2.16.840.1.113883.10.20.24.3.33 (open)]Table SEQ Table \* ARABIC167: Intervention Recommended ContextsUsed By:Contains Entries:Patient PreferenceProvider PreferenceReasonThis clinical statement represents a recommendation for an intervention.An intervention is an influencing force or act that occurs in order to modify a given state of affairs. An intervention is any action carried out (by a healthcare provider or a consumer) to improve or maintain the health of a subject of care with the expectation of producing an outcome. Table SEQ Table \* ARABIC168: Intervention Recommended Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.33']@classCode1..1SHALL137062.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALLx_DocumentProcedureMood136862.16.840.1.113883.5.1001 (ActMood) = INTtemplateId1..1SHALL13687@root1..1SHALL136882.16.840.1.113883.10.20.24.3.32@extension1..1SHALL13689code1..1SHALL13690effectiveTime1..1SHALL13703low1..1SHALL13704high1..1SHALL13705entryRelationship0..1MAY13694@typeCode1..1SHALL136952.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13696entryRelationship0..1MAY13697@typeCode1..1SHALL136982.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13699entryRelationship0..1MAY13700@typeCode1..1SHALL137012.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13702Conforms to Procedure Activity Act template (2.16.840.1.113883.10.20.22.4.12).SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13706).SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13686).SHALL contain exactly one [1..1] templateId (CONF:13687) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.32" (CONF:13688).SHALL contain exactly one [1..1] @extension (CONF:13689).SHALL contain exactly one [1..1] code (CONF:13690).SHALL contain exactly one [1..1] effectiveTime (CONF:13703).This effectiveTime SHALL contain exactly one [1..1] low (CONF:13704).This effectiveTime SHALL contain exactly one [1..1] high (CONF:13705).MAY contain zero or one [0..1] entryRelationship (CONF:13694) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13695).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:13696).MAY contain zero or one [0..1] entryRelationship (CONF:13697) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13698).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:13699).MAY contain zero or one [0..1] entryRelationship (CONF:13700) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13701).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:13702).Intervention Result[act: templateId 2.16.840.1.113883.10.20.24.3.34 (open)]Table SEQ Table \* ARABIC169: Intervention Result ContextsUsed By:Contains Entries:Patient PreferenceProvider PreferenceReasonResultStatusIntervention results are the findings identified as a result of the intervention.Table SEQ Table \* ARABIC170: Intervention Result Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.24.3.34']@classCode1..1SHALL137412.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL137172.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL13710@root1..1SHALL137112.16.840.1.113883.10.20.24.3.66@extension1..1SHALL13712code1..1SHALL13713statusCode1..1SHALL13721@code1..1SHALL137222.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL13714low1..1SHALL13715high1..1SHALL13716entryRelationship1..1SHALL13718@typeCode1..1SHALL137192.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13720entryRelationship0..1MAY13729@typeCode1..1SHALL137302.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL13731entryRelationship0..1MAY13732@typeCode1..1SHALL137332.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL13734entryRelationship0..1MAY13735@typeCode1..1SHALL137362.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL13737entryRelationship0..1MAY13738@typeCode1..1SHALL137392.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13740Conforms to Procedure Activity Act template (2.16.840.1.113883.10.20.22.4.12).SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13741).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13717).SHALL contain exactly one [1..1] templateId (CONF:13710) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.66" (CONF:13711).SHALL contain exactly one [1..1] @extension (CONF:13712).SHALL contain exactly one [1..1] code (CONF:13713).SHALL contain exactly one [1..1] statusCode (CONF:13721).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13722).SHALL contain exactly one [1..1] effectiveTime (CONF:13714).This effectiveTime SHALL contain exactly one [1..1] low (CONF:13715).This effectiveTime SHALL contain exactly one [1..1] high (CONF:13716).SHALL contain exactly one [1..1] entryRelationship (CONF:13718) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13719).SHALL contain exactly one [1..1] Result (templateId:2.16.840.1.113883.10.20.24.3.87) (CONF:13720).MAY contain zero or one [0..1] entryRelationship (CONF:13729) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13730).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:13731).MAY contain zero or one [0..1] entryRelationship (CONF:13732) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13733).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:13734).MAY contain zero or one [0..1] entryRelationship (CONF:13735) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13736).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:13737).MAY contain zero or one [0..1] entryRelationship (CONF:13738) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13739).SHALL contain exactly one [1..1] Status (templateId:2.16.840.1.113883.10.20.24.3.93) (CONF:13740).Procedure Activity Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.13 (open)]Table SEQ Table \* ARABIC171: Procedure Activity Observation ContextsUsed By:Contains Entries:IndicationInstructionsMedication ActivityService 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.Table SEQ Table \* ARABIC172: Procedure Activity Observation Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Procedure Activity Observationobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.13']@classCode1..1SHALL82822.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL82372.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALLSET<II>8238@root1..1SHALL105202.16.840.1.113883.10.20.22.4.13procedureIdid1..*SHALLII8239procedureTypecode1..1SHALLCE8240procedureFreeTextTypeoriginalText0..1SHOULDED8242reference/@value0..1SHOULD8243statusCode1..1SHALLCS82452.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode)value1..1SHALLANY8368procedureDateTimeeffectiveTime0..1SHOULDTS or IVL<TS>8246priorityCode0..1MAYCE82472.16.840.1.113883.1.11.16866 (ActPriority)methodCode0..1MAYSET<CE>8248procedureBodyTypetargetSiteCode0..*SHOULDSET<CD>8250code1..1SHALLCE101212.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)performer0..*SHOULD8251procedureProviderassignedEntity1..1SHALL8252id1..*SHALLII8253addr1..1SHALLSET<AD>8254telecom1..1SHALLSET<TEL>8255representedOrganization0..1SHOULD8256id0..*SHOULDII8257name0..*MAYPN8258addr1..1SHALLSET<AD>8259telecom1..1SHALLSET<TEL>8260participant0..*MAY8261@typeCode1..1SHALL82622.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOCentryRelationship0..*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..1SHALLII8270entryRelationship0..1MAY8272@typeCode1..1SHALL82732.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL8274trueentryRelationship0..*MAY8276@typeCode1..1SHALL82772.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONentryRelationship0..1MAY8279@typeCode1..1SHALL82802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPSHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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" (CONF:10520).SHALL contain at least one [1..*] id (CONF:8239).SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:8240).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), ICD9 Procedures (CodeSystem: 2.16.840.1.113883.6.4) (CONF:8241).This code SHOULD contain zero or one [0..1] originalText (CONF:8242).The originalText, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:8243).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:8244).SHALL contain exactly one [1..1] statusCode, where the @code SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:8245).SHALL contain exactly one [1..1] value with @xsi:type="ANY" (CONF:8368).SHOULD contain zero or one [0..1] effectiveTime (CONF:8246).MAY contain zero or one [0..1] priorityCode, where the @code SHALL be selected from ValueSet ActPriority 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:8247).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 with @xsi:type="CE", 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:10121).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] addr (CONF:8259).The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:8260).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) (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:8263).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) (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) (CONF:8268).This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:8269).This encounter SHALL contain exactly one [1..1] id (CONF:8270).Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:8271).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) (CONF:8273).SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:8274).SHALL contain exactly one [1..1] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:8275).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) (CONF:8277).SHALL contain exactly one [1..1] Indication (templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:8278).MAY contain zero or one [0..1] entryRelationship (CONF:8279) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:8280).SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:8281).Diagnostic Study Performed[observation: templateId 2.16.840.1.113883.10.20.24.3.18 (open)]Table SEQ Table \* ARABIC173: Diagnostic Study Performed ContextsUsed By:Contains Entries:Facility LocationPatient PreferenceProvider PreferenceRadiation Dosage and DurationReasonThis template indicates that a diagnostic study has been completed. Diagnostic studies are those that are not performed in the clinical laboratory. Such studies include but are not limited to imaging studies, cardiology studies (electrocardiogram, treadmill stress testing), pulmonary function testing, vascular laboratory testing, and others. A time/date stamp is required.Table SEQ Table \* ARABIC174: Diagnostic Study Performed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.18']@moodCode1..1SHALL129502.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12951@root1..1SHALL129522.16.840.1.113883.10.20.24.3.18@extension1..1SHALL12953statusCode1..1SHALL12956@code1..1SHALL129572.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12958low1..1SHALL12959high1..1SHALL12960participant0..1MAY13031entryRelationship0..1MAY12963@typeCode1..1SHALL129642.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12965entryRelationship0..1MAY12966@typeCode1..1SHALL129672.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12968entryRelationship0..1MAY12969@typeCode1..1SHALL129702.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12971entryRelationship0..1MAY13389@typeCode1..1SHALL133902.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL13391Conforms to Procedure Activity Observation template (2.16.840.1.113883.10.20.22.4.13).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12950).SHALL contain exactly one [1..1] templateId (CONF:12951) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.18" (CONF:12952).SHALL contain exactly one [1..1] @extension (CONF:12953).SHALL contain exactly one [1..1] statusCode (CONF:12956).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12957).SHALL contain exactly one [1..1] effectiveTime (CONF:12958).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12959).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12960).MAY contain zero or one [0..1] Facility Location (templateId:2.16.840.1.113883.10.20.24.3.100) (CONF:13031).MAY contain zero or one [0..1] entryRelationship (CONF:12963) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12964).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12965).MAY contain zero or one [0..1] entryRelationship (CONF:12966) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12967).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12968).MAY contain zero or one [0..1] entryRelationship (CONF:12969) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12970).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12971).MAY contain zero or one [0..1] entryRelationship (CONF:13389) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:13390).SHALL contain exactly one [1..1] Radiation Dosage and Duration (templateId:2.16.840.1.113883.10.20.24.3.91) (CONF:13391).Physical Exam Performed[observation: templateId 2.16.840.1.113883.10.20.24.3.59 (open)]Table SEQ Table \* ARABIC175: Physical Exam Performed ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonA physical exam has been completed. A time/date stamp is required.Table SEQ Table \* ARABIC176: Physical Exam Performed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.59']@moodCode1..1SHALL126432.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12644@root1..1SHALL126452.16.840.1.113883.10.20.24.3.59@extension1..1SHALL12646statusCode1..1SHALL12649@code1..1SHALL126502.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12651low1..1SHALL12652high1..1SHALL12653targetSiteCode0..1MAY12655entryRelationship0..1MAY12656@typeCode1..1SHALL126572.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12658entryRelationship0..1MAY12659@typeCode1..1SHALL126602.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12661entryRelationship0..1MAY12662@typeCode1..1SHALL126632.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12664Conforms to Procedure Activity Observation template (2.16.840.1.113883.10.20.22.4.13).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12643).SHALL contain exactly one [1..1] templateId (CONF:12644) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.59" (CONF:12645).SHALL contain exactly one [1..1] @extension (CONF:12646).SHALL contain exactly one [1..1] statusCode (CONF:12649).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12650).SHALL contain exactly one [1..1] effectiveTime (CONF:12651).This effectiveTime SHALL contain exactly one [1..1] low (CONF:12652).This effectiveTime SHALL contain exactly one [1..1] high (CONF:12653).MAY contain zero or one [0..1] targetSiteCode (CONF:12655).MAY contain zero or one [0..1] entryRelationship (CONF:12656) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12657).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12658).MAY contain zero or one [0..1] entryRelationship (CONF:12659) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12660).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12661).MAY contain zero or one [0..1] entryRelationship (CONF:12662) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12663).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12664).Procedure Activity Procedure[procedure: templateId 2.16.840.1.113883.10.20.22.4.14 (open)]Table SEQ Table \* ARABIC177: Procedure Activity Procedure ContextsUsed By:Contains Entries:Reaction Observation (optional)IndicationInstructionsMedication ActivityProduct 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.Table SEQ Table \* ARABIC178: Procedure Activity Procedure Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Procedure Activity Procedureprocedure[templateId/@root = '2.16.840.1.113883.10.20.22.4.14']@classCode1..1SHALL76522.16.840.1.113883.5.6 (HL7ActClass) = PROC@moodCode1..1SHALL76532.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)templateId1..1SHALLSET<II>7654@root1..1SHALL105212.16.840.1.113883.10.20.22.4.14procedureIdid1..*SHALLII7655procedureTypecode1..1SHALLCE7656originalText0..1SHOULDED7658procedureFreeTextTypereference/@value0..1SHOULD7659statusCode1..1SHALLCS76612.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode)procedureDateTimeeffectiveTime0..1SHOULDTS or IVL<TS>7662priorityCode0..1MAYCE76682.16.840.1.113883.1.11.16866 (ActPriority)methodCode0..1MAYSET<CE>7670bodySitetargetSiteCode0..*SHOULD7683code1..1SHALLCE101222.16.840.1.113883.3.88.12.3221.8.9 (Body Site Value Set)specimen0..*MAY7697specimenRole1..1SHALL7704id0..*SHOULDII7716performer0..*SHOULD7718procedureProviderassignedEntity1..1SHALL7720id1..*SHALLII7722addr1..1SHALLSET<AD>7731telecom1..1SHALLSET<TEL>7732representedOrganization0..1SHOULD7733id0..*SHOULDII7734name0..*MAYPN7735addr1..1SHALLSET<AD>7736telecom1..1SHALLSET<TEL>7737participant0..*MAY7751@typeCode1..1SHALL77522.16.840.1.113883.5.1002 (HL7ActRelationshipType) = DEVparticipant0..*MAY7765@typeCode1..1SHALL77662.16.840.1.113883.5.90 (HL7ParticipationType) = LOCentryRelationship0..*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..1SHALLII7773entryRelationship0..1MAY7775@typeCode1..1SHALL77762.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL7777trueentryRelationship0..*MAY7779@typeCode1..1SHALL77802.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONentryRelationship0..1MAY7886@typeCode1..1SHALL78872.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMPSHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (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" (CONF:10521).SHALL contain at least one [1..*] id (CONF:7655).SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:7656).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), ICD9 Procedures (CodeSystem: 2.16.840.1.113883.6.104), ICD10 Procedure Coding System (CodeSystem: 2.16.840.1.113883.6.4) (CONF:7657).This code SHOULD contain zero or one [0..1] originalText (CONF:7658).The originalText, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7659).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:7660).SHALL contain exactly one [1..1] statusCode, where the @code 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, where the @code SHALL be selected from ValueSet ActPriority 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 with @xsi:type="CE", 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:10122).MAY contain zero or more [0..*] specimen (CONF:7697).This specimen is for representing specimens obtained from a procedure (CONF:8008).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:7717).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] addr (CONF:7736).The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:7737).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) (CONF:7752).SHALL contain exactly one [1..1] Product Instance (templateId:2.16.840.1.113883.10.20.22.4.37) (CONF:7754).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) (CONF:7766).SHALL contain exactly one [1..1] Service Delivery Location (templateId:2.16.840.1.113883.10.20.22.4.32) (CONF:7767).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) (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) (CONF:7771).This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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:7774).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) (CONF:7776).SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:7777).SHALL contain exactly one [1..1] Instructions (templateId:2.16.840.1.113883.10.20.22.4.20) (CONF:7778).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) (CONF:7780).SHALL contain exactly one [1..1] Indication (templateId:2.16.840.1.113883.10.20.22.4.19) (CONF:7781).MAY contain zero or one [0..1] entryRelationship (CONF:7886) such that itSHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:7887).SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:7888).Device Applied[procedure: templateId 2.16.840.1.113883.10.20.24.3.7 (open)]Table SEQ Table \* ARABIC179: Device Applied ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonThis template indicates that equipment designed to treat, monitor, or diagnose a patient's status is in use (e.g., an antithrombotic device has been placed on the patient's legs to prevent thromboembolism, or a cardiac pacemaker is in place).Notes: This is the corresponding QRDA template to the QDM pattern Device, Applied.Table SEQ Table \* ARABIC180: Device Applied Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.24.3.7']@moodCode1..1SHALL123902.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12391@root1..1SHALL123922.16.840.1.113883.10.20.24.3.7@extension1..1SHALL12393code1..1SHALL12414@code1..1SHALL124152.16.840.1.113883.6.96 (SNOMED-CT) = 360030002statusCode1..1SHALL123942.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12395targetSiteCode0..1MAY12416participant1..1SHALL12396@typeCode1..1SHALL123972.16.840.1.113883.5.90 (HL7ParticipationType) = DEVparticipantRole1..1SHALL12398@classCode1..1SHALL123992.16.840.1.113883.5.110 (RoleClass) = MANUplayingDevice1..1SHALL12400@classCode1..1SHALL124012.16.840.1.113883.5.90 (HL7ParticipationType) = DEVcode1..1SHALL12402entryRelationship0..1MAY12403@typeCode1..1SHALL124042.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12405entryRelationship0..1MAY12406@typeCode1..1SHALL124072.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12408entryRelationship0..1MAY12409@nullFlavor1..1SHALL124102.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12411Conforms to Procedure Activity Procedure template (2.16.840.1.113883.10.20.22.4.14).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12390).SHALL contain exactly one [1..1] templateId (CONF:12391) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.7" (CONF:12392).SHALL contain exactly one [1..1] @extension (CONF:12393).SHALL contain exactly one [1..1] code (CONF:12414).This code SHALL contain exactly one [1..1] @code, which SHALL be selected from CodeSystem SNOMED-CT (2.16.840.1.113883.6.96)="360030002" application of device (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12415).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from CodeSystem ActStatus (2.16.840.1.113883.5.14)="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12394).SHALL contain exactly one [1..1] effectiveTime (CONF:12395).MAY contain zero or one [0..1] targetSiteCode (CONF:12416).SHALL contain exactly one [1..1] participant (CONF:12396) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12397).SHALL contain exactly one [1..1] participantRole (CONF:12398).This participantRole SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem RoleClass (2.16.840.1.113883.5.110)="MANU" manufactured product (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:12399).This participantRole SHALL contain exactly one [1..1] playingDevice (CONF:12400).This playingDevice SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="DEV" device (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12401).This playingDevice SHALL contain exactly one [1..1] code (CONF:12402).MAY contain zero or one [0..1] entryRelationship (CONF:12403) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12404).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12405).MAY contain zero or one [0..1] entryRelationship (CONF:12406) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12407).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12408).MAY contain zero or one [0..1] entryRelationship (CONF:12409) such that itSHALL contain exactly one [1..1] @nullFlavor, which SHALL be selected from CodeSystem HL7ActRelationshipType (2.16.840.1.113883.5.1002)="RSON" has reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12410).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12411).Procedure Performed[procedure: templateId 2.16.840.1.113883.10.20.24.3.64 (open)]Table SEQ Table \* ARABIC181: Procedure Performed ContextsUsed By:Contains Entries:Procedure Adverse Event (required)Procedure Intolerance (required)Diagnostic Study Intolerance (required)Diagnostic Study Adverse Event (required)Patient Data Section QDM (optional)Incision DatetimeOrdinalityPatient PreferenceProvider PreferenceReasonThis clinical statement represents a procedure that has been performed.A procedure is a course of action intended to achieve a result in the care of persons with health problems. It is generally invasive and involves physical contact. A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses and/or providing treatment. Some of these procedures are not reimbursed. Note that procedure is distinct from intervention.Table SEQ Table \* ARABIC182: Procedure Performed Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.24.3.64']@moodCode1..1SHALLx_DocumentProcedureMood112612.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLII11262@root1..1SHALLuid112632.16.840.1.113883.10.20.24.3.64@extension1..1SHALLst11264code1..1SHALL11265effectiveTime1..1SHALLIVL_TS11669low1..1SHALLIVXB_TS11670high1..1SHALLIVXB_TS11671methodCode0..1MAYCE11568entryRelationship0..1MAYEntryRelationship11274@typeCode1..1SHALLx_ActRelationshipEntryRelationship112752.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALLObservation11492entryRelationship0..1MAYEntryRelationship11283@typeCode1..1SHALLx_ActRelationshipEntryRelationship112842.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALLObservation11495entryRelationship0..1MAYEntryRelationship11285@typeCode1..1SHALLx_ActRelationshipEntryRelationship112862.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALLObservation11496entryRelationship0..1MAYEntryRelationship11371@typeCode1..1SHALLx_ActRelationshipEntryRelationship113722.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALLObservation11498entryRelationship0..1MAYEntryRelationship11410@typeCode1..1SHALLx_ActRelationshipEntryRelationship115002.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALLObservation11499Conforms to Procedure Activity Procedure template (2.16.840.1.113883.10.20.22.4.14).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11261).SHALL contain exactly one [1..1] templateId (CONF:11262) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.64" (CONF:11263).SHALL contain exactly one [1..1] @extension (CONF:11264).SHALL contain exactly one [1..1] code (CONF:11265).SHALL contain exactly one [1..1] effectiveTime (CONF:11669).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11670).This effectiveTime SHALL contain exactly one [1..1] high (CONF:11671).MAY contain zero or one [0..1] methodCode (CONF:11568).MAY contain zero or one [0..1] entryRelationship (CONF:11274) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11275).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:11492).MAY contain zero or one [0..1] entryRelationship (CONF:11283) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11284).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11495).MAY contain zero or one [0..1] entryRelationship (CONF:11285) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11286).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11496).MAY contain zero or one [0..1] entryRelationship (CONF:11371) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11372).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11498).MAY contain zero or one [0..1] entryRelationship (CONF:11410) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11500).SHALL contain exactly one [1..1] Incision Datetime (templateId:2.16.840.1.113883.10.20.24.3.89) (CONF:11499).Procedure Result[procedure: templateId 2.16.840.1.113883.10.20.24.3.66 (open)]Table SEQ Table \* ARABIC183: Procedure Result ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)OrdinalityPatient PreferenceProvider PreferenceRadiation Dosage and DurationReasonResultStatusProcedure Results are the findings identified as a result of the procedure.Table SEQ Table \* ARABIC184: Procedure Result Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueprocedure[templateId/@root = '2.16.840.1.113883.10.20.24.3.66']@moodCode1..1SHALL111142.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11109@root1..1SHALL111102.16.840.1.113883.10.20.24.3.66@extension1..1SHALL11111code1..1SHALL11112statusCode1..1SHALL11680@code1..1SHALL116812.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11113low1..1SHALL11696high1..1SHALL11697entryRelationship1..1SHALL11115@typeCode1..1SHALL111162.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL11117entryRelationship0..1MAY11682@typeCode1..1SHALL116832.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJobservation1..1SHALL11684entryRelationship0..1MAY11685@typeCode1..1SHALL117002.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL11701entryRelationship0..1MAY11686@typeCode1..1SHALL116872.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11688entryRelationship0..1MAY11689@typeCode1..1SHALL116902.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11691entryRelationship0..1MAY11692@typeCode1..1SHALL116932.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11694entryRelationship0..1MAY11695@typeCode1..1SHALL116982.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL11699Conforms to Procedure Activity Procedure template (2.16.840.1.113883.10.20.22.4.14).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11114).SHALL contain exactly one [1..1] templateId (CONF:11109) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.66" (CONF:11110).SHALL contain exactly one [1..1] @extension (CONF:11111).SHALL contain exactly one [1..1] code (CONF:11112).SHALL contain exactly one [1..1] statusCode (CONF:11680).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11681).SHALL contain exactly one [1..1] effectiveTime (CONF:11113).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11696).This effectiveTime SHALL contain exactly one [1..1] high (CONF:11697).SHALL contain exactly one [1..1] entryRelationship (CONF:11115) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11116).SHALL contain exactly one [1..1] Result (templateId:2.16.840.1.113883.10.20.24.3.87) (CONF:11117).MAY contain zero or one [0..1] entryRelationship (CONF:11682) such that itSHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11683).SHALL contain exactly one [1..1] Ordinality (templateId:2.16.840.1.113883.10.20.24.3.86) (CONF:11684).MAY contain zero or one [0..1] entryRelationship (CONF:11685) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11700).SHALL contain exactly one [1..1] Radiation Dosage and Duration (templateId:2.16.840.1.113883.10.20.24.3.91) (CONF:11701).MAY contain zero or one [0..1] entryRelationship (CONF:11686) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11687).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11688).MAY contain zero or one [0..1] entryRelationship (CONF:11689) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11690).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11691).MAY contain zero or one [0..1] entryRelationship (CONF:11692) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11693).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:11694).MAY contain zero or one [0..1] entryRelationship (CONF:11695) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11698).SHALL contain exactly one [1..1] Status (templateId:2.16.840.1.113883.10.20.24.3.93) (CONF:11699).Procedure Adverse Event[observation: templateId 2.16.840.1.113883.10.20.24.3.61 (open)]Table SEQ Table \* ARABIC185: Procedure Adverse Event ContextsUsed By:Contains Entries:Patient PreferenceProcedure PerformedProvider PreferenceReactionThis clinical statement represents an adverse event caused by a procedure. An adverse event is an unexpected or dangerous reaction to procedure. Serious adverse events are those that are fatal, life-threatening, permanently or significantly disabling, or require or prolonging hospitalization.Table SEQ Table \* ARABIC186: Procedure Adverse Event Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.61']@classCode1..1SHALL113732.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL113742.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11375@root1..1SHALL113762.16.840.1.113883.10.20.24.3.29id1..1SHALL11377code1..1SHALL11378@code1..1SHALL113792.16.840.1.113883.6.96 (SNOMED-CT) = 281647001statusCode1..1SHALL113812.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11382low1..1SHALL11383high0..1SHOULD11384entryRelationship1..1SHALL11385@typeCode1..1SHALL113862.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUS@inversionInd1..1SHALL11387trueprocedure1..1SHALL11388entryRelationship0..1SHOULD11396@typeCode1..1SHALL113972.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL11398trueobservation1..1SHALL11479entryRelationship0..1MAY11411@typeCode1..1SHALL114122.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11468entryRelationship0..1MAY11414@typeCode1..1SHALL114152.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL11605SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11373).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11374).SHALL contain exactly one [1..1] templateId (CONF:11375).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.29" (CONF:11376).SHALL contain exactly one [1..1] id (CONF:11377).SHALL contain exactly one [1..1] code (CONF:11378).This code SHALL contain exactly one [1..1] @code="281647001" Adverse reaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11379).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11381).SHALL contain exactly one [1..1] effectiveTime (CONF:11382).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11383).This effectiveTime SHOULD contain zero or one [0..1] high (CONF:11384).SHALL contain exactly one [1..1] entryRelationship (CONF:11385) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11386).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11387).SHALL contain exactly one [1..1] Procedure Performed (templateId:2.16.840.1.113883.10.20.24.3.64) (CONF:11388).SHOULD contain zero or one [0..1] entryRelationship (CONF:11396) such that itSHALL contain exactly one [1..1] @typeCode="MFST" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11397).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11398).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:11479).MAY contain zero or one [0..1] entryRelationship (CONF:11411) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11412).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11468).MAY contain zero or one [0..1] entryRelationship (CONF:11414) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11415).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11605).Procedure Intolerance[observation: templateId 2.16.840.1.113883.10.20.24.3.62 (open)]Table SEQ Table \* ARABIC187: Procedure Intolerance ContextsUsed By:Contains Entries:Patient PreferenceProcedure PerformedProvider PreferenceReactionThis clinical statement template represents an intolerance to a procedure generally perceived and reported by the patient. For example. a patient may report that a certain physical therapy procedure causes them too much pain to continue complying with the regime.Table SEQ Table \* ARABIC188: Procedure Intolerance Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.62']@classCode1..1SHALL114332.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL114342.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11435@root1..1SHALL114362.16.840.1.113883.10.20.24.3.30id1..1SHALL11437code1..1SHALL11438@code1..1SHALL114392.16.840.1.113883.3.560 (National Quality Forum (NQF)) = INTOL-XstatusCode1..1SHALL11441@code1..1SHALL114422.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL11443low1..1SHALL11444high0..1SHOULD11445entryRelationship0..1SHOULD11457@typeCode1..1SHALL114582.16.840.1.113883.5.1002 (HL7ActRelationshipType) = MFST@inversionInd1..1SHALL11459trueobservation1..1SHALL11477entryRelationship0..1MAY11460@typeCode1..1SHALL114612.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL11478entryRelationship0..1MAY11462@typeCode1..1SHALL114632.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL11464entryRelationship1..1SHALL11601@typeCode1..1SHALL116022.16.840.1.113883.5.90 (HL7ParticipationType) = CAUS@inversionInd1..1SHALL11603trueobservation1..1SHALL11604SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11433).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11434).SHALL contain exactly one [1..1] templateId (CONF:11435).This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.30" (CONF:11436).SHALL contain exactly one [1..1] id (CONF:11437).SHALL contain exactly one [1..1] code (CONF:11438).This code SHALL contain exactly one [1..1] @code="INTOL-X" intolerance (CodeSystem: National Quality Forum (NQF) 2.16.840.1.113883.3.560) (CONF:11439).SHALL contain exactly one [1..1] statusCode (CONF:11441).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:11442).SHALL contain exactly one [1..1] effectiveTime (CONF:11443).This effectiveTime SHALL contain exactly one [1..1] low (CONF:11444).This effectiveTime SHOULD contain zero or one [0..1] high (CONF:11445).SHOULD contain zero or one [0..1] entryRelationship (CONF:11457) such that itSHALL contain exactly one [1..1] @typeCode="MFST" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11458).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11459).SHALL contain exactly one [1..1] Reaction (templateId:2.16.840.1.113883.10.20.24.3.85) (CONF:11477).MAY contain zero or one [0..1] entryRelationship (CONF:11460) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11461).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:11478).MAY contain zero or one [0..1] entryRelationship (CONF:11462) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11463).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:11464).SHALL contain exactly one [1..1] entryRelationship (CONF:11601) such that itSHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:11602).SHALL contain exactly one [1..1] @inversionInd="true" (CONF:11603).SHALL contain exactly one [1..1] Procedure Performed (templateId:2.16.840.1.113883.10.20.24.3.64) (CONF:11604).Product Instance[participantRole: templateId 2.16.840.1.113883.10.20.22.4.37 (open)]Table SEQ Table \* ARABIC189: Product Instance ContextsUsed By:Contains Entries:Procedure Activity Procedure (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.Table SEQ Table \* ARABIC190: Product Instance Constraints OverviewNameXPathCard.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..1SHALLSET<II>7901@root1..1SHALL105222.16.840.1.113883.10.20.22.4.37id1..*SHALLII7902playingDevice1..1SHALL7903code0..1SHOULDCE7904scopingEntity1..1SHALL7905id1..*SHALLII7908SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (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 with @xsi:type="CE" (CONF:7904).SHALL contain exactly one [1..1] scopingEntity (CONF:7905).This scopingEntity SHALL contain at least one [1..*] id (CONF:7908).Provider Care Experience[observation: templateId 2.16.840.1.113883.10.20.24.3.67 (open)]Table SEQ Table \* ARABIC191: Provider Care Experience ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceInformation collected from providers about their perception of the care provided.Notes: This is the corresponding QRDA template for the QDM pattern Provider Care Experience. No consolidated CDA templates seem can be reused.Table SEQ Table \* ARABIC192: Provider Care Experience Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.67']@classCode1..1SHALL124792.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL124802.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12481@root1..1SHALL124822.16.840.1.113883.10.20.24.3.67@extension1..1SHALL12483id1..*SHALL12484code1..1SHALL124852.16.840.1.113883.6.96 (SNOMED-CT) = 405193005statusCode1..1SHALL124862.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12487value1..1SHALLCD12572entryRelationship1..1SHALL12488@typeCode1..1SHALL124892.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL12490entryRelationship1..1SHALL12491@typeCode1..1SHALL124922.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL12493SHALL contain exactly one [1..1] @classCode, which SHALL be selected from CodeSystem HL7ActClass (2.16.840.1.113883.5.6)="OBS" observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12479).SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from CodeSystem ActMood (2.16.840.1.113883.5.1001)="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:12480).SHALL contain exactly one [1..1] templateId (CONF:12481) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.67" (CONF:12482).SHALL contain exactly one [1..1] @extension (CONF:12483).SHALL contain at least one [1..*] id (CONF:12484).SHALL contain exactly one [1..1] code, which SHALL be selected from CodeSystem SNOMED-CT (2.16.840.1.113883.6.96)="405193005" caregiver satisfaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:12485).SHALL contain exactly one [1..1] statusCode, which SHALL be selected from CodeSystem ActStatus (2.16.840.1.113883.5.14)="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:12486).SHALL contain exactly one [1..1] effectiveTime (CONF:12487).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:12572).SHALL contain exactly one [1..1] entryRelationship (CONF:12488) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="RSON" has reason (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12489).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12490).SHALL contain exactly one [1..1] entryRelationship (CONF:12491) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="RSON" has reason (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12492).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12493).Provider Preference[observation: templateId 2.16.840.1.113883.10.20.24.3.84 (open)]Table SEQ Table \* ARABIC193: Provider Preference ContextsUsed By:Contains Entries:Care Goal (optional)Procedure Intolerance (optional)Procedure Performed (optional)Procedure Recommended (optional)Procedure Adverse Event (optional)Procedure Order (optional)Communication from Patient to Provider (optional)Procedure Result (optional)Laboratory Test Performed (optional)Diagnostic Study Intolerance (optional)Diagnostic Study Adverse Event (optional)Laboratory Test Recommended (optional)Communication from Provider to Provider (optional)Communication from Provider to Patient (optional)Encounter Performed (optional)Encounter Active (optional)Encounter Recommended (optional)Encounter Order (optional)Laboratory Test Order (optional)Diagnosis Active (optional)Diagnosis Inactive (optional)Diagnosis Resolved (optional)Medication Active (optional)Device Adverse Event (required)Device Allergy (optional)Device Intolerance (optional)Symptom Active (optional)Symptom Inactive (optional)Symptom Resolved (optional)Device Order (optional)Device Recommended (optional)Device Applied (optional)Medication Administered (optional)Patient Care Experience (optional)Provider Care Experience (required)Risk Category Assessment (optional)Physical Exam Performed (optional)Physical Exam Recommended (optional)Physical Exam Order (optional)Physical Exam Finding (optional)Laboratory Test Result (optional)Functional Status Performed (optional)Functional Status Order (optional)Functional Status Recommended (optional)Functional Status Result (optional)Symptom Assessed (optional)Diagnostic Study Performed (optional)Laboratory Test Adverse Event (optional)Intervention Adverse Event (optional)Intervention Performed (optional)Intervention Order (optional)Intervention Intolerance (optional)Intervention Recommended (optional)Intervention Result (optional)Preferences are choices made by care providers relative to options for care or treatment (including scheduling, care experience, and meeting of personal health goals).Table SEQ Table \* ARABIC194: Provider Preference Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.84']@classCode1..1SHALLActClassObservation111262.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALLx_ActMoodDocumentObservation111272.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLII11128@root1..1SHALLuid111292.16.840.1.113883.10.20.24.3.84@extension1..1SHALLst11130id1..1SHALLII11356code1..1SHALL11131@code1..1SHALLcs111322.16.840.1.113883.6.96 (SNOMED-CT) = 103323008value1..1SHALLCD11323SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11126).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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).This templateId SHALL contain exactly one [1..1] @extension (CONF:11130).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) (CONF:11132).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11323).Radiation Dosage and Duration[observation: templateId 2.16.840.1.113883.10.20.24.3.91 (open)]Table SEQ Table \* ARABIC195: Radiation Dosage and Duration ContextsUsed By:Contains Entries:Procedure Result (optional)Diagnostic Study Performed (optional)The amount of and/or the duration of radiation that was given during a procedure. Table SEQ Table \* ARABIC196: Radiation Dosage and Duration Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.91']@classCode1..1SHALL132762.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL132772.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL13278@root1..1SHALL132792.16.840.1.113883.10.20.24.3.91@extension1..1SHALL13280id1..*SHALL13281code1..1SHALL13282statusCode1..1SHALL13284@code1..1SHALL132852.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime0..1SHOULD13286low1..1SHALL13292high1..1SHALL13293value0..1SHOULD13287SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13276).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13277).SHALL contain exactly one [1..1] templateId (CONF:13278) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.91" (CONF:13279).SHALL contain exactly one [1..1] @extension (CONF:13280).SHALL contain at least one [1..*] id (CONF:13281).SHALL contain exactly one [1..1] code (CONF:13282).SHALL contain exactly one [1..1] statusCode (CONF:13284).This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13285).SHOULD contain zero or one [0..1] effectiveTime (CONF:13286).The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:13292).The effectiveTime, if present, SHALL contain exactly one [1..1] high (CONF:13293).SHOULD contain zero or one [0..1] value (CONF:13287).Reaction Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.9 (open)]Table SEQ Table \* ARABIC197: Reaction Observation ContextsUsed By:Contains Entries:Medication Activity (optional)Medication ActivityProcedure Activity ProcedureSeverity ObservationThis 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.Table SEQ Table \* ARABIC198: Reaction Observation Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Reaction Observationobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.9']@classCode1..1SHALL73252.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73262.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLSET<II>7323@root1..1SHALL105232.16.840.1.113883.10.20.22.4.9id1..1SHALLII7329code1..1SHALLCE7327reactionFreeTexttext0..1SHOULDED7330reference/@value0..1SHOULD7331statusCode1..1SHALLCS73282.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime0..1SHOULDTS or IVL<TS>7332low0..1SHOULDTS7333high0..1SHOULDTS7334reactionCodedvalue1..1SHALLCD73352.16.840.1.113883.3.88.12.3221.7.4 (Problem)severityentryRelationship0..1SHOULD7580@typeCode1..1SHALL75812.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ@inversionInd1..1SHALL10375trueentryRelationship0..*MAY7337@typeCode1..1SHALL73382.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSON@inversionInd1..1SHALL7343trueentryRelationship0..*MAY7340@typeCode1..1SHALL73412.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSON@inversionInd1..1SHALL7344trueSHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7325).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (CONF:10523).SHALL contain exactly one [1..1] id (CONF:7329).SHALL contain exactly one [1..1] code with @xsi:type="CE" (CONF:7327).The value set for this code element has not been specified. Implementers are allowed to use any code system, such as SNOMED CT, a locally determined code, or a nullFlavor (CONF:9107).SHOULD contain zero or one [0..1] text (CONF:7330).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7331).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:7377).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7328).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 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:7335).SHOULD 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) (CONF:7581).SHALL contain exactly one [1..1] @inversionInd="true" TRUE (CONF:10375).SHALL contain exactly one [1..1] Severity Observation (templateId:2.16.840.1.113883.10.20.22.4.8) (CONF:7582).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) (CONF:7338).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7343).SHALL contain exactly one [1..1] Procedure Activity Procedure (templateId:2.16.840.1.113883.10.20.22.4.14) (CONF:7339).This procedure activity is intended to contain information about procedures that were performed in response to an allergy reaction (CONF:7583).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) (CONF:7341).SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7344).SHALL contain exactly one [1..1] Medication Activity (templateId:2.16.840.1.113883.10.20.22.4.16) (CONF:7342).This medication activity is intended to contain information about medications that were administered in response to an allergy reaction (CONF:7584).Reaction[observation: templateId 2.16.840.1.113883.10.20.24.3.85 (open)]Table SEQ Table \* ARABIC199: Reaction ContextsUsed By:Contains Entries:Procedure Intolerance (optional)Procedure Adverse Event (optional)Diagnostic Study Intolerance (optional)Diagnostic Study Adverse Event (optional)Device Adverse Event (required)Device Allergy (required)Laboratory Test Adverse Event (optional)Intervention Adverse Event (optional)Intervention Intolerance (optional)This conformant result observation clinical statement requires an effectiveTime. A result observation represents an undesired symptom, finding, etc., due to an administered substance, device, diagnostic study, intervention, laboratory test or procedure. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions. Table SEQ Table \* ARABIC200: Reaction Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.85']templateId1..1SHALL11332@root1..1SHALL113332.16.840.1.113883.10.20.24.3.85@extension1..1SHALL11660code1..1SHALL11661@code1..1SHALL116622.16.840.1.113883.6.96 (SNOMED-CT) = 263851003effectiveTime1..1SHALL11370value1..1SHALLCD11663Conforms to Reaction Observation template (2.16.840.1.113883.10.20.22.4.9).SHALL contain exactly one [1..1] templateId (CONF:11332) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.85" (CONF:11333).SHALL contain exactly one [1..1] @extension (CONF:11660).SHALL contain exactly one [1..1] code (CONF:11661).This code SHALL contain exactly one [1..1] @code="263851003" reaction (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11662).SHALL contain exactly one [1..1] effectiveTime (CONF:11370).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11663).Reason[observation: templateId 2.16.840.1.113883.10.20.24.3.88 (open)]Table SEQ Table \* ARABIC201: Reason ContextsUsed By:Contains Entries:Procedure Performed (optional)Procedure Recommended (optional)Procedure Order (optional)Procedure Result (optional)Laboratory Test Performed (optional)Laboratory Test Recommended (optional)Encounter Performed (optional)Encounter Active (optional)Encounter Recommended (optional)Encounter Order (optional)Laboratory Test Order (optional)Diagnosis Active (optional)Diagnosis Inactive (optional)Diagnosis Resolved (optional)Device Order (optional)Device Recommended (optional)Device Applied (optional)Patient Characteristic Expired (optional)Patient Characteristic Clinical Trial Participant (optional)Physical Exam Performed (optional)Physical Exam Recommended (optional)Physical Exam Order (optional)Physical Exam Finding (optional)Laboratory Test Result (optional)Functional Status Performed (optional)Functional Status Order (optional)Functional Status Recommended (optional)Functional Status Result (optional)Diagnostic Study Performed (optional)Intervention Performed (optional)Intervention Order (optional)Intervention Recommended (optional)Intervention Result (optional)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.Table SEQ Table \* ARABIC202: Reason Constraints OverviewNameXPathCard.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..1SHALL113602.16.840.1.113883.10.20.24.3.88@extension1..1SHALL13192code1..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) (CONF:11357).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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).This templateId SHALL contain exactly one [1..1] @extension (CONF:13192).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) (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) (CONF:11365).SHALL contain exactly one [1..1] effectiveTime (CONF:11366).SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:11367).Reporting Parameters Act[act: templateId 2.16.840.1.113883.10.20.17.3.8 (open)]Table SEQ Table \* ARABIC203: Reporting Parameters Act ContextsUsed By:Contains Entries:Reporting Parameters Section (required)The reporting parameters act provides information about the reporting time interval, and helps provide context for the patient data being reported to the receiving organization. The receiving organization may tell the reporting hospitals what information to include, such as dates representing the quarters of the year for which patient data is desired.Table SEQ Table \* ARABIC204: Reporting Parameters Act Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueact[templateId/@root = '2.16.840.1.113883.10.20.17.3.8']@classCode1..1SHALL32692.16.840.1.113883.5.6 (HL7ActClass) = ACT@moodCode1..1SHALL32702.16.840.1.113883.5.1001 (ActMood) = EVNcode1..1SHALLCD32722.16.840.1.113883.6.96 (SNOMED-CT) = 252116004effectiveTime1..1SHALL3273low1..1SHALL3274high1..1SHALL3275SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:3269).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:3270).SHALL contain exactly one [1..1] code with @xsi:type="CD"="252116004" Observation Parameters (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:3272).SHALL contain exactly one [1..1] effectiveTime (CONF:3273).This effectiveTime SHALL contain exactly one [1..1] low (CONF:3274).This effectiveTime SHALL contain exactly one [1..1] high (CONF:3275).Result Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.2 (open)]This clinical statement represents details of a lab, radiology, or other study performed on a patient.Table SEQ Table \* ARABIC205: Result Observation Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Result Observationobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.2']@classCode1..1SHALL71302.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL71312.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLSET<II>7136@root1..1SHALL91382.16.840.1.113883.10.20.22.4.2resultIDid1..*SHALLII7137resultTypecode1..1SHALLCE7133text0..1SHOULDED7138reference/@value0..1SHOULD7139resultStatusstatusCode1..1SHALLCS71342.16.840.1.113883.5.14 (ActStatus) = completedresultDateTimeeffectiveTime1..1SHALLTS or IVL<TS>7140resultValuevalue1..1SHALLANY7143resultInterpretationinterpretationCode0..*SHOULDCE7147methodCode0..1MAYSET<CE>7148targetSiteCode0..1MAYSET<CD>7153author0..1MAY7149resultReferenceRangereferenceRange0..*SHOULD7150observationRange1..1SHALL7151code0..0SHALL NOT7152SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7130).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (CONF:9138).SHALL contain at least one [1..*] id (CONF:7137).SHALL contain exactly one [1..1] code with @xsi:type="CE" (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:7166).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:9109).SHOULD contain zero or one [0..1] text (CONF:7138).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7139).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:9119).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7134).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:7141).SHALL contain exactly one [1..1] value with @xsi:type="ANY" (CONF:7143).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).MAY contain zero or one [0..1] author (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).Functional Status Result[observation: templateId 2.16.840.1.113883.10.20.24.3.28 (open)]Table SEQ Table \* ARABIC206: Functional Status Result ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonThe functional status assessment result value(s).Functional status assessment is specific tools that evaluate an individual patient's actual physical or behavioral performance as an indicator of capabilities at a point in time. The functional status assessment can be used in measurement to determine change in physical or behavioral performance over time.Table SEQ Table \* ARABIC207: Functional Status Result Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.28']@classCode1..1SHALL128502.16.840.1.113883.5.6 (HL7ActClass) = OBStemplateId1..1SHALL12835@root1..1SHALL128362.16.840.1.113883.10.20.24.3.28@extension1..1SHALL12837entryRelationship0..1MAY12841@typeCode1..1SHALL128422.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12843entryRelationship0..1MAY12844@typeCode1..1SHALL128452.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12846entryRelationship0..1MAY12847@typeCode1..1SHALL128482.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12849Conforms to Result Observation template (2.16.840.1.113883.10.20.22.4.2).SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:12850).SHALL contain exactly one [1..1] templateId (CONF:12835) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.28" (CONF:12836).SHALL contain exactly one [1..1] @extension (CONF:12837).MAY contain zero or one [0..1] entryRelationship (CONF:12841) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12842).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12843).MAY contain zero or one [0..1] entryRelationship (CONF:12844) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12845).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12846).MAY contain zero or one [0..1] entryRelationship (CONF:12847) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12848).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12849).Laboratory Test Result[observation: templateId 2.16.840.1.113883.10.20.24.3.40 (open)]Table SEQ Table \* ARABIC208: Laboratory Test Result ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonStatusThe result of a study in the clinical laboratory (traditionally chemistry, hematology, microbiology, serology, urinalysis, blood bank). A time/date stamp is required. Table SEQ Table \* ARABIC209: Laboratory Test Result Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.40']templateId1..1SHALL11765@root1..1SHALL117662.16.840.1.113883.10.20.24.3.40@extension1..1SHALL12750entryRelationship0..1MAY11762@typeCode1..1SHALL117632.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFRobservation1..1SHALL11764entryRelationship0..1MAY12741@typeCode1..1SHALL127422.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12743entryRelationship0..1MAY12744@typeCode1..1SHALL127452.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12746entryRelationship0..1MAY12747@typeCode1..1SHALL127482.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12749Conforms to Result Observation template (2.16.840.1.113883.10.20.22.4.2).SHALL contain exactly one [1..1] templateId (CONF:11765) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.40" (CONF:11766).SHALL contain exactly one [1..1] @extension (CONF:12750).MAY contain zero or one [0..1] entryRelationship (CONF:11762) such that itSHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:11763).SHALL contain exactly one [1..1] Status (templateId:2.16.840.1.113883.10.20.24.3.93) (CONF:11764).MAY contain zero or one [0..1] entryRelationship (CONF:12741) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12742).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12743).MAY contain zero or one [0..1] entryRelationship (CONF:12744) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12745).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12746).MAY contain zero or one [0..1] entryRelationship (CONF:12747) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12748).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12749).Physical Exam Finding[observation: templateId 2.16.840.1.113883.10.20.24.3.57 (open)]Table SEQ Table \* ARABIC210: Physical Exam Finding ContextsUsed By:Contains Entries:Patient Data Section QDM (optional)Patient PreferenceProvider PreferenceReasonThe result or finding of a physical exam. A time/date stamp is required.Table SEQ Table \* ARABIC211: Physical Exam Finding Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.57']templateId1..1SHALL12705@root1..1SHALL127062.16.840.1.113883.10.20.24.3.57@extension1..1SHALL12707entryRelationship0..1MAY12716@typeCode1..1SHALL127172.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12718entryRelationship0..1MAY12719@typeCode1..1SHALL127202.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12721entryRelationship0..1MAY12722@typeCode1..1SHALL127232.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSONobservation1..1SHALL12724Conforms to Result Observation template (2.16.840.1.113883.10.20.22.4.2).SHALL contain exactly one [1..1] templateId (CONF:12705) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.57" (CONF:12706).SHALL contain exactly one [1..1] @extension (CONF:12707).MAY contain zero or one [0..1] entryRelationship (CONF:12716) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12717).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12718).MAY contain zero or one [0..1] entryRelationship (CONF:12719) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12720).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12721).MAY contain zero or one [0..1] entryRelationship (CONF:12722) such that itSHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:12723).SHALL contain exactly one [1..1] Reason (templateId:2.16.840.1.113883.10.20.24.3.88) (CONF:12724).Result[observation: templateId 2.16.840.1.113883.10.20.24.3.87 (open)]Table SEQ Table \* ARABIC212: Result ContextsUsed By:Contains Entries:Procedure Result (required)Intervention Result (required)Table SEQ Table \* ARABIC213: Result Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.87']templateId1..1SHALL11672@root1..1SHALL116732.16.840.1.113883.10.20.24.3.87@extension1..1SHALL11678Conforms to Result Observation template (2.16.840.1.113883.10.20.22.4.2).SHALL contain exactly one [1..1] templateId (CONF:11672) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.87" (CONF:11673).SHALL contain exactly one [1..1] @extension (CONF:11678).Risk Category Assessment[observation: templateId 2.16.840.1.113883.10.20.24.3.69 (open)]Table SEQ Table \* ARABIC214: Risk Category Assessment ContextsUsed By:Contains Entries:Patient PreferenceProvider PreferenceAn assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (used for assessing pressure ulcer risk), APACHE Score (used for estimating mortality in critically ill patients), Mini-Mental Status Exam (used to assess cognitive function), APGAR Score (used to assess the health of a newborn), and Glasgow Coma Scale (used for assessment of coma and impaired consciousness.)Notes: This is the corresponding QRDA template for the QDM pattern Risk Category Assessment.Table SEQ Table \* ARABIC215: Risk Category Assessment Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.69']@classCode1..1SHALL130742.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL130752.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL12496@root1..1SHALL124972.16.840.1.113883.10.20.24.3.67@extension1..1SHALL12498id1..*SHALL12499code1..1SHALL12500derivationExpr0..1MAY13684statusCode1..1SHALL130802.16.840.1.113883.5.14 (ActStatus) = completedeffectiveTime1..1SHALL12502value1..1SHALL12543entryRelationship0..1MAY12503@typeCode1..1SHALL125042.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL12505entryRelationship0..1MAY12506@typeCode1..1SHALL125072.16.840.1.113883.5.90 (HL7ParticipationType) = RSONobservation1..1SHALL12508SHALL contain exactly one [1..1] @classCode="OBS" observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:13074).SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:13075).SHALL contain exactly one [1..1] templateId (CONF:12496) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.67" (CONF:12497).SHALL contain exactly one [1..1] @extension (CONF:12498).SHALL contain at least one [1..*] id (CONF:12499).SHALL contain exactly one [1..1] code (CONF:12500).MAY contain zero or one [0..1] derivationExpr (CONF:13684).Such derivation expression can contain a text calculation of how the components total up to the summed score (CONF:13685).SHALL contain exactly one [1..1] statusCode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:13080).SHALL contain exactly one [1..1] effectiveTime (CONF:12502).SHALL contain exactly one [1..1] value (CONF:12543).MAY contain zero or one [0..1] entryRelationship (CONF:12503) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="RSON" has reason (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12504).SHALL contain exactly one [1..1] Patient Preference (templateId:2.16.840.1.113883.10.20.24.3.83) (CONF:12505).MAY contain zero or one [0..1] entryRelationship (CONF:12506) such that itSHALL contain exactly one [1..1] @typeCode, which SHALL be selected from CodeSystem HL7ParticipationType (2.16.840.1.113883.5.90)="RSON" has reason (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:12507).SHALL contain exactly one [1..1] Provider Preference (templateId:2.16.840.1.113883.10.20.24.3.84) (CONF:12508).Service Delivery Location[participantRole: templateId 2.16.840.1.113883.10.20.22.4.32 (open)]Table SEQ Table \* ARABIC216: Service Delivery Location ContextsUsed By:Contains Entries:Procedure Activity Procedure (optional)Procedure Activity Observation (optional)Procedure Activity Act (optional)Encounter Activities (optional)Encounter Recommended (optional)Encounter Order (optional)This clinical statement represents the location of a service event where an act, observation or procedure took place.Table SEQ Table \* ARABIC217: Service Delivery Location Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueparticipantRole[templateId/@root = '2.16.840.1.113883.10.20.22.4.32']@classCode1..1SHALL77582.16.840.1.113883.5.111 (RoleCode) = SDLOCtemplateId1..1SHALLSET<II>7635@root1..1SHALL105242.16.840.1.113883.10.20.22.4.32code1..1SHALLCE77592.16.840.1.113883.1.11.20275 (HealthcareServiceLocation)addr0..*SHOULDSET<AD>7760telecom0..*SHOULDSET<TEL>7761playingEntity0..1MAY7762@classCode1..1SHALL77632.16.840.1.113883.5.41 (EntityClass) = PLCname0..1MAYPN7764SHALL contain exactly one [1..1] @classCode="SDLOC" (CodeSystem: RoleCode 2.16.840.1.113883.5.111) (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 with @xsi:type="CE", where the @code SHALL be selected from ValueSet HealthcareServiceLocation 2.16.840.1.113883.1.11.20275 DYNAMIC (CONF:7759).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) (CONF:7763).This @classCode MAY contain zero or one [0..1] name (CONF:7764).Severity Observation[observation: templateId 2.16.840.1.113883.10.20.22.4.8 (open)]Table SEQ Table \* ARABIC218: Severity Observation ContextsUsed By:Contains Entries:Reaction Observation (optional)Diagnosis Active (optional)Diagnosis Inactive (optional)Diagnosis Resolved (optional)Symptom Active (optional)Symptom Inactive (optional)Symptom Resolved (optional)Symptom Assessed (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 Obervation, Reaction Observation or both. 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.Table SEQ Table \* ARABIC219: Severity Observation Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueGreen Severity Observationobservation[templateId/@root = '2.16.840.1.113883.10.20.22.4.8']@classCode1..1SHALL73452.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL73462.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALLSET<II>7347@root1..1SHALL105252.16.840.1.113883.10.20.22.4.8code1..1SHALLCE73492.16.840.1.113883.5.4 (ActCode) = SEVseverityFreeTexttext0..1SHOULDED7350reference/@value0..1SHOULD7351statusCode1..1SHALLCS73522.16.840.1.113883.5.14 (ActStatus) = completedseverityCodedvalue1..1SHALLCD73562.16.840.1.113883.3.88.12.3221.6.8 (Problem Severity)interpretationCode0..*SHOULDCE9117code0..1SHOULDCE91182.16.840.1.113883.1.11.78 (Observation Interpretation (HL7))SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:7345).SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (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" (CONF:10525).SHALL contain exactly one [1..1] code with @xsi:type="CE"="SEV" Severity Observation (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:7349).SHOULD contain zero or one [0..1] text (CONF:7350).The text, if present, SHOULD contain zero or one [0..1] reference/@value (CONF:7351).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:7378).SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:7352).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).SHOULD contain zero or more [0..*] interpretationCode (CONF:9117).The interpretationCode, if present, SHOULD contain zero or one [0..1] code with @xsi:type="CE", where the @code SHOULD be selected from ValueSet Observation Interpretation (HL7) 2.16.840.1.113883.1.11.78 DYNAMIC (CONF:9118).Status[observation: templateId 2.16.840.1.113883.10.20.24.3.93 (open)]Table SEQ Table \* ARABIC220: Status ContextsUsed By:Contains Entries:Procedure Result (optional)Laboratory Test Result (optional)Intervention Result (optional)The particular stage of the subject within a defined process (e.g., whether a patient is discharged, a test is completed, a medication is discontinued or is on hold, or a report is finalized.Table SEQ Table \* ARABIC221: Status Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed Valueobservation[templateId/@root = '2.16.840.1.113883.10.20.24.3.93']@classCode1..1SHALL118792.16.840.1.113883.5.6 (HL7ActClass) = OBS@moodCode1..1SHALL118802.16.840.1.113883.5.1001 (ActMood) = EVNtemplateId1..1SHALL11881@root1..1SHALL118822.16.840.1.113883.10.20.24.3.93@extension1..1SHALL11883id1..*SHALL11884code1..1SHALL11885@code1..1SHALL118862.16.840.1.113883.6.96 (SNOMED-CT) = 263490005value1..1SHALL11887SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:11879).SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:11880).SHALL contain exactly one [1..1] templateId (CONF:11881) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.93" (CONF:11882).SHALL contain exactly one [1..1] @extension (CONF:11883).SHALL contain at least one [1..*] id (CONF:11884).SHALL contain exactly one [1..1] code (CONF:11885).This code SHALL contain exactly one [1..1] @code="263490005" status (CodeSystem: SNOMED-CT 2.16.840.1.113883.6.96) (CONF:11886).SHALL contain exactly one [1..1] value (CONF:11887).Supporting TemplatesFacility Location[Participant2: templateId 2.16.840.1.113883.10.20.24.3.100 (open)]Table SEQ Table \* ARABIC222: Facility Location ContextsUsed By:Contains Entries:Encounter Performed (optional)Diagnostic Study Performed (optional)Encounter Active (optional)This clinical statement represents the location where an act, observation or procedure took place.Table SEQ Table \* ARABIC223: Facility Location Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueParticipant2[templateId/@root = '2.16.840.1.113883.10.20.24.3.100']@typeCode1..1SHALL133742.16.840.1.113883.5.90 (HL7ParticipationType) = LOCtemplateId1..1SHALL13375@root1..1SHALL133762.16.840.1.113883.10.20.24.3.100@extension1..1SHALL13377time1..1SHALL13371low1..1SHALL13384high1..1SHALL13385participantRole1..1SHALL13372@classCode1..1SHALL133732.16.840.1.113883.5.110 (RoleClass) = SDLOCcode1..1SHALL13378addr0..*SHOULD13379telecom0..*SHOULD13380playingEntity0..1MAY13381@classCode1..1SHALL133822.16.840.1.113883.5.41 (EntityClass) = PLCname0..1MAY13383SHALL contain exactly one [1..1] @typeCode="LOC" location (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:13374).SHALL contain exactly one [1..1] templateId (CONF:13375) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.100" (CONF:13376).SHALL contain exactly one [1..1] @extension (CONF:13377).SHALL contain exactly one [1..1] time (CONF:13371).This time SHALL contain exactly one [1..1] low (CONF:13384).This time SHALL contain exactly one [1..1] high (CONF:13385).SHALL contain exactly one [1..1] participantRole (CONF:13372).This participantRole SHALL contain exactly one [1..1] @classCode="SDLOC" service delivery location (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:13373).This participantRole SHALL contain exactly one [1..1] code (CONF:13378).This participantRole SHOULD contain zero or more [0..*] addr (CONF:13379).This participantRole SHOULD contain zero or more [0..*] telecom (CONF:13380).This participantRole MAY contain zero or one [0..1] playingEntity (CONF:13381).The playingEntity, if present, SHALL contain exactly one [1..1] @classCode="PLC" place (CodeSystem: EntityClass 2.16.840.1.113883.5.41) (CONF:13382).The playingEntity, if present, MAY contain zero or one [0..1] name (CONF:13383).Transfer From[Participant2: templateId 2.16.840.1.113883.10.20.24.3.81 (open)]Table SEQ Table \* ARABIC224: Transfer From ContextsUsed By:Contains Entries:Encounter Performed (optional)Transfer of care refers to the different locations or settings a patient is released to, or received from, in order to ensure the coordination and continuity of healthcare. Transfer from specifies the setting from which a patient is received (e.g., home, acute care hospital, skilled nursing).Notes: This is the corresponding QRDA template to the QDM pattern Transfer From. It is modeled as a participant to an encounter.Table SEQ Table \* ARABIC225: Transfer From Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueParticipant2[templateId/@root = '2.16.840.1.113883.10.20.24.3.81']@typeCode1..1SHALL131882.16.840.1.113883.5.90 (HL7ParticipationType) = ORGtemplateId1..1SHALL13189@root1..1SHALL131902.16.840.1.113883.10.20.24.3.81@extension1..1SHALL13191time1..1SHALL13185participantRole1..1SHALL13186@classCode1..1SHALL131872.16.840.1.113883.5.110 (RoleClass) = LOCESHALL contain exactly one [1..1] @typeCode="ORG" origin (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:13188).SHALL contain exactly one [1..1] templateId (CONF:13189) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.81" (CONF:13190).SHALL contain exactly one [1..1] @extension (CONF:13191).SHALL contain exactly one [1..1] time (CONF:13185).SHALL contain exactly one [1..1] participantRole (CONF:13186).This participantRole SHALL contain exactly one [1..1] @classCode="LOCE" located entity (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:13187).Transfer To[Participant2: templateId 2.16.840.1.113883.10.20.24.3.82 (open)]Table SEQ Table \* ARABIC226: Transfer To ContextsUsed By:Contains Entries:Encounter Performed (optional)Transfer of care refers to the different locations or settings a patient is released to, or received from, in order to ensure the coordination and continuity of healthcare. "Transfer to" specifies the setting the patient is released to (e.g., home, acute care hospital, skilled nursing).Notes: This is the corresponding QRDA template to the QDM pattern Transfer To. It is modeled as a participant to an encounter.Table SEQ Table \* ARABIC227: Transfer To Constraints OverviewNameXPathCard.VerbData TypeCONF#Fixed ValueParticipant2[templateId/@root = '2.16.840.1.113883.10.20.24.3.82']@typeCode1..1SHALL131812.16.840.1.113883.5.90 (HL7ParticipationType) = DSTtemplateId1..1SHALL13182@root1..1SHALL131832.16.840.1.113883.10.20.24.3.82@extension1..1SHALL13184time1..1SHALL13178participantRole1..1SHALL13179@classCode1..1SHALL131802.16.840.1.113883.5.110 (RoleClass) = LOCESHALL contain exactly one [1..1] @typeCode="DST" destination (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:13181).SHALL contain exactly one [1..1] templateId (CONF:13182) such that itSHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.24.3.82" (CONF:13183).SHALL contain exactly one [1..1] @extension (CONF:13184).SHALL contain exactly one [1..1] time (CONF:13178).SHALL contain exactly one [1..1] participantRole (CONF:13179).This participantRole SHALL contain exactly one [1..1] @classCode="LOCE" located entity (CodeSystem: RoleClass 2.16.840.1.113883.5.110) (CONF:13180).ReferencesHL7 Clinical Document Architecture (CDA Release 2). Implementation Guide for CDA Release 2.0, Consolidated CDA Templates. December 2011.HL7 Implementation Guide for CDA Release 2.0, Quality Reporting Document Architecture (QRDA). March 2009.HL7 Version 3 Interoperability Standards, Normative Edition 2010. (must be an HL7 member)HL7 Version 3 Publishing Facilitator's Guide bulleted list with hyperlinksProbably many itemsQDM to QRDA MappiNG TableTable SEQ Table \* ARABIC 228: HQMF QDM Pattern to CDA Template Mapping Table4/4/12 Posting Note: This table does not yet contain all the QDM DataTypes or CDA MappingsQuality Data Type or Atribute NameQuality Data TypePattern IDCDA Template NameCDA Template IDAge Observation2.16.840.1.113883.10.20.22.4.31Care Goal2.16.840.1.113883.3.560.1.9Care Goal2.16.840.1.113883.10.20.24.3.1Communication: From Patient to Provider2.16.840.1.113883.3.560.1.30Communication from Patient to Provider2.16.840.1.113883.10.20.24.3.2Communication: From Provider to Patient2.16.840.1.113883.3.560.1.31Communication from Provider to Patient2.16.840.1.113883.10.20.24.3.3Communication: From Provider to Provider2.16.840.1.113883.3.560.1.29Communication from Provider to Provider2.16.840.1.113883.10.20.24.3.4Device, Adverse Event2.16.840.1.113883.3.560.1.34Device Adverse Event2.16.840.1.113883.10.20.24.3.5Device, Allergy2.16.840.1.113883.3.560.1.35Device Allergy2.16.840.1.113883.10.20.24.3.6Device, Applied2.16.840.1.113883.3.560.1.10Device Applied2.16.840.1.113883.10.20.24.3.7Device, Intolerance2.16.840.1.113883.3.560.1.36Device Intolerance2.16.840.1.113883.10.20.24.3.8Device, Order2.16.840.1.113883.3.560.1.37Device Order2.16.840.1.113883.10.20.24.3.9Device, Recommended2.16.840.1.113883.3.560.1.80Device Recommended2.16.840.1.113883.10.20.24.3.10Diagnosis, Active2.16.840.1.113883.3.560.1.2Diagnosis Active2.16.840.1.113883.10.20.24.3.11Diagnosis, Inactive2.16.840.1.113883.3.560.1.23Diagnosis Inactive2.16.840.1.113883.10.20.24.3.13Diagnosis, Resolved2.16.840.1.113883.3.560.1.24Diagnosis Resolved2.16.840.1.113883.10.20.24.3.14Diagnostic Study, Adverse Event2.16.840.1.113883.3.560.1.38Diagnostic Study Adverse Event2.16.840.1.113883.10.20.24.3.15Diagnostic Study, Intolerance2.16.840.1.113883.3.560.1.39Diagnostic Study Intolerance2.16.840.1.113883.10.20.24.3.16Diagnostic Study, Performed2.16.840.1.113883.3.560.1.3Diagnostic Study Performed2.16.840.1.113883.10.20.24.3.18Drug Vehicle2.16.840.1.113883.10.20.22.4.24Encounter Active2.16.840.1.113883.10.20.24.3.21Encounter Activities2.16.840.1.113883.10.20.22.4.49Encounter Order2.16.840.1.113883.10.20.24.3.22Encounter Performed2.16.840.1.113883.10.20.24.3.23Encounter Recommended2.16.840.1.113883.10.20.24.3.24Functional Status Order2.16.840.1.113883.10.20.24.3.25Functional Status Performed2.16.840.1.113883.10.20.24.3.26Functional Status Recommended2.16.840.1.113883.10.20.24.3.27Functional Status Result2.16.840.1.113883.10.20.24.3.28Health Status Observation2.16.840.1.113883.10.20.22.4.5Immunization Medication Information2.16.840.1.113883.10.20.22.4.54Incision Datetime2.16.840.1.113883.10.20.24.3.89Indication2.16.840.1.113883.10.20.22.4.19Instructions2.16.840.1.113883.10.20.22.4.20Intervention Adverse Event2.16.840.1.113883.10.20.24.3.29Intervention Intolerance2.16.840.1.113883.10.20.24.3.30Intervention Order2.16.840.1.113883.10.20.24.3.31Intervention Performed2.16.840.1.113883.10.20.24.3.32Intervention Recommended2.16.840.1.113883.10.20.24.3.33Intervention Result2.16.840.1.113883.10.20.24.3.34Laboratory Test Adverse Event2.16.840.1.113883.10.20.24.3.35Laboratory Test Intolerance2.16.840.1.113883.10.20.24.3.36Laboratory Test Order2.16.840.1.113883.10.20.24.3.37Laboratory Test Performed2.16.840.1.113883.10.20.24.3.38Laboratory Test Recommended2.16.840.1.113883.10.20.24.3.39Laboratory Test Result2.16.840.1.113883.10.20.24.3.40Medication Active2.16.840.1.113883.10.20.24.3.41Medication Activity2.16.840.1.113883.10.20.22.4.16Medication Administered2.16.840.1.113883.10.20.24.3.42Medication Administered HQMF2.16.840.1.113883.3.560.1.14Medication Dispense2.16.840.1.113883.10.20.22.4.18Medication Information2.16.840.1.113883.10.20.22.4.23Medication Supply Order2.16.840.1.113883.10.20.22.4.17Ordinality2.16.840.1.113883.10.20.24.3.86Patient Care Experience2.16.840.1.113883.10.20.24.3.48Patient Characteristic Clinical Trial Participant2.16.840.1.113883.10.20.24.3.51Patient Characteristic Expired2.16.840.1.113883.10.20.24.3.54Patient Characteristic Payer2.16.840.1.113883.10.20.24.3.55Patient Preference2.16.840.1.113883.10.20.24.3.83Physical Exam Finding2.16.840.1.113883.10.20.24.3.57Physical Exam Order2.16.840.1.113883.10.20.24.3.58Physical Exam Performed2.16.840.1.113883.10.20.24.3.59Physical Exam Recommended2.16.840.1.113883.10.20.24.3.60Plan of Care Activity Encounter2.16.840.1.113883.10.20.22.4.40Plan of Care Activity Observation2.16.840.1.113883.10.20.22.4.44Plan of Care Activity Procedure2.16.840.1.113883.10.20.22.4.41Plan of Care Activity Supply2.16.840.1.113883.10.20.22.4.43Precondition for Substance Administration2.16.840.1.113883.10.20.22.4.25Problem Observation2.16.840.1.113883.10.20.22.4.4Problem Status2.16.840.1.113883.10.20.22.4.6Problem Status Active2.16.840.1.113883.10.20.24.3.94Problem Status Inactive2.16.840.1.113883.10.20.24.3.95Problem Status Resolved2.16.840.1.113883.10.20.24.3.96Procedure Activity Act2.16.840.1.113883.10.20.22.4.12Procedure Activity Observation2.16.840.1.113883.10.20.22.4.13Procedure Activity Procedure2.16.840.1.113883.10.20.22.4.14Procedure Adverse Event2.16.840.1.113883.10.20.24.3.61Procedure Intolerance2.16.840.1.113883.10.20.24.3.62Procedure Order2.16.840.1.113883.10.20.24.3.63Procedure Performed2.16.840.1.113883.10.20.24.3.64Procedure Recommended2.16.840.1.113883.10.20.24.3.65Procedure Result2.16.840.1.113883.10.20.24.3.66Product Instance2.16.840.1.113883.10.20.22.4.37Provider Care Experience2.16.840.1.113883.10.20.24.3.67Provider Preference2.16.840.1.113883.10.20.24.3.84Radiation Dosage and Duration2.16.840.1.113883.10.20.24.3.91Reaction2.16.840.1.113883.10.20.24.3.85Reaction Observation2.16.840.1.113883.10.20.22.4.9Reason2.16.840.1.113883.10.20.24.3.88Result2.16.840.1.113883.10.20.24.3.87Result Observation2.16.840.1.113883.10.20.22.4.2Risk Category Assessment2.16.840.1.113883.10.20.24.3.69Service Delivery Location2.16.840.1.113883.10.20.22.4.32Severity Observation2.16.840.1.113883.10.20.22.4.8Status2.16.840.1.113883.10.20.24.3.93Symptom Active2.16.840.1.113883.10.20.24.3.76Symptom Assessed2.16.840.1.113883.10.20.24.3.77Symptom Inactive2.16.840.1.113883.10.20.24.3.78Symptom Resolved2.16.840.1.113883.10.20.24.3.79Facility Location2.16.840.1.113883.10.20.24.3.100Transfer From2.16.840.1.113883.10.20.24.3.81Transfer To2.16.840.1.113883.10.20.24.3.82Acronyms and AbbreviationsAHIMAAmerican Health Information Management AssociationCCD Continuity of Care DocumentCCRContinuity of Care RecordCDAClinical Document ArchitectureCDA R2CDA Release 2CDC Centers for Disease Control and PreventionCHCAThe Child Health Corporation of AmericaCMSCenters for Medicare and Medicaid ServicesCRSCare Record SummaryDSTU Draft Standard for Trial UseEHRElectronic Health RecordHL7Health Level SevenIGImplementation GuideIHEIntegrating the Healthcare EnterpriseIHTSDOInternational Health Terminology Standard Development OrganisationIOMInstitute of MedicineLOINCLogical Observation Identifiers Names and CodesNHINNationwide Health Information NetworkNHSN National Healthcare Safety NetworkOIDObject identifierPHIN VADS Public Health Information Network Vocabulary Access and Distribution SystemQDMQuality Data ModelQRDAQuality Reporting Document ArchitectureR2Release 2RIM Reference Information ModelRMIM Refined Message Information ModelSDWG Structured Documents Working GroupSNOMED CTSystematized Nomenclature of Medicine, Clinical TermsXML Extensible Mark-up LanguageChange Log (r1 vs R2)Document and Section Codes?(Non-normative)This guide uses LOINC codes to identify the type of report and the sections within the reports.Table SEQ Table \* ARABIC 229: Document and Section CodescodeSystemNamecodeMeaning….Template IDs Used in this GuideThis appendix lists all templateIds used in this guide in alphabetical order and in hierarchical order showing containment.Table SEQ Table \* ARABIC230: Alphabetical List of Template IDs in This GuideTemplate TitleTemplate TypetemplateIdQDM-Based QRDAdocument2.16.840.1.113883.10.20.24.1.2QRDA Category I Frameworkdocument2.16.840.1.113883.10.20.24.1.1US Realm Headerdocument2.16.840.1.113883.10.20.22.1.1US Realm Address (AD.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.2US Realm Date and Time (DT.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.3US Realm Patient Name (PTN.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.1Measure Sectionsection2.16.840.1.113883.10.20.24.2.2Measure Section QDMsection2.16.840.1.113883.10.20.24.2.3Patient Data Sectionsection2.16.840.1.113883.10.20.17.2.4Patient Data Section QDMsection2.16.840.1.113883.10.20.24.2.1Reporting Parameters Sectionsection2.16.840.1.113883.10.20.17.2.1Age Observationentry2.16.840.1.113883.10.20.22.4.31Care Goalentry2.16.840.1.113883.10.20.24.3.1Communication from Patient to Providerentry2.16.840.1.113883.10.20.24.3.2Communication from Provider to Patiententry2.16.840.1.113883.10.20.24.3.3Communication from Provider to Providerentry2.16.840.1.113883.10.20.24.3.4Device Adverse Evententry2.16.840.1.113883.10.20.24.3.5Device Allergyentry2.16.840.1.113883.10.20.24.3.6Device Appliedentry2.16.840.1.113883.10.20.24.3.7Device Intoleranceentry2.16.840.1.113883.10.20.24.3.8Device Orderentry2.16.840.1.113883.10.20.24.3.9Device Recommendedentry2.16.840.1.113883.10.20.24.3.10Diagnosis Activeentry2.16.840.1.113883.10.20.24.3.11Diagnosis Inactiveentry2.16.840.1.113883.10.20.24.3.13Diagnosis Resolvedentry2.16.840.1.113883.10.20.24.3.14Diagnostic Study Adverse Evententry2.16.840.1.113883.10.20.24.3.15Diagnostic Study Intoleranceentry2.16.840.1.113883.10.20.24.3.16Diagnostic Study Performedentry2.16.840.1.113883.10.20.24.3.18Drug Vehicleentry2.16.840.1.113883.10.20.22.4.24eMeasure Reference QDMentry2.16.840.1.113883.10.20.24.3.97Encounter Activeentry2.16.840.1.113883.10.20.24.3.21Encounter Activitiesentry2.16.840.1.113883.10.20.22.4.49Encounter Orderentry2.16.840.1.113883.10.20.24.3.22Encounter Performedentry2.16.840.1.113883.10.20.24.3.23Encounter Recommendedentry2.16.840.1.113883.10.20.24.3.24Functional Status Orderentry2.16.840.1.113883.10.20.24.3.25Functional Status Performedentry2.16.840.1.113883.10.20.24.3.26Functional Status Recommendedentry2.16.840.1.113883.10.20.24.3.27Functional Status Resultentry2.16.840.1.113883.10.20.24.3.28Health Status Observationentry2.16.840.1.113883.10.20.22.4.5Immunization Medication Informationentry2.16.840.1.113883.10.20.22.4.54Incision Datetimeentry2.16.840.1.113883.10.20.24.3.89Indicationentry2.16.840.1.113883.10.20.22.4.19Instructionsentry2.16.840.1.113883.10.20.22.4.20Intervention Adverse Evententry2.16.840.1.113883.10.20.24.3.29Intervention Intoleranceentry2.16.840.1.113883.10.20.24.3.30Intervention Orderentry2.16.840.1.113883.10.20.24.3.31Intervention Performedentry2.16.840.1.113883.10.20.24.3.32Intervention Recommendedentry2.16.840.1.113883.10.20.24.3.33Intervention Resultentry2.16.840.1.113883.10.20.24.3.34Laboratory Test Adverse Evententry2.16.840.1.113883.10.20.24.3.35Laboratory Test Intoleranceentry2.16.840.1.113883.10.20.24.3.36Laboratory Test Orderentry2.16.840.1.113883.10.20.24.3.37Laboratory Test Performedentry2.16.840.1.113883.10.20.24.3.38Laboratory Test Recommendedentry2.16.840.1.113883.10.20.24.3.39Laboratory Test Resultentry2.16.840.1.113883.10.20.24.3.40Measure Referenceentry2.16.840.1.113883.10.20.24.3.98Medication Activeentry2.16.840.1.113883.10.20.24.3.41Medication Activityentry2.16.840.1.113883.10.20.22.4.16Medication Administeredentry2.16.840.1.113883.10.20.24.3.42Medication Administered HQMFentry2.16.840.1.113883.3.560.1.14Medication Dispenseentry2.16.840.1.113883.10.20.22.4.18Medication Informationentry2.16.840.1.113883.10.20.22.4.23Medication Supply Orderentry2.16.840.1.113883.10.20.22.4.17Ordinalityentry2.16.840.1.113883.10.20.24.3.86Patient Care Experienceentry2.16.840.1.113883.10.20.24.3.48Patient Characteristic Clinical Trial Participantentry2.16.840.1.113883.10.20.24.3.51Patient Characteristic Expiredentry2.16.840.1.113883.10.20.24.3.54Patient Characteristic Payerentry2.16.840.1.113883.10.20.24.3.55Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Physical Exam Findingentry2.16.840.1.113883.10.20.24.3.57Physical Exam Orderentry2.16.840.1.113883.10.20.24.3.58Physical Exam Performedentry2.16.840.1.113883.10.20.24.3.59Physical Exam Recommendedentry2.16.840.1.113883.10.20.24.3.60Plan of Care Activity Encounterentry2.16.840.1.113883.10.20.22.4.40Plan of Care Activity Observationentry2.16.840.1.113883.10.20.22.4.44Plan of Care Activity Procedureentry2.16.840.1.113883.10.20.22.4.41Plan of Care Activity Supplyentry2.16.840.1.113883.10.20.22.4.43Precondition for Substance Administrationentry2.16.840.1.113883.10.20.22.4.25Problem Observationentry2.16.840.1.113883.10.20.22.4.4Problem Statusentry2.16.840.1.113883.10.20.22.4.6Problem Status Activeentry2.16.840.1.113883.10.20.24.3.94Problem Status Inactiveentry2.16.840.1.113883.10.20.24.3.95Problem Status Resolvedentry2.16.840.1.113883.10.20.24.3.96Procedure Activity Actentry2.16.840.1.113883.10.20.22.4.12Procedure Activity Observationentry2.16.840.1.113883.10.20.22.4.13Procedure Activity Procedureentry2.16.840.1.113883.10.20.22.4.14Procedure Adverse Evententry2.16.840.1.113883.10.20.24.3.61Procedure Intoleranceentry2.16.840.1.113883.10.20.24.3.62Procedure Orderentry2.16.840.1.113883.10.20.24.3.63Procedure Performedentry2.16.840.1.113883.10.20.24.3.64Procedure Recommendedentry2.16.840.1.113883.10.20.24.3.65Procedure Resultentry2.16.840.1.113883.10.20.24.3.66Product Instanceentry2.16.840.1.113883.10.20.22.4.37Provider Care Experienceentry2.16.840.1.113883.10.20.24.3.67Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Radiation Dosage and Durationentry2.16.840.1.113883.10.20.24.3.91Reactionentry2.16.840.1.113883.10.20.24.3.85Reaction Observationentry2.16.840.1.113883.10.20.22.4.9Reasonentry2.16.840.1.113883.10.20.24.3.88Reporting Parameters Actentry2.16.840.1.113883.10.20.17.3.8Resultentry2.16.840.1.113883.10.20.24.3.87Result Observationentry2.16.840.1.113883.10.20.22.4.2Risk Category Assessmententry2.16.840.1.113883.10.20.24.3.69Service Delivery Locationentry2.16.840.1.113883.10.20.22.4.32Severity Observationentry2.16.840.1.113883.10.20.22.4.8Statusentry2.16.840.1.113883.10.20.24.3.93Symptom Activeentry2.16.840.1.113883.10.20.24.3.76Symptom Assessedentry2.16.840.1.113883.10.20.24.3.77Symptom Inactiveentry2.16.840.1.113883.10.20.24.3.78Symptom Resolvedentry2.16.840.1.113883.10.20.24.3.79Facility Locationsubentry2.16.840.1.113883.10.20.24.3.100Transfer Fromsubentry2.16.840.1.113883.10.20.24.3.81Transfer Tosubentry2.16.840.1.113883.10.20.24.3.82Table SEQ Table \* ARABIC231: Hierarchical List of Template IDs in This GuideTemplate TitleTemplate TypetemplateIdQDM-Based QRDAdocument2.16.840.1.113883.10.20.24.1.2Measure Section QDMsection2.16.840.1.113883.10.20.24.2.3eMeasure Reference QDMentry2.16.840.1.113883.10.20.24.3.97Patient Data Section QDMsection2.16.840.1.113883.10.20.24.2.1Care Goalentry2.16.840.1.113883.10.20.24.3.1Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Communication from Patient to Providerentry2.16.840.1.113883.10.20.24.3.2Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Communication from Provider to Patiententry2.16.840.1.113883.10.20.24.3.3Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Communication from Provider to Providerentry2.16.840.1.113883.10.20.24.3.4Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Device Adverse 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Administeredentry2.16.840.1.113883.10.20.24.3.42Medication Activityentry2.16.840.1.113883.10.20.22.4.16Drug Vehicleentry2.16.840.1.113883.10.20.22.4.24Indicationentry2.16.840.1.113883.10.20.22.4.19Instructionsentry2.16.840.1.113883.10.20.22.4.20Medication Dispenseentry2.16.840.1.113883.10.20.22.4.18Immunization Medication Informationentry2.16.840.1.113883.10.20.22.4.54Medication Informationentry2.16.840.1.113883.10.20.22.4.23Medication Supply Orderentry2.16.840.1.113883.10.20.22.4.17Immunization Medication Informationentry2.16.840.1.113883.10.20.22.4.54Instructionsentry2.16.840.1.113883.10.20.22.4.20Medication Informationentry2.16.840.1.113883.10.20.22.4.23Medication Informationentry2.16.840.1.113883.10.20.22.4.23Medication Supply Orderentry2.16.840.1.113883.10.20.22.4.17Immunization Medication Informationentry2.16.840.1.113883.10.20.22.4.54Instructionsentry2.16.840.1.113883.10.20.22.4.20Medication Informationentry2.16.840.1.113883.10.20.22.4.23Precondition for Substance Administrationentry2.16.840.1.113883.10.20.22.4.25Reaction Observationentry2.16.840.1.113883.10.20.22.4.9Procedure Activity Procedureentry2.16.840.1.113883.10.20.22.4.14Indicationentry2.16.840.1.113883.10.20.22.4.19Instructionsentry2.16.840.1.113883.10.20.22.4.20Product Instanceentry2.16.840.1.113883.10.20.22.4.37Service Delivery Locationentry2.16.840.1.113883.10.20.22.4.32Severity Observationentry2.16.840.1.113883.10.20.22.4.8Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Patient Characteristic Clinical Trial Participantentry2.16.840.1.113883.10.20.24.3.51Reasonentry2.16.840.1.113883.10.20.24.3.88Patient Characteristic Expiredentry2.16.840.1.113883.10.20.24.3.54Reasonentry2.16.840.1.113883.10.20.24.3.88Patient Characteristic Payerentry2.16.840.1.113883.10.20.24.3.55Physical Exam Orderentry2.16.840.1.113883.10.20.24.3.58Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Reasonentry2.16.840.1.113883.10.20.24.3.88Procedure Adverse Evententry2.16.840.1.113883.10.20.24.3.61Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Procedure Performedentry2.16.840.1.113883.10.20.24.3.64Incision Datetimeentry2.16.840.1.113883.10.20.24.3.89Ordinalityentry2.16.840.1.113883.10.20.24.3.86Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Reasonentry2.16.840.1.113883.10.20.24.3.88Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Reactionentry2.16.840.1.113883.10.20.24.3.85Procedure Intoleranceentry2.16.840.1.113883.10.20.24.3.62Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Procedure Performedentry2.16.840.1.113883.10.20.24.3.64Incision Datetimeentry2.16.840.1.113883.10.20.24.3.89Ordinalityentry2.16.840.1.113883.10.20.24.3.86Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Reasonentry2.16.840.1.113883.10.20.24.3.88Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Reactionentry2.16.840.1.113883.10.20.24.3.85Risk Category Assessmententry2.16.840.1.113883.10.20.24.3.69Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Symptom Assessedentry2.16.840.1.113883.10.20.24.3.77Ordinalityentry2.16.840.1.113883.10.20.24.3.86Patient Preferenceentry2.16.840.1.113883.10.20.24.3.83Provider Preferenceentry2.16.840.1.113883.10.20.24.3.84Severity Observationentry2.16.840.1.113883.10.20.22.4.8US Realm Address (AD.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.2US Realm Patient Name (PTN.US.FIELDED)unspecified2.16.840.1.113883.10.20.22.5.1Summary of VocabulariesFor the user’s convenience, this table summarizes the vocabularies (code systems) used in this guide.Table SEQ Table \* ARABIC 232: List of VocabulariesRoot OIDscodeSystemcodeSystemName2.16.840.1.113883.5.25HL7 Confidentiality Code2.16.840.1.113883.5.4HL7 actCode2.16.840.1.113883.5.83HL7 Observation Interpretation 2.16.840.1.113883.6.259HL7 HealthcareServiceLocation2.16.840.1.113883.12.162HL7 RouteOfAdministration2.16.840.1.113883.6.1LOINC?2.16.840.1.113883.6.88RxNorm2.16.840.1.113883.6.96SNOMED CT2.16.840.1.113883.6.104ICD-9-CM Procedure 2.16.840.1.113883.6.59CVX2.16.840.1.113883.6.243PHVS_Occupation_CDC2.16.840.1.113883.6.101NUCCProviderCodesSummary of Single-Value Bindings following tables summarize single-value bindings used in this guide.Table SEQ Table \* ARABIC 233: Single-value Bindings from SNOMED CTSingle-value Bindings: SNOMED CT VocabularycodeNHSN Display NameStandard codeDisplay NamecodeSystemcodeSystem Name305351004Admitted to ICUIntensive Care Environment2.16.840.1.113883.6.96SNOMED CTPreviously Published TemplatesThe following templates have been published and are therefore closed for ballot in this draft. They are indicated in the text of this guide by a notation such as [Closed for comments; published December 2011] following the template name.Table SEQ Table \* ARABIC 234: Previously Published Templates (Closed for Ballot)Template TitleTemplate TypetemplateIdUS Realm Headerdocument2.16.840.1.113883.10.20.22.1.1US Realm Address (AD.US.FIELDED2.16.840.1.113883.10.20.22.5.2QRDA Category II Report DraftThis appendix includes the Category II Patient List Report from the QRDA DSTU, release 1, published in March 2009.Header ConstraintsThis section describes constraints that apply to the QRDA Category?II report Header.Header AttributesClinicalDocument/realmCodeThe realmCode element shall be present where the value of @code is US.Figure SEQ Figure \* ARABIC 36: realmCode Category?II example<realmCode code="US"/>ClinicalDocument/typeIDThe value of typeID/@root shall be 2.16.840.1.113883.1.3 and value of typeID/@extension shall be POCD_HD000040.ClinicalDocument/templateIdThis ClinicalDocument/templateId element identifies the template that defines constraints on the content of a QRDA Category II document.A category two QRDA report shall contain at least one ClinicalDocument/templateId element.The value of one ClinicalDocument/templateId/@root shall be 2.16.840.1.113883.10.20.13, representing conformance to the generic Category?II framework constraints.Figure SEQ Figure \* ARABIC 37: ClinicalDocument/templateId Category II example<templateId root= "2.16.840.1.113883.10.20.13"/> <!-- conforms to the DSTU -->ClinicalDocument/codeA QRDA Category?II report shall contain exactly one ClinicalDocument/code with a value of 55183-8 2.16.840.1.113883.6.1 LOINC static.ClinicalDocument/titleA QRDA Category?II report shall contain exactly one ClinicalDocument/title element valued with a case-insensitive, text string containing "QRDA Patient List Report".ParticipantsThis section describes the participants in the QRDA Category?II report.recordTargetCDA requires a recordTarget. A QRDA Category?II report contains information on many patients, and therefore nullifies this participation.The patientRole shall contain an id element where the value of @nullFlavor is NA.Figure SEQ Figure \* ARABIC 38: Null flavor recordTarget Category?II example<recordTarget> <patientRole> <id nullFlavor="NA"/> </patientRole></recordTarget>AuthorThe author may be a device (e.g., data aggregation software), a person (e.g., a quality manager), or an organization (e.g., a processing entity).A QRDA Category?II shall contain one or more ClinicalDocument/ author/assignedAuthor/assignedPerson and/or ClinicalDocument/author/assignedAuthor/representedOrganization and/or ClinicalDocument/author/assignedAuthor/authoringDevice.The example below shows how a processing entity can be represented as the author.Figure SEQ Figure \* ARABIC 39: AssignedAuthor as a processing entity Category?II example <author> <time value="20080513"/> <assignedAuthor> <id nullFlavor="NA"/> <representedOrganization> <id root="2.16.840.1.113883.19.598"/> <name>Good Health Processing Entity</name> </representedOrganization> </assignedAuthor> </author>InformantA QRDA Category?II report must have a stated source so that any data within the report can be validated. The source of the report is the reporting facility, represented using the CCD "Source of Information" construct, via the informant participant.A QRDA Category?II report shall contain exactly one ClinicalDocument/informant, which represents the reporting facility.An organization source of information shall be represented with informant.Figure SEQ Figure \* ARABIC 40: Informant Category?II example <informant> <assignedEntity> <id nullFlavor="NA"/> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> </representedOrganization> </assignedEntity> </informant>CustodianThe custodian is the organization that is responsible for maintaining the QRDA Category?II report. The custodian will vary. The custodian is not necessarily the reporting entity, as there may be workflows where the processing entity itself assumes custodianship.A QRDA Category?II report shall contain exactly one custodian/assignedCustodian/representedCustodianOrganization/id element.The value of custodian/assignedCustodian/representedCustodianOrganization/id element @root shall be the id root of the custodian.Figure SEQ Figure \* ARABIC 41: Custodian Category?II example <custodian> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> </representedCustodianOrganization> </assignedCustodian> </custodian>legalAuthenticatorA legal authenticator is a verifier who officially authenticates the accuracy of the document. An example would be the health care organization that compiles the quality report. A legalAuthenticator is required, but the value will vary depending on the workflow or rules of the organizations. A QRDA Category?II report shall contain exactly one legalAuthenticator element.QRDA Category?II report legalAuthenticator shall contain exactly one ClinicalDocument/legalAuthenticator/time element.A QRDA Category?II report shall contain exactly one signatureCode element.The value of a QRDA ClinicalDocument/signatureCode/@code shall be S.A QRDA Category?II report shall contain exactly one assignedEntity element that represents the legalAuthenticator of the document.The ClinicalDocument/assignedEntity shall contain an id element.Figure SEQ Figure \* ARABIC 42: legalAuthenticator Category?II example <legalAuthenticator> <time value="20080513"/> <signatureCode code="S"/> <assignedEntity> <id nullFlavor="NA"/> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> </representedOrganization> </assignedEntity> </legalAuthenticator>Participant ScenariosThe following table shows a number of scenarios and the values for various participants.Table SEQ Table \* ARABIC 235: QRDA Category?II/III Participant ScenariosAuthorCustodianEncom-passing Encounter / encounter ParticipantEncom-passing Encounter / responsible PartyInform-antLegal Authen-ticatorPartici-pantSCENARIO: The health care enterprise (e.g., Good Health Clinic) collecting the data sends QRDA Category?I reports to a processing entity, which then generates the QRDA Category?II and/or QRDA Category?III reports. This scenario focuses on the participants in the corresponding QRDA Category?II or QRDA Category?III instance.QRDA Category?II/III reportDevice (scoped by Process-ing Entity)Varies depending on workflow. Capture the entity that is in charge of maintain-ing the informa-tion.NoneNone(aka "reporting entity") Good Health Clinic Varies depending on workflow and business rules.NoneBody ConstraintsA QRDA Category?II report requires a structuredBody. The report will typically contain several sections and subsections. The top-level sections may be either Measure sections, where each section is reporting quality data defined by a single measure, or they may be Measure Set sections, where each section contains one or more Measure sections, or they may be both. There will also be a single top-level Reporting Parameters section. This is illustrated in the Category II/II use of Measure Set and Measure sections figure. The figure on QRDA Category II Patient List Report shows an example of a QRDA Category?II report.Figure SEQ Figure \* ARABIC 43: Category?II/III use of Measure Set and Measure sectionsReporting Parameter SectionMeasure Set SectionMeasure SectionMeasure SectionMeasure SectionMeasure Set SectionMeasure SectionMeasure SectionMeasure SectionMeasure SectionMeasure SectionA QRDA Category?II report shall contain exactly one ClinicalDocument/component/structuredBody.A QRDA Category?II report shall contain exactly one Reporting Parameters section.A QRDA Category?II report shall contain at least one and may contain more than one Measure Set section containing information about the measure set.A QRDA Category?II report shall contain at least one and may contain more than one Measure section each containing information about a single measure.Figure SEQ Figure \* ARABIC 44: Sample QRDA Category?II Patient List ReportSection ConstraintsThis section describes constraints that apply to the QRDA Category?II report sections. A section is required for each measure being reported.Reporting Parameters SectionThe Reporting Parameters section provides information about the reporting time interval and may contain other information that helps provide context for the patient data being reported.The Reporting Parameters section shall contain a section/code element.The value for section/code shall be 55187-9 Reporting Parameters 2.16.840.1.113883.6.1 LOINC static.The Reporting Parameters section shall be valued with section/title with a case-insensitive, text string containing "Reporting Parameters".The Reporting Parameters section shall contain exactly one Observation Parameters Act.The value for act/@classCode in an Observation Parameters Act shall be ACT 2.16.840.1.113883.5.6 ActClass static.The value for act/@moodCode in an Observation Parameters Act shall be EVN 2.16.840.1.113883.5.1001 ActMood static.The reporting time period in a Reporting Period Act shall be represented with an effectiveTime/low element combined with a high element representing respectively the first and last days of the period reported.Figure SEQ Figure \* ARABIC 45: Reporting parameters section Catgory II example<section> <code code="55187-9" codeSystem="2.16.840.1.113883.6.1" <title>Reporting Parameters</title> <text> <list> <item>Reporting period: 01 Jan 2007 - 31 Dec 2007</item> </list> </text> <entry> <act classCode="ACT" moodCode="EVN"> <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters" /> <effectiveTime> <low value="20080101" /> <!-- The first day of reported period. --> <high value="20080331" /> <!-- The last day of reported period. --> </effectiveTime> </act> </entry></section>Measure SectionEach QRDA Category?II Measure section corresponds to one measure, and contains a measure identifier along with measure-specific data. Data for each patient listed in a QRDA Category?II report’s Measure section includes patient data elements, measure-specific grouping data elements, and qualification data elements.A patient data element is information about a particular person (as opposed to a population). Examples include: individual’s test results, individual’s encounter location, individual’s date of birth.A measure-specific grouping data element defines a subgroup population criterion. These data elements define how patient data elements are to be cumulated into aggregate data elements. Examples include:a measure-specific grouping data element of “primary surgeon” indicates that the primary surgeon of an individual’s operative procedure be captured in the QRDA Category?I report, and that aggregate data elements in a QRDA Category?III report are to be calculated per each primary surgeon;a measure-specific grouping data element of “outborn” indicates that the infant in a neonatal population was not born at the reporting hospital and will be cohorted into an “outborn” group in the QRDA Category?III report.A qualification data element is patient-level information about the status of quality compliance, e.g., assertion of whether a particular patient meets a measure’s numerator criteria. In the figure QRDA Category II Patient List Report, the patient data elements are “ROP Present?” and “Alive at Discharge?”; measure-specific grouping data elements, such as “outborn”, are not present; and the qualification data elements are “Numerator”, “Denominator”, and “Exclusion”.The Measure section shall contain a templateId uniquely identifying the Measure name and versionThe Measure section shall contain a section/code element.The value for section/code shall be 55186-1 Measure 2.16.840.1.113883.6.1 LOINC static.Each Measure section shall be valued with section/title with a case-insensitive, text string containing "measure section: <measure name>".The Measure Section may contain a section/text element for the description of the measure.Representation of the Measure Data ElementsNote to readers: This section is in draft form, and requires more review before being brought to formal ballot. It is presented here as a walk through of a detailed example. Conformance statements have yet to be created. The Structured Documents Working Group welcomes your review and feedback on the overall approach.The Measure section Category II example figure illustrates evolving design decisions. Each QRDA Category?II Measure section contains an outer act in event mood for each patient (line 4). This outer act has act/id to uniquely identify the act, act/code corresponding to the measure, and act/text where optionally one can give a description of the measure.Because the QRDA Category?II report contains data on many patients, the participant relationship (line 13) is used to specify each patient’s medical record number; participant/typeCode equals RCT (record target).Patient data elements come next (lines 21, 31) and are components of the outer act (beginning on line 4). The complete representation of the data elements are to be described in the measure-specific IG. The QRDA Category?II framework document recommends that the patient data elements use existing CCD and other CDA IG templates where possible, and uses SNOMED CT per the “Using SNOMED CT in HL7 Version 3” DSTU.Measure-specific grouping data elements aren’t present in this example.Qualification data elements (beginning on line 49) come next. A key point here is that a measure defines its aggregate data elements, and the purpose of the qualification is to assert whether or not a patient is to be counted in the corresponding aggregate. For instance, the Healthcare Effectiveness Data and Information Set (HEDIS) “Treat Adults w/Acute Bronchitis” defines the following aggregate data elements:Eligible population by ER/urgent care visitsEligible population by non-ER/urgent care visitsExclusions for comorbid conditionsExclusions for completing diagnosisExclusions for Medication HistoryNumerator by ER/urgent care visitsNumerator by non-ER/urgent care visitsetc.For each of these elements, the QRDA Category?II report will say whether or not the patient qualified, whereas the QRDA Category?III report will show the total number of patients that qualified. A patient that qualifies is given an integer value of 1, whereas a value of 0 indicates the patient didn’t qualify. Integer values are used to facilitate deriving the QRDA Category?III aggregate data element values.Figure SEQ Figure \* ARABIC 46: Measure section Category?II example<section><!-- One measure per section, so this FAKE templateID would represent the ROP measure --> <templateId root="2.16.840.1.113883.19.5"/> <code code="55186-1" codeSystem="2.16.840.1.113883.6.1" /> <title>Measure Section: Retinopathy of Prematurity</title> ...<!-- Data for patient 123456789 --><entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <id root="d71b78bb-0d69-470c-aaf5-fb15382edf84"/> <!-- Fake code for illustration --> <code code="22222-X" codeSystem="2.16.840.1.113883.6.1" displayName="Retinopathy of Prematurity (ROP)"/> <text>Retinopathy of Prematurity incidence in neonates; BW >= 1500gm.</text> <statusCode code="completed"/><!-- Patient details are represented via the CDA Clinical Statement generic participant --> <participant typeCode="RCT"> <participantRole classCode="PAT"> <id extension="123456789" root="2.16.840.1.113883.19.5"/> </participantRole> </participant> <!-- Patient data elements that determine numerator qualification --> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN" negationInd="false"> <id root="f7a66e8a-f6e5-48fe-93e5-f0f1ed462c80"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <value xsi:type="CD" code="362.21" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="Retrolental Fibroplasia"/> </observation> </entryRelationship><!-- Patient data elements that determine exclusion qualification --> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN" negationInd="false"> <id root="f6cf4175-cfd0-4b4b-9dc8-f9f28d1bde3d"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <value xsi:type="CD" code="371827001" codeSystem="2.16.840.1.113883.6.96" displayName="Patient discharged alive"/> </observation> </entryRelationship><!--Patient details related to Denominator inclusion/exclusion aren't included,since it is assumed here that the Category?II report only includes those meeting denominator criteria. --><!-- Qualification data elements --> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <id root="fe179f97-10bc-411f-8afe-7eb1419220db"/> <code code="NUM" codeSystem="codeSystemOID" displayName="Numerator"/> <statusCode code="completed"/> <value xsi:type="INT" value="1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <id root="9a11fd9a-2fc4-48bf-b66e-7a288f977a99"/> <code code="DEN" codeSystem="codeSystemOID" displayName="Denominator"/> <statusCode code="completed"/> <value xsi:type="INT" value="1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <id root="f7b6b575-d9e4-4c78-b71f-63e38996f010"/> <code code="EXCL" codeSystem="codeSystemOID" displayName="Exclusion"/> <statusCode code="completed"/> <value xsi:type="INT" value="0"/> </observation> </entryRelationship> </act> </entry>...</section> <!-- Data for remaining patients would come next... -->QRDA Category III Report DraftThis appendix includes the Category III Calculated Report from the QRDA DSTU, release 1, published in March 2009.Header ConstraintsThis section describes constraints that apply to the QRDA Category?III report Header.Header AttributesClinicalDocument/realmCodeThe realmCode element shall be present where the value of @code is US.Figure SEQ Figure \* ARABIC 47: realmCode Category?III example<realmCode code="US"/>ClinicalDocument/typeIDThe value of typeID/@root shall be 2.16.840.1.113883.1.3 and value of typeID/@extension shall be POCD_HD000040.ClinicalDocument/templateIdThis ClinicalDocument/templateId element identifies the template that defines constraints on the content of a QRDA Category III document.A QRDA Category?III report shall contain at least one ClinicalDocument/templateId element.The value of one ClinicalDocument/templateId/@root shall be 2.16.840.1.113883.10.20.14 representing conformance to the generic QRDA Category?III framework constraints.Figure SEQ Figure \* ARABIC 48: ClinicalDocument/templateId Category III example<templateId root= "2.16.840.1.113883.10.20.14"/> <!-- conforms to the DSTU -->ClinicalDocument/codeA QRDA Category?III report shall contain exactly one ClinicalDocument/code with a value of 55184-6 2.16.840.1.113883.6.1 LOINC static.ClinicalDocument/titleA QRDA Category?III report shall contain exactly one ClinicalDocument/title element valued with a case-insensitive, text string containing “QRDA Calculated Summary Report.”ParticipantsThis section describes the participants in the QRDA Category?III report.recordTargetCDA requires a recordTarget. A QRDA Category?II report contains information on many patients, and therefore nullifies this participation.The value of patientRole shall contain an id element where the value of @nullFlavor is NA.Figure SEQ Figure \* ARABIC 49: Null flavor recordTarget Category?III example <recordTarget> <patientRole> <id nullFlavor="NA"/> </patientRole> </recordTarget>AuthorThe author may be a device (e.g., data aggregation software), a person (e.g., a quality manager), or an organization (e.g., a processing entity).A QRDA Category?III shall contain one or more ClinicalDocument/author/assignedAuthor/assignedPerson and/or ClinicalDocument/author/assignedAuthor/representedOrganization and/or ClinicalDocument/author/assignedAuthor/authoringDevice.The example shows how a processing entity can be represented as the author.Figure SEQ Figure \* ARABIC 50: AssignedAuthor as a processing entity Category?III example <author> <time value="20080513"/> <assignedAuthor> <id nullFlavor="NA"/> <representedOrganization> <id root="2.16.840.1.113883.19.598"/> <name>Good Health Processing Entity</name> </representedOrganization> </assignedAuthor> </author>InformantA QRDA Category?II report must have a stated source so that any data within the report can be validated. The source of the report is the reporting facility, represented using the CCD "Source of Information" construct, via the informant participant.A QRDA Category?III report shall contain exactly one ClinicalDocument/informant, who represents the reporting facility.An organization source of information shall be represented with informant.Figure SEQ Figure \* ARABIC 51: Informant Category?III example <informant> <assignedEntity> <id nullFlavor="NA"/> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> </representedOrganization> </assignedEntity> </informant>CustodianThe custodian is the organization that is responsible for maintaining the QRDA Category?II report. The custodian is not necessarily the reporting entity, as there may be workflows where the processing entity itself assumes custodianship.A QRDA Category?III report shall contain exactly one custodian/assignedCustodian/representedCustodianOrganization/id element.The value of custodian/assignedCustodian/representedCustodianOrganization/id element @root shall be the id root of the custodian.Figure SEQ Figure \* ARABIC 52: Custodian Category?III example <custodian> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> </representedCustodianOrganization> </assignedCustodian> </custodian>legalAuthenticatorA legal authenticator is a verifier who officially authenticates the accuracy of the document. An example would be the health care organization that compiles the quality report. A legalAuthenticator is required, but the value will vary depending on the workflow or rules of the organization.A QRDA Category?III report shall contain exactly one legalAuthenticator element.A QRDA Category?III report legalAuthenticator shall contain exactly one ClinicalDocument/legalAuthenticator/time element.A QRDA Category?III report shall contain exactly one signatureCode element.The value of a QRDA ClinicalDocument/signatureCode/@code shall be S.A QRDA Category?III report shall contain exactly one assignedEntity element the represents the legalAuthenticator of the document.The ClinicalDocument/assigned entity shall contain an id element.Figure SEQ Figure \* ARABIC 53: legalAuthenticator Category?III example <legalAuthenticator> <time value="20080513"/> <signatureCode code="S"/> <assignedEntity> <id nullFlavor="NA"/> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Good Health Clinic</name> </representedOrganization> </assignedEntity> </legalAuthenticator>Participant ScenariosThe QRDA Category II/II Particpant Senarios table shows a number of scenarios and the values for various participants.Body ConstraintsA QRDA Category?III report requires a structuredBody. The report will typically contain several sections and subsections. The top-level sections may be either Measure sections, where each section is reporting quality data defined by a single measure; or they may be Measure Set sections, where each section contains one or more Measure sections; or they may be both. There will also be a single top-level Reporting Parameters section. This is illustrated above in the figure Category II/III use of Measure Set and Measure sections.The Sample Category III QRDA Calculated Summary Report figure shows an example of a QRDA Category?III report.A QRDA Category?III report shall contain exactly one ClinicalDocument/component/structuredBody.A QRDA Category?III report shall contain at least one and may contain more than one Measure Set section containing information about the measure set.A QRDA Category?III report shall contain at least one and may contain more than one Measure section, each containing information about a single measure.A QRDA Category?III report shall contain exactly one Reporting Parameters section.Figure SEQ Figure \* ARABIC 54: Sample Category?III QRDA Calculated Summary ReportSection ConstraintsThis section describes constraints that apply to the QRDA Category?III report sections. A section is required for each measure being reported.Reporting Parameters SectionThe Reporting Parameters section provides information about the reporting time interval and may contain other information that helps provide context for the patient data being reported.The Reporting Parameters section shall contain a section/code element.The value for section/code shall be 55187-9 Reporting Parameters 2.16.840.1.113883.6.1 LOINC static.The Reporting Parameters section shall be valued with section/title with a case-insensitive, text string containing "Reporting Parameters".The Reporting Parameters section shall contain exactly one Observation Parameters Act.The value for act/@classCode in an Observation Parameters Act shall be ACT 2.16.840.1.113883.5.6 ActClass static.The value for act/@moodCode in an Observation Parameters Act shall be EVN 2.16.840.1.113883.5.1001 ActMood static.The reporting time period in a Reporting Period Act shall be represented with an effectiveTime/low element combined with a high element representing respectively the first and last days of the period reported.Figure SEQ Figure \* ARABIC 55: Reporting parameters section Category?III example<section> <code code="55187-9" codeSystem="2.16.840.1.113883.6.1" /> <title>Reporting Parameters</title> <text> <list> <item>Reporting period: 01 Jan 2007 - 31 Dec 2007</item> <item>Aggregation level: Healthcare professional</item> <item>Aggregation level: Site of care</item> </list> </text> <entry> <act classCode="ACT" moodCode="EVN"> <id root="55a43e20-6463-46eb-81c3-9a3a1ad41225"/> <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters"/> <effectiveTime> <low value="20070101"/> <high value="20071231"/> </effectiveTime> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code nullFlavor="OTH"><originalText>Aggregation level</originalText></code> <value xsi:type="CD" code="223366009" codeSystem="2.16.840.1.113883.6.96" displayName="Healthcare professional"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code nullFlavor="OTH"><originalText>Aggregation level</originalText></code> <value xsi:type="CD" code="43741000" codeSystem="2.16.840.1.113883.6.96" displayName="Site of care"/> </observation> </entryRelationship> </act> </entry></section>Measure SectionEach QRDA Category?III Measure section corresponds to one measure and contains a measure identifier, along with aggregate data elements and measure-specific grouping data elements.An aggregate data element is a measure-specified calculated summary derived from patient data elements. Examples include: the number of patients meeting a measure’s numerator criteria, the number of patients meeting a measure’s denominator criteria, and the number of patients excluded due to weight criteria.A measure-specific grouping data element defines a subgroup population criterion. These data elements define how patient data elements are to be cumulated into aggregate data elements. Examples include:a measure-specific grouping data element of “primary surgeon” indicates that the primary surgeon of an individual’s operative procedure be captured in the QRDA Category?I report, and that aggregate data elements in a QRDA Category?III report are to be calculated per each primary surgeon;a measure-specific grouping data element of “outborn” indicates that the infant in a neonatal population was not born at the reporting hospital and will be cohorted into an “outborn” group in the QRDA Category?III report.In the Sample Category II QRDA Calculated Summary Report figure, aggregate data elements are “Numerator”, “Denominator”, “Exclusions”, and “Percentage”; and measure-specific grouping data elements are “Provider” and “Location”.Each Measure section shall contain a templateId uniquely identifying the Measure name and versionEach Measure section shall contain a section/code element.The value for section/code shall be 55186-1 Measure 2.16.840.1.113883.6.1 LOINC static.Each Measure section shall be valued with section/title with a case-insensitive, text string containing "measure section: <measure name>".The Measure Section may contain a section/text element for the description of the measure.Representation of the Measure Data ElementsRepresentation of a measure act within a Measure section will identify the constraints for each measure act. The measure act will contain participant elements if the specific measures require aggregation or grouping in specific ways such as by provider or location.A key point is that a measure defines its aggregate data elements, and the purpose of the qualification in a QRDA Category?II report is to assert whether or not a patient is to be counted in the corresponding aggregate. For instance, the HEDIS “Treat Adults w/Acute Bronchitis” defines the following aggregate data elements:Eligible population by ER/urgent care visitsEligible population by non-ER/urgent care visitsExclusions for comorbid conditionsExclusions for completing diagnosisExclusions for Medication HistoryNumerator by ER/urgent care visitsNumerator by non-ER/urgent care visitsetc.For each of these elements, the QRDA Category?II report will say whether or not the patient qualified, whereas the QRDA Category?III report will show the total number of patients that qualified.Each QRDA Category?III Measure section contains an outer act in event mood for each unique combination of measure-specific grouping data elements. This outer act has act/id to uniquely identify the act, act/code corresponding to the measure, and act/text where optionally one can give a description of the measure.Measure data, whether aggregate data elements or measure-specific grouping data elements, shall be represented with clinical statements.Measure data using SNOMED shall be represented per the “Using SNOMED CT? in HL7 Version 3” DSTU.Measure data should use CCD and other CDA IG templates where possible.A QRDA Category?III report Measure section shall contain a Measure Event Act in event mood for each unique combination of measure-specific grouping data elements.A Measure Event Act shall contain exactly one act/code to encode the particular measure.A Measure Event Act shall represent a measure-specific grouping data element of a performing provider with act/performer [@typeCode="PRF"] representing the provider associated with the patients whose measure data is being reported.Figure SEQ Figure \* ARABIC 56: Act/performer Category?III example representing a provider with which to group data<performer> <assignedEntity> <id extension="00017" root="2.16.840.1.113883.19.5"/> <assignedPerson> <name> <given>Robert</given> <family>Jones</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity></performer>A Measure Event Act shall represent a measure-specific grouping data element of encounter location with the CCD Location Participation (2.16.840.1.113883.10.20.1.45).Figure SEQ Figure \* ARABIC 57: Location Category?III example representing a clinic with which to group data<participant typeCode="LOC"> <templateId root="2.16.840.1.113883.5.90"/> <participantRole classCode="SDLOC"> <playingEntity classCode="PLC"> <name>Good Health Clinic</name> </playingEntity> </participantRole></participant>Aggregation data elements and measure-specific grouping data elements shall be components within a Measure Event Act.entryRelationships shall be used to link aggregation data elements and measure-specific grouping data elements with the corresponding Reporting Parameter section.Figure SEQ Figure \* ARABIC 58: entryRelationship Category?III example referring to the reporting parameters<entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <id root="55a43e20-6463-46eb-81c3-9a3a1ad41225"/> <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters"/> </act></entryRelationship>In the QRDA Category?III Measure section, aggregate data elements such as numerator, denominator, or exclusion are modeled as observations. The example shows the use of a local code. Standard codes, such as SNOMED, for these commonly used terms in quality reporting, would be preferred, but will have to be requested.An aggregate data element shall be represented with Observation.The value for observation/@moodCode in an aggregate data element shall be EVN 2.16.840.1.113883.5.1001 ActMood static.An aggregate data element should contain at least one observation/id.An aggregate data element shall contain exactly one observation/statusCode.The value of observation/statusCode shall be Completed.Figure SEQ Figure \* ARABIC 59: entryRelationship Category?III observation of an integer value as a numerator example<entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <id root="b61afff0-1654-4122-aa1d-7113d3b26c3a"/> <code code="NUM" codeSystem="TCNYcodeSystemOID" displayName="Numerator"/> <statusCode code="completed"/> <value xsi:type="INT" value="4"/> </observation></entryRelationship> ................
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