USRealmHeader

US Realm Header

draftC-CDA Templates4.0.0logical61 key elements

This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents. Further specification, such as ClinicalDocument/code, are provided in document templates that conform to this template.

In all C-CDA documents, at least one section SHALL contain clinically relevant information. A document that contains only empty sections is unhelpful to providers and fails to meet the essential purpose of conveying meaningful clinical data. Such documents contribute to inefficiencies and frustration in the healthcare process, as they do not provide the necessary information for informed decision-making.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader
ID
USRealmHeader
Type
Base Definition
ClinicalDocument
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
realmCode1..1
1+
realmCode.code
1+
typeId
1+
templateId
1+
:us-realm1..1
1+
templateId.root
1+
templateId.extension
1+
code.code
1+
code.codeSystem
1+
title
1+
The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
confidentialityCode.code
1+
languageCode
1+
recordTarget.patientRole.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
𝗨𝗦𝗖𝗗𝗜: Address
recordTarget.patientRole.telecom
1+
𝗨𝗦𝗖𝗗𝗜: Phone Number / Email
recordTarget.patientRole.patient
1+
recordTarget.patientRole.patient.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
recordTarget.patientRole.patient.birthTime
1+
𝗨𝗦𝗖𝗗𝗜: Date of Birth - **MAY** be precise to the minute (CONF:4537-32418) (For cases where information about newborn's time of birth needs to be captured)
recordTarget.patientRole.patient.raceCode
1+
𝗨𝗦𝗖𝗗𝗜: Race
recordTarget.patientRole.patient.ethnicGroupCode
1+
𝗨𝗦𝗖𝗗𝗜: Ethnicity
recordTarget.patientRole.patient.guardian.guardianPerson
1+
recordTarget.patientRole.patient.guardian.guardianPerson.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
recordTarget.patientRole.patient.birthplace.place.addr
1+
recordTarget.patientRole.patient.languageCommunication.languageCode
1+
recordTarget.patientRole.providerOrganization.id
1+
recordTarget.patientRole.providerOrganization.name
1+
recordTarget.patientRole.providerOrganization.telecom
1+
recordTarget.patientRole.providerOrganization.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
author.assignedAuthor.id.root
1+
author.assignedAuthor.code.code
1+
author.assignedAuthor.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
author.assignedAuthor.telecom
1+
author.assignedAuthor.assignedPerson.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName
1+
author.assignedAuthor.assignedAuthoringDevice.softwareName
1+
dataEnterer.assignedEntity.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
dataEnterer.assignedEntity.telecom
1+
dataEnterer.assignedEntity.assignedPerson
1+
dataEnterer.assignedEntity.assignedPerson.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
informant.assignedEntity
1+
informant.assignedEntity.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
informant.assignedEntity.assignedPerson
1+
informant.assignedEntity.assignedPerson.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
informant.relatedEntity
1+
custodian.assignedCustodian.representedCustodianOrganization.name
1+
custodian.assignedCustodian.representedCustodianOrganization.telecom
1+
custodian.assignedCustodian.representedCustodianOrganization.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
informationRecipient.intendedRecipient.informationRecipient.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
informationRecipient.intendedRecipient.receivedOrganization.name1..1
1+
legalAuthenticator.signatureCode.code
1+
legalAuthenticator.assignedEntity.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
legalAuthenticator.assignedEntity.telecom
1+
legalAuthenticator.assignedEntity.assignedPerson
1+
legalAuthenticator.assignedEntity.assignedPerson.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
authenticator.signatureCode.code
1+
authenticator.assignedEntity.addr
http://hl7.org/cda/stds/core/StructureDefinition/AD
1+
authenticator.assignedEntity.telecom
1+
authenticator.assignedEntity.assignedPerson
1+
authenticator.assignedEntity.assignedPerson.name
http://hl7.org/cda/stds/core/StructureDefinition/PN
1+
documentationOf.serviceEvent.effectiveTime
http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
1+
documentationOf.serviceEvent.effectiveTime.low
1+
componentOf.encompassingEncounter.id
1+