Back To Index  <<  Back To Templates

draft Template   BC CDA ClinicalDocument

Template (internal) 2.16.840.1.113883.3.51.60.2.1 - BCCDAClinicalDocument2
Id 2.16.840.1.113883.3.51.60.2.1
Version valid from 2016‑04‑02 11:52:37 status draft Under develeopment
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Description Pilot BC CDA template 
Used by / Uses
Used by 0 templates, Uses 9 templates
Uses Template id as Name Version
2.16.840.1.113883.3.1937.99.61.26.10.19 Include BCCDArecordTarget1 DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.4 Include CDAauthor DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.10 Include CDAdataEnterer DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.5 Include CDAinformationRecipient DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.3 Include BcCDAauthenticator DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.12 Include CDAparticipant DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.13 Include CDArelatedDocument DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.16 Include CDAcomponentOf DYNAMIC
2.16.840.1.113883.10.12.201 Containment CDASection DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.2 (2005‑09‑07)
Item DT Card Conf Description Label
hl7:ClinicalDocument
M (BCCDAClinicalDocument2)
treetree @classCode
cs 1 .. 1 F DOCCLIN
treetree @moodCode
cs 1 .. 1 F EVN
  Constraint The root of a document conforming to this specification SHALL be a ClinicalDocument element from the urn:hl7-org:v3 namespace.
treetree hl7:realmCode
CS CNE 1 .. 1 M (BCCDAClinicalDocument2)
treeblank treetree @code
1 .. 1 F CA-BC
treetree hl7:typeId
II 1 .. 1 M (BCCDAClinicalDocument2)
treeblank treetree @root
uid 1 .. 1 F 2.16.840.1.113883.1.3
treeblank treetree @extension
st 1 .. 1 F POCD_HD000040
treetree hl7:templateId
II 1 .. 1 M (BCCDAClinicalDocument2)
treeblank treetree @root
uid 1 .. 1 F 2.16.840.1.113883.3.51.60.2.1
treetree hl7:id
II 1 .. 1 M (BCCDAClinicalDocument2)
treeblank treetree @extension
uid 1 .. 1 R
treeblank treetree @root
uid 1 .. 1 R
  Constraint id SHALL contain exactly one [1..1 ] id with an id.root containing the ID’s namespace OID

 id.extension attribute SHALL be a GUID
treetree hl7:code
CE 1 .. 1 M (BCCDAClinicalDocument2)
  Constraint The value for code.code SHOULD be selected from the value set 2.16.840.1.113883.2.20.5.1 pCLOCD DocumentTypeCodes   DYNAMIC and MAY be selected from 2.16.840.1.113883.6.1 LOINC DocumentTypeCodes   DYNAMIC. The OID of the code system used SHALL be placed in the code.codeSystem attribute, and the code system name SHOULD be placed in the code.codeSystemName attribute. The code.displayName attribute SHOULD contain the text equivalent of the code. This text value will probably be the same as the value of ClinicalDocument/title ,  or very similar.
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
treetree hl7:title
ST 1 .. 1 M (BCCDAClinicalDocument2)
  Constraint The value for ClinicalDocument/title SHALL contain exactly one [1..1] title element valued with a string that specifies the local name used for the document.

 The value for ClinicalDocument/title SHOULD match the official text for the ClinicalDocument/code   and SHALL NOT conflict with it.
treetree hl7:effectiveTime
TS 1 .. 1 M (BCCDAClinicalDocument2)
  Constraint The effectiveTime.value SHALL be precise to the day, and SHOULD be precise to the minute and, if more precise than day, SHALL include a time zone offset.
treetree hl7:confidentialityCode
CE 1 .. 1 M (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
or
@code shall be "N"
@codeSystem shall be "2.16.840.1.113883.5.25"
@displayName shall be "Normal"
treetree hl7:languageCode
CS 1 .. 1 M (BCCDAClinicalDocument2)
treeblank treetree @code
1 .. 1 F en
treetree hl7:setId
II 1 .. 1 M (BCCDAClinicalDocument2)
  Constraint setId.extension SHALL be a GUID

 setId SHALL contain exactly 1 [1..1] versionNumber

Where setId is leveraged, subsequent related documents must have the same ClinicalDocument/setID value as the first document in the series.   
treetree hl7:versionNumber
INT 1 .. 1 M (BCCDAClinicalDocument2)
  Constraint versionNumber.value attribute SHALL be an integer representing the version of the document, with the initial version of 1, incrementing with each version of the document.

 Where setId is leveraged, the versionNumber SHALL be set at the value of “1” for the original version of the document, and in the instance of a replacement document the versionNumber SHALL be an increment of 1 from the document version it replaces.
Included from 2.16.840.1.113883.3.1937.99.61.26.10.19 BC CDA recordTarget (DYNAMIC) 1..* Mandatory
treetree hl7:recordTarget
1 .. * M (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 F RCT
treeblank treetree @contextControlCode
cs 1 .. 1 F OP
treeblank treetree hl7:patientRole
1 .. 1 M (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 1 .. 1 F PAT
treeblank treeblank treetree hl7:id
II 1 .. * R (BCCDAClinicalDocument2)
  Constraint One  patientRole/id SHOULD be the BC PHN, for which the OID root is 2.16.840.1.113883.4.50

 Additional patientRole/id values MAY be a local identifier and MAY be an out of province PHN
treeblank treeblank treetree hl7:addr
AD 0 .. * (BCCDAClinicalDocument2)
  Constraint If present, addr SHALL conform to the restrictions for the described common elements for addresses. 
treeblank treeblank treetree hl7:telecom
TEL 0 .. * (BCCDAClinicalDocument2)
  Constraint If present, telecom   SHALL conform to the restrictions for the pan-Canadian datatype flavor TEL.PHONE or TEL.EMAIL
treeblank treeblank treetree hl7:patient
1 .. 1 M (BCCDAClinicalDocument2)
Included from 2.16.840.1.113883.3.1937.99.61.26.10.4 BC CDA author (DYNAMIC) 1..* Required
treetree hl7:author
1 .. * R (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 F AUT
treeblank treetree @contextControlCode
cs 1 .. 1 F OP
treeblank treetree hl7:functionCode
CE 0 .. 1 (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
treeblank treetree hl7:time
TS 1 .. 1 M (BCCDAClinicalDocument2)
  Constraint The author/time.value SHALL be precise to the day and SHOULD be precise to the minute. If more precise than the day, SHALL include a time zone offset.  This represents the date/time that the clinical document was dictated by the assignedPerson .  In instances where the clinical document is authored by an a ssignedAuthoringDevice , this date/time represents the time that the document was created by the device. (e.g. ECG auto-interpretation)
treeblank treetree hl7:assignedAuthor
1 .. 1 M (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 1 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:id
II 1 .. * M (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:code
CE 0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.111 (Role Code)
treeblank treeblank treetree hl7:addr
AD 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:telecom
TEL 0 .. * (BCCDAClinicalDocument2)
Choice min 0 element(s) and max 1 element(s). Elements to choose from:
  • hl7:assignedPerson containing hl7:name from template CDA Person (DYNAMIC)
  • hl7:assignedAuthoringDevice containing hl7:code from template CDA Device (DYNAMIC)
treeblank treeblank treeblank treetree hl7:assignedPerson
(BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)
treeblank treeblank treeblank treetree hl7:assignedAuthoringDevice
(BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC)
treeblank treeblank treetree hl7:representedOrganization
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.61.26.10.10 BC CDA dataEnterer (DYNAMIC) 0..1
treetree hl7:dataEnterer
0 .. 1 (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 F ENT
treeblank treetree @contextControlCode
cs 1 .. 1 F OP
  Constraint if dataEnterer is not the same as the author , dataEnterer SHOULD be present
treeblank treetree hl7:time
TS 0 .. 1 (BCCDAClinicalDocument2)
treeblank treetree hl7:assignedEntity
1 .. 1 M (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.61.26.10.5 BC CDA informationRecipient (DYNAMIC) 0..*
treetree hl7:informationRecipient
0 .. * (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
treeblank treetree hl7:intendedRecipient
1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 1 .. 1 R
  CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.16772 x_InformationRecipientRole (DYNAMIC)
treeblank treeblank treetree hl7:id
II 0 .. * R (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:addr
AD 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:telecom
TEL 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:informationRecipient
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)
treeblank treeblank treetree hl7:receivedOrganization
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.61.26.10.3 BC CDA authenticator (DYNAMIC) 0..*
Included from 2.16.840.1.113883.3.1937.99.61.26.10.12 BC CDA participant (DYNAMIC) 0..*
treetree hl7:participant
0 .. * (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)
treeblank treetree @contextControlCode
cs 0 .. 1 F OP
treeblank treetree hl7:functionCode
CE 0 .. 1 (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
treeblank treetree hl7:time
IVL_TS 0 .. 1 (BCCDAClinicalDocument2)
treeblank treetree hl7:associatedEntity
1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 1 .. 1 R
  CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)
treeblank treeblank treetree hl7:id
II 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:code
CE 0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.111 (Role Code)
treeblank treeblank treetree hl7:addr
AD 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:telecom
TEL 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:associatedPerson
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)
treeblank treeblank treetree hl7:scopingOrganization
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.61.26.10.12 BC CDA participant (DYNAMIC) 0..*
treetree hl7:participant
0 .. * (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)
treeblank treetree @contextControlCode
cs 0 .. 1 F OP
treeblank treetree hl7:functionCode
CE 0 .. 1 (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
treeblank treetree hl7:time
IVL_TS 0 .. 1 (BCCDAClinicalDocument2)
treeblank treetree hl7:associatedEntity
1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 1 .. 1 R
  CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)
treeblank treeblank treetree hl7:id
II 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:code
CE 0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.111 (Role Code)
treeblank treeblank treetree hl7:addr
AD 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:telecom
TEL 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:associatedPerson
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)
treeblank treeblank treetree hl7:scopingOrganization
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.61.26.10.13 BC CDA relatedDocument (DYNAMIC) 0..*
treetree hl7:relatedDocument
0 .. * (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
treeblank treetree hl7:parentDocument
1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 0 .. 1 F DOCCLIN
treeblank treeblank treetree @moodCode
cs 0 .. 1 F EVN
treeblank treeblank treetree hl7:id
II 1 .. * R (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:code
CD 0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
treeblank treeblank treetree hl7:text
ED 0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:setId
II 0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:versionNumber
INT 0 .. 1 (BCCDAClinicalDocument2)
Included from 2.16.840.1.113883.3.1937.99.61.26.10.16 BC CDA componentOf (DYNAMIC) 1..1 Mandatory
treetree hl7:componentOf
1 .. 1 M (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 0 .. 1 F COMP
treeblank treetree hl7:encompassingEncounter
1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 0 .. 1 F ENC
treeblank treeblank treetree @moodCode
cs 0 .. 1 F EVN
treeblank treeblank treetree hl7:id
II 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:code
CE 0 .. 1 (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
treeblank treeblank treetree hl7:effectiveTime
IVL_TS 1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treetree hl7:dischargeDispositionCode
CE 0 .. 1 (BCCDAClinicalDocument2)
  CONF
shall be drawn from concept domain "EncounterDischargeDisposition"
treeblank treeblank treetree hl7:responsibleParty
0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @typeCode
cs 0 .. 1 F RESP
  Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
treeblank treeblank treetree hl7:encounterParticipant
0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @typeCode
cs 1 .. 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
treeblank treeblank treeblank treetree hl7:time
IVL_TS 0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree hl7:assignedEntity
1 .. 1 R (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
treeblank treeblank treetree hl7:location
0 .. 1 (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @typeCode
cs 0 .. 1 F LOC
treeblank treeblank treeblank treetree hl7:healthCareFacility
1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treeblank treeblank treetree @classCode
cs 0 .. 1 F SDLOC
treeblank treeblank treeblank treeblank treetree hl7:id
II 0 .. * (BCCDAClinicalDocument2)
treeblank treeblank treeblank treeblank treetree hl7:code
CE 0 .. 1 (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
treeblank treeblank treeblank treeblank treetree hl7:location
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)
treeblank treeblank treeblank treeblank treetree hl7:serviceProviderOrganization
0 .. 1 (BCCDAClinicalDocument2)
  Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
treetree hl7:component
1 .. 1 M (BCCDAClinicalDocument2)
treeblank treetree @typeCode
cs 1 .. 1 F COMP
treeblank treetree @contextConductionInd
bl 1 .. 1 R
treeblank treetree hl7:structuredBody
1 .. 1 R (BCCDAClinicalDocument2)
treeblank treeblank treetree @classCode
cs 0 .. 1 F DOCBODY
treeblank treeblank treetree @moodCode
cs 0 .. 1 F EVN
treeblank treeblank treetree hl7:confidentialityCode
CE 0 .. 1 (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
treeblank treeblank treetree hl7:languageCode
CS 0 .. 1 (BCCDAClinicalDocument2)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 Language (DYNAMIC)
treeblank treeblank treetree hl7:component
where
[hl7:section [hl7:templateId/@root='2.16.840.1.113883.10.12.201']]
1 .. * R (BCCDAClinicalDocument2)
treeblank treeblank treeblank treetree @typeCode
cs 0 .. 1 F COMP
treeblank treeblank treeblank treetree @contextConductionInd
bl 1 .. 1 R
  Contains 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC)