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draft Template  BC CDA ClinicalDocumentBCHeader

Id 2.16.840.1.113883.3.51.60.2.0 Effective Date valid from 2016‑04‑03 18:54:58
Status draft Draft Version Label
Name BCCDAClinicalDocumentBCHeader Display Name BC CDA ClinicalDocumentBCHeader
Description Pilot BC CDA template
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 templates, Uses 12 templates
Uses Template id as Name Version
2.16.840.1.113883.3.1937.99.61.26.10.36 Include BCCDArecordTarget DYNAMIC
2.16.840.1.113883.3.51.60.1.4 Include CDAauthor DYNAMIC
2.16.840.1.113883.3.51.60.1.6 Include CDAcustodian DYNAMIC
2.16.840.1.113883.3.51.60.1.5 Include CDAinformationRecipient DYNAMIC
2.16.840.1.113883.3.51.60.1.7 Include CDAdataEnterer DYNAMIC
2.16.840.1.113883.3.51.60.1.8 Include BcCDAauthenticator DYNAMIC
2.16.840.1.113883.3.51.60.1.10 Include CDAdocumentationOf DYNAMIC
2.16.840.1.113883.3.51.60.1.12 Include CDAinFulfillmentOf DYNAMIC
2.16.840.1.113883.3.51.60.1.20 Include BCCDArelatedDocument DYNAMIC
2.16.840.1.113883.3.51.60.1.11 Include CDAcomponentOf DYNAMIC
2.16.840.1.113883.3.1937.99.61.26.10.39 Include BCCDAPRCP 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)
Example
Example of a ClinicalDocument/title element
<title>Lab Report</title>
Item DT Card Conf Description Label
hl7:ClinicalDocument
1 … 1 M CONF‑BC0001
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 CWE 1 … 1 M CONF‑BC0001
treeblank treetree @code
1 … 1 F CA-BC
treetree hl7:typeId
II 1 … 1 M CONF‑BC0002
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 CONF‑BC0001
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.3.51.60.2.0
treetree hl7:id
II 1 … 1 M CONF‑BC0001
treeblank treetree @extension
uid 1 … 1 R
treeblank treetree @root
oid 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 CONF‑BC0001
  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.
  CONF
@codeSystem shall be "2.16.840.1.113883.6.1"
or
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.99.61.26.11.1 pCLOCD (DYNAMIC)
  Example
Example of a ClinicalDocument/code element
<code codeSystem="2.16.840.1.113883.6.1" code="11502-2" displayName="Lab Report"/>
treetree hl7:title
ST 1 … 1 M CONF‑BC0001
  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.
  Example
Example of a ClinicalDocument/title element
<title>Lab Report</title>
treetree hl7:effectiveTime
TS 1 … 1 M CONF‑BC0001
  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.
  Example
Example of a ClinicalDocument/effectiveTime element
<effectiveTime value="201210251150-0800"/>
treetree hl7:confidentialityCode
CE 1 … 1 M CONF‑BC0001
  Constraint CONF-BC0028:  confidentialityCode.code SHOULD be fixed to N (normal) from Value Set 2.16.840.1.113883.2.20.3.139 x_BasicConfidentialityKind STATIC.  Where appropriate to the use case, the following values from x_BasicConfidentialityKind may also be used: Restricted, Very Restricted, and Taboo.
treeblank treetree @code
1 … 1 F N
treeblank treetree @codeSystem
1 … 1 F 2.16.840.1.113883.5.25 (Confidentiality)
treeblank treetree @displayName
1 … 1 F Normal
  Example <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/>
treetree hl7:languageCode
CS 1 … 1 M CONF‑BC0001
  CONF
@code shall be "en"
or
@code shall be "en-CA"
  Example <languageCode code="en-CA"/>
treetree hl7:setId
II 0 … 1 M

notice Warning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CONF‑BC0001
  Constraint setId.extension SHALL be a GUID

Where setId is leveraged, CDA document SHALL contain exactly 1 [1..1] versionNumber element

Where setId is leveraged, subsequent related documents must have the same ClinicalDocument/setID value as the first document in the series. 

ClinicalDocument/setId and ClinicalDocument/versionNumber  are used to denote document revision numbers. The ClinicalDocument/effectiveTime is set to the time of the new revision.  The ClinicalDocument/relatedDocument.typeCodewould be set to RPLC (replace), unless for specific instances for Diagnosting Imaging, where it may be set to XFRM (transform).   
treetree hl7:versionNumber
INT 0 … 1 M

notice Warning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CONF‑BC0001
  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 1 … 1 M from 2.16.840.1.113883.3.1937.99.61.26.10.36 BC CDA recordTarget (DYNAMIC)
treetree hl7:recordTarget
1 … 1 M CONF‑BC0001
treeblank treetree @typeCode
cs 0 … 1 F RCT
treeblank treetree @contextControlCode
cs 0 … 1 F OP
treeblank treetree hl7:patientRole
1 … 1 R CONF‑BC0001
treeblank treeblank treetree @classCode
cs 0 … 1 F PAT
treeblank treeblank treetree hl7:id
II 1 … * R CONF‑BC0001
treeblank treeblank treetree hl7:addr
AD 0 … * CONF‑BC0001
treeblank treeblank treetree hl7:telecom
TEL 0 … * CONF‑BC0001
treeblank treeblank treetree hl7:patient
0 … 1 CONF‑BC0001
treeblank treeblank treeblank treetree @classCode
cs 0 … 1 F PSN
treeblank treeblank treeblank treetree @determinerCode
cs 0 … 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:id
II 0 … 1 CONF‑BC0001
treeblank treeblank treeblank treetree hl7:name
PN 0 … * CONF‑BC0001
treeblank treeblank treeblank treetree hl7:administrativeGenderCode
CE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
treeblank treeblank treeblank treetree hl7:birthTime
TS 0 … 1 CONF‑BC0001
treeblank treeblank treeblank treetree hl7:maritalStatusCode
CE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12212 MaritalStatus (DYNAMIC)
treeblank treeblank treeblank treetree hl7:religiousAffiliationCode
CE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19185 ReligiousAffiliation (DYNAMIC)
treeblank treeblank treeblank treetree hl7:raceCode
CE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14914 Race (DYNAMIC)
treeblank treeblank treeblank treetree hl7:ethnicGroupCode
CE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15836 Ethnicity (DYNAMIC)
treeblank treeblank treeblank treetree hl7:guardian
0 … * CONF‑BC0001
treeblank treeblank treeblank treeblank treetree @classCode
cs 1 … 1 F GUARD
treeblank treeblank treeblank treeblank treetree hl7:id
II 0 … * CONF‑BC0001
treeblank treeblank treeblank treeblank treetree hl7:code
CE 0 … 1 CONF‑BC0001
treeblank treeblank treeblank treeblank treeblank treetree @codeSystem
1 … 1 F 2.16.840.1.113883.5.111 (Role Code)
treeblank treeblank treeblank treeblank treetree hl7:addr
AD 0 … * CONF‑BC0001
treeblank treeblank treeblank treeblank treetree hl7:telecom
TEL 0 … * CONF‑BC0001
Choice 1 … 1 Elements to choose from:
treeblank treeblank treeblank treeblank treeblank treetree hl7:guardianPerson
Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) CONF‑BC0001
treeblank treeblank treeblank treeblank treeblank treetree hl7:guardianOrganization
Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) CONF‑BC0001
treeblank treeblank treeblank treetree hl7:birthplace
0 … 1 CONF‑BC0001
treeblank treeblank treeblank treeblank treetree @classCode
cs 0 … 1 F BIRTHPL
treeblank treeblank treeblank treeblank treetree hl7:place
1 … 1 R CONF‑BC0001
treeblank treeblank treeblank treeblank treeblank treetree @classCode
cs 0 … 1 F PLC
treeblank treeblank treeblank treeblank treeblank treetree @determinerCode
cs 0 … 1 F INSTANCE
treeblank treeblank treeblank treeblank treeblank treetree hl7:name
EN 0 … 1 CONF‑BC0001
treeblank treeblank treeblank treeblank treeblank treetree hl7:addr
AD 0 … 1 CONF‑BC0001
treeblank treeblank treeblank treetree hl7:languageCommunication
0 … * CONF‑BC0001
treeblank treeblank treeblank treeblank treetree hl7:languageCode
CS 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
treeblank treeblank treeblank treeblank treetree hl7:modeCode
CE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
treeblank treeblank treeblank treeblank treetree hl7:proficiencyLevelCode
CE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
treeblank treeblank treeblank treeblank treetree hl7:preferenceInd
BL 0 … 1 CONF‑BC0001
treeblank treeblank treetree hl7:providerOrganization
0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) CONF‑BC0001
Included 1 … * M from 2.16.840.1.113883.3.51.60.1.4 BC CDA author (DYNAMIC)
treetree hl7:author
1 … * M CONF‑BC0001
treeblank treetree @typeCode
cs 1 … 1 F AUT
treeblank treetree @contextControlCode
cs 1 … 1 F OP
treeblank treetree hl7:time
TS 1 … 1 M CONF‑BC0001
  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 CONF‑BC0001
treeblank treeblank treetree @classCode
cs 1 … 1 F ASSIGNED
treeblank treeblank treetree hl7:id
II 1 … * M CONF‑BC0001
  Constraint If the author is a Provider, the id elements SHALL conform to section 4.2.1.3.

If the
author is a not a Provider, assignedAuthor/id   MAY be a locally assigned identifier
treeblank treeblank treetree hl7:code
CE 0 … 1 CONF‑BC0001
treeblank treeblank treeblank treetree @codeSystem
1 … 1 F 2.16.840.1.113883.5.111 (Role Code)
treeblank treeblank treetree hl7:addr
AD 0 … * CONF‑BC0001
treeblank treeblank treetree hl7:telecom
TEL 0 … * CONF‑BC0001
Choice 0 … 1 Elements to choose from:
treeblank treeblank treeblank treetree hl7:assignedPerson
1 … 1 R CONF‑BC0001
Included 0 … * from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)
treeblank treeblank treeblank treeblank treetree @classCode
cs 1 … 1 F PSN
treeblank treeblank treeblank treeblank treetree @determinerCode
cs 1 … 1 F INSTANCE
treeblank treeblank treeblank treeblank treetree hl7:name
PN 0 … * R CONF‑BC0100
  Constraint assignedEntity/assignedPerson.name element SHALL  conform to the constraints in the common section on names
treeblank treeblank treeblank treetree hl7:assignedAuthoringDevice
1 … 1 R CONF‑BC0001
Included 0 … * from 2.16.840.1.113883.3.51.60.1.21 BC CDA Device (DYNAMIC)
treeblank treeblank treeblank treetree @classCode
cs 1 … 1 F DEV
treeblank treeblank treeblank treetree @determinerCode
cs 1 … 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:code
CE 0 … * CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
treeblank treeblank treeblank treetree hl7:manufacturerModelName
SC 0 … * CONF‑BC0001
treeblank treeblank treeblank treetree hl7:softwareName
SC 0 … * CONF‑BC0001
Included 0 … 1 R from 2.16.840.1.113883.3.51.60.1.6 BC CDA custodian (DYNAMIC)
treetree hl7:custodian
0 … 1 R CONF‑BC0082
treeblank treetree @typeCode
cs 1 … 1 F CST
treeblank treetree hl7:assignedCustodian
1 … 1 M CONF‑BC0084
treeblank treeblank treetree @classCode
cs 1 … 1 F ASSIGNED
treeblank treeblank treetree hl7:representedCustodianOrganization
1 … 1 M CONF‑BC0085
treeblank treeblank treeblank treetree @classCode
cs 1 … 1 F ORG
treeblank treeblank treeblank treetree @determinerCode
cs 1 … 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:id
II 1 … 1 M CONF‑BC0086
  Constraint

a.If the clinical document is generated from a Health Authority, this id SHALL contain the root OID of the Health Authority, and the facility id shall be used as the extension. 

b.If the clinical document is generated from an EMR, this id SHALL NOT contain the root OID of a Health Authority or of the BC Ministry of Health.

treeblank treeblank treeblank treetree hl7:name
ON 0 … 1 CONF‑BC0087
Included 0 … * from 2.16.840.1.113883.3.51.60.1.5 BC CDA informationRecipient (DYNAMIC)
treetree hl7:informationRecipient
0 … * CONF‑BC0001
treeblank treetree @typeCode
cs 1 … 1 R
  Constraint informationRecipient SHALL have the attribute typeCode which SHALL be either “ PRCP ” ( primary recipient ) or “ TRC ( secondary recipient ),  from HL7 Value Set x_InformationRecipient.   

There SHALL be at least one [1..*] primary recipient (“
PRCP ).
treeblank treetree hl7:intendedRecipient
1 … 1 M CONF‑BC0001
treeblank treeblank treetree @classCode
cs 1 … 1 F ASSIGNED
treeblank treeblank treetree hl7:id
II 1 … 2 R CONF‑BC0001
  Constraint If the informationRecipient is a Provider, the id elements SHALL conform to section 4.2.1.3.

If the informationRecipient is a not a Provider, intendedRecipient/id.extension MAY be a locally assigned identifier
treeblank treeblank treetree hl7:addr
AD 0 … * CONF‑BC0001
  Constraint If present, intendedRecipient/addr SHALL conform to the restrictions for the described in common elements for addresses.
treeblank treeblank treetree hl7:telecom
TEL 0 … * CONF‑BC0001
  Constraint If present, telecom SHALL conform to the restrictions for the pan-Canadian data type flavor TEL.PHONE or TEL.EMAIL
treeblank treeblank treetree hl7:informationRecipient
1 … 1 R CONF‑BC0001
Included 0 … * from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)
treeblank treeblank treeblank treetree @classCode
cs 1 … 1 F PSN
treeblank treeblank treeblank treetree @determinerCode
cs 1 … 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:name
PN 0 … * R CONF‑BC0100
  Constraint assignedEntity/assignedPerson.name element SHALL  conform to the constraints in the common section on names
treeblank treeblank treetree hl7:receivedOrganization
0 … 1 CONF‑BC0001
Included 0 … * from 2.16.840.1.113883.3.51.60.1.5.1 BC CDA Organization (DYNAMIC)
treeblank treeblank treeblank treetree @classCode
cs 1 … 1 F ORG
treeblank treeblank treeblank treetree @determinerCode
cs 1 … 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:id
II 0 … * R CONF‑BC0001
treeblank treeblank treeblank treetree hl7:name
ON 0 … * R CONF‑BC0001
Included 0 … 1 from 2.16.840.1.113883.3.51.60.1.7 BC CDA dataEnterer (DYNAMIC)
treetree hl7:dataEnterer
0 … 1 CONF‑BC0001
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 1 … 1 M CONF‑BC0001
  Constraint The dataEnterer/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 transcribed by the dataEnterer . 
treeblank treetree hl7:assignedEntity
1 … 1 M Contains 2.16.840.1.113883.3.51.60.1.7.1 BC CDA assignedEntity (DYNAMIC) CONF‑BC0001
where [not(@nullFlavor)]
Included 0 … * from 2.16.840.1.113883.3.51.60.1.8 BC CDA authenticator (DYNAMIC)
treetree hl7:authenticator
0 … * CONF‑BC0001
treeblank treetree @typeCode
cs 1 … 1 F AUTHEN
treeblank treetree hl7:time
TS 1 … 1 R CONF‑BC0001
  Constraint

time SHALL be precise to the day and SHOULD be precise to the minute and, if more precise than the day, SHALL include a time zone offset
treeblank treetree hl7:signatureCode
CS 1 … 1 R CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
treeblank treetree hl7:assignedEntity
1 … 1 R Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) CONF‑BC0001
Included 0 … * from 2.16.840.1.113883.3.51.60.1.10 BC CDA documentationOf (DYNAMIC)
treetree hl7:documentationOf
0 … * R CONF‑BC0001
treeblank treetree @typeCode
cs 1 … 1 F DOC
  Constraint documentationOf/serviceEventMAY be present. Where present, serviceEvent  SHALL conform to the requirements specified in the general BC header definition.
treeblank treetree hl7:serviceEvent
1 … 1 M CONF‑BC0001
treeblank treeblank treetree @classCode
cs 1 … 1 F ACT
treeblank treeblank treetree @moodCode
cs 1 … 1 F EVN
treeblank treeblank treetree hl7:id
II 0 … * CONF‑BC0001
treeblank treeblank treetree hl7:code
CE 0 … 1 CONF‑BC0001
  Constraint The value of ServiceEvent/code SHOULD be from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC, or the value of ServiceEvent/code MAY be from ICD10-CA (codeSystem 2.16.840.1.113881.6.94) or CCI (codeSystem 2.16.840.1.113883.6.94).
treeblank treeblank treeblank treetree @codeSystem
1 … 1 F 2.16.840.1.113883.5.4 (Act Code)
treeblank treeblank treetree hl7:effectiveTime
IVL_TS 1 … 1 M CONF‑BC0001
treeblank treeblank treetree hl7:performer
0 … * CONF‑BC0001
treeblank treeblank treeblank treetree @typeCode
cs 1 … 1 R
  Constraint If present, performer SHALL contain the typeCode attribute whose value SHALL be either “PPRF” (primary performer) or “SPRF” (secondary performer).
treeblank treeblank treeblank treetree hl7:assignedEntity
1 … 1 M Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) CONF‑BC0001
where [not(@nullFlavor)]
Included 0 … * from 2.16.840.1.113883.3.51.60.1.12 BC CDA inFulfillmentOf (DYNAMIC)
treetree hl7:inFulfillmentOf
0 … * CONF‑BC0001
treeblank treetree @typeCode
cs 1 … 1 F FLFS
  Constraint As per the XD-LAB specification, the inFulfillmentOf/orderelement MAY be present and represents the Placer Order (HL7 V2: ORC-2) or the Placer Group (HL7 V2: ORC-4) that was fulfilled, the identifier of which is carried in inFulfillmentOf/order/id.  When present, these elements conform to the constraints described in the general header section of this guide.

If  the inFulfillmentOf/order element is present, it SHALL contain exactly one [1..1] statusCode(HL7 V2: ORC-5),which represents the status code of the order.  Therefore, if present, code.codeSystem SHALL contain “statusCode” and  code.code SHALL contain “completed,” “active,” or “aborted.”
treeblank treetree hl7:order
1 … 1 M CONF‑BC0001
treeblank treeblank treetree @classCode
cs 1 … 1 F ACT
treeblank treeblank treetree @moodCode
cs 1 … 1 F RQO
treeblank treeblank treetree hl7:id
II 1 … * M CONF‑BC0001
treeblank treeblank treetree hl7:code
CE 0 … 1 CONF‑BC0001
  Constraint inFulfillmentOf/order element MAY contain one [0..1] code element.  If present, code SHALL contain the status code of the order. Therefore, if present, code.codeSystem SHALL contain “statusCode” and  code.code SHALL contain “completed,” “active,” or “aborted.”
Included 0 … 2 from 2.16.840.1.113883.3.51.60.1.20 BC CDA relatedDocument (DYNAMIC)
treetree hl7:relatedDocument
0 … 2 CONF‑BC0001
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 M CONF‑BC0001
treeblank treeblank treetree @classCode
cs 1 … 1 F DOCCLIN
treeblank treeblank treetree @moodCode
cs 1 … 1 F EVN
treeblank treeblank treetree hl7:id
II 1 … 1 M CONF‑BC0001
  Constraint ClinicalDocument/relatedDocument/ParentDocument/id/@root SHALL be the ClinicalDocument/Id/@root for the document it relates to.

ClinicalDocument/relatedDocument/ParentDocument/id/@extension SHALL be the ClinicalDocument/Id/@extension for the document it relates to

ClinicalDocument/relatedDocument/ParentDocument/id/@assigningAuthorityName SHALL be the ClinicalDocument/Id/@assigningAuthorityName for the document it relates to.
treeblank treeblank treetree hl7:code
CD 0 … 1 CONF‑BC0001
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 CONF‑BC0001
  Constraint parentDocument MAY contain the text element with the text.mediaType attribute set to indicate the MIME type of the related document.

The related document SHALL NOT be embedded in parentDocument/text element.

When sending a relatedDocument, the ClinicalDocument/relatedDocument.typeCode   SHALL be present, set at the value of “RPLC” for the original version of the document, and in the instance of a replacement document the versionNumber if present, SHALL be an increment of 1 from the document version it replaces. 

Replacement documents are meant to completely replace the previous version of a document, and as such SHALL NOT be handled as addendums in receiving systems.

Replacement documents SHALL represent a transitive relationship, where document A.1 can be replaced by A.2, A.2 can be replaced by A.3, and so on.  Multiple documents SHALL NOT replace the same document; i.e. A.1 being replaced by A.2 and also by A.3.

Receiving systems MAY retain parent documents that are considered superseded for historical and auditing purposes.  If parent documents are maintained, the receiving system SHALL very clearly identify the parent document as superseded by a more current version of the document.

treeblank treeblank treetree hl7:setId
II 0 … 1 CONF‑BC0001
treeblank treeblank treetree hl7:versionNumber
INT 0 … 1 CONF‑BC0001
Included 0 … 1 from 2.16.840.1.113883.3.51.60.1.11 BC CDA componentOf (DYNAMIC)
treetree hl7:componentOf
0 … 1 CONF‑BC0001
treeblank treetree @typeCode
cs 1 … 1 F COMP
treeblank treetree hl7:encompassingEncounter
1 … 1 R CONF‑BC0001
treeblank treeblank treetree @classCode
cs 1 … 1 F ENC
treeblank treeblank treetree @moodCode
cs 1 … 1 F EVN
treeblank treeblank treetree hl7:id
II 0 … * CONF‑BC0001
treeblank treeblank treetree hl7:effectiveTime
IVL_TS 1 … 1 R CONF‑BC0001
treeblank treeblank treetree hl7:responsibleParty
0 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) CONF‑BC0001
treeblank treeblank treeblank treetree @typeCode
cs 1 … 1 F RESP
treeblank treeblank treetree hl7:encounterParticipant
0 … * CONF‑BC0001
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)
  Constraint MAY contain zero or more [0..*] encounterParticipant elements . If present, the encounterParticipant/assignedEntity element SHALL have at least one of assignedPerson or representedOrganization element present.
treeblank treeblank treeblank treetree hl7:assignedEntity
1 … 1 R Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) CONF‑BC0001
Included 0 … * from 2.16.840.1.113883.3.1937.99.61.26.10.39 BC CDA primarycarephysician (DYNAMIC)
treetree hl7:participant
0 … * CONF‑8504
treeblank treetree @typeCode
cs 1 … 1 F IND
treeblank treetree @contextControlCode
cs 1 … 1 F OP
treeblank treetree hl7:functionCode
CE 1 … 1 M CONF‑8506
treeblank treeblank treetree @code
1 … 1 F PCP
treeblank treeblank treetree @codeSystem
1 … 1 F 2.16.840.1.113883.2.20.3.
treeblank treeblank treetree @displayName
1 … 1 F Primary Care Physician
treeblank treeblank treetree @codeSystemName
1 … 1 F HL7ParticipationFunction
treeblank treetree hl7:associatedEntity
1 … 1 M CONF‑8507
treeblank treeblank treetree @classCode
cs 1 … 1 F PROV
treeblank treeblank treetree hl7:id
II 1 … 2 R CONF‑BC0097, CONF‑BC0098
  Constraint If the participant is a provider, the id elements SHALL conform to section 4.2.1.3.

If the participant is a not a Provider, associatedEntity/id.extension MAY be a locally assigned identifier
treeblank treeblank treetree hl7:code
CE 0 … 1 CONF‑8507
treeblank treeblank treeblank treetree @codeSystem
1 … 1 F 2.16.840.1.113883.5.111 (Role Code)
treeblank treeblank treetree hl7:addr
AD 0 … * CONF‑BC0101
treeblank treeblank treetree hl7:telecom
TEL 0 … * CONF‑BC0102
treeblank treeblank treetree hl7:associatedPerson
1 … 1 M Contains 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC) CONF‑8508
where [not(@nullFlavor)]
treetree hl7:component
1 … 1 M CONF‑BC0001
treeblank treetree @typeCode
cs 1 … 1 F COMP
treeblank treetree @contextConductionInd
bl 1 … 1 F true
treeblank treetree hl7:structuredBody
1 … 1 M CONF‑BC0001
treeblank treeblank treetree @classCode
cs 1 … 1 F DOCBODY
treeblank treeblank treetree @moodCode
cs 1 … 1 F EVN
treeblank treeblank treetree hl7:confidentialityCode
CE CNE 0 … 1 CONF‑BC0001
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.99.61.26.11.66 x_NormalRestrictedTabooConfidentialityKind (DYNAMIC)
treeblank treeblank treetree hl7:languageCode
CS 0 … 1 CONF‑BC0001
treeblank treeblank treetree hl7:component
1 … * M Contains 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC) CONF‑BC0001
where [hl7:section [hl7:templateId/@root='2.16.840.1.113883.10.12.201']]
treeblank treeblank treeblank treetree @typeCode
cs 1 … 1 F COMP
treeblank treeblank treeblank treetree @contextConductionInd
bl 1 … 1 F true