Name Flags Card. Type Description & Constraints Section Section XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, <a href="http://hl7.org/cda/stds/core/2.0.0-sd-snapshot1/StructureDefinition-InfrastructureRoot.html" title="When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.">typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension templateId:section 1..1 II @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.10 @extension 1..1 st Required Pattern: 2014-06-09 code 1..1 CE Plan of Treatment @code 1..1 cs Required Pattern: 18776-5 @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1 title 1..1 ST text 1..1 xhtml Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply entry:plannedObs 0..* Entry observation 1..1 PlannedObservation Base for all types and resources entry:plannedEnc 0..* Entry encounter 1..1 PlannedEncounter Base for all types and resources entry:plannedAct 0..* Entry act 1..1 PlannedAct Base for all types and resources entry:plannedProc 0..* Entry procedure 1..1 PlannedProcedure Base for all types and resources entry:plannedMed 0..* Entry substanceAdministration 1..1 PlannedMedicationActivity Base for all types and resources entry:plannedSupply 0..* Entry supply 1..1 PlannedSupply Base for all types and resources entry:instruction 0..* Entry act 1..1 Instruction Base for all types and resources entry:handoffCommParticipants 0..* Entry act 1..1 HandoffCommunicationParticipants Base for all types and resources entry:nutrition 0..* Entry act 1..1 NutritionRecommendation Base for all types and resources entry:plannedImmunization 0..* Entry substanceAdministration 1..1 PlannedImmunizationActivity Base for all types and resources entry:goal 0..* Entry observation 1..1 GoalObservation Base for all types and resources Documentation for this format
HL7 International - Structured Documents
This section, formerly known as "Plan of Care", contains data that define pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. These are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed. This section may also contain information about ongoing care of the patient, clinical reminders, patient's values, beliefs, preferences, care expectations, and overarching care goals. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures. Values may include the importance of quality of life over longevity. These values are taken into account when prioritizing all problems and their treatments. Beliefs may include comfort with dying or the refusal of blood transfusions because of the patient's religious convictions. Preferences may include liquid medicines over tablets, or treatment via secure email instead of in person. Care expectations may range from being treated only by female clinicians, to expecting all calls to be returned within 24 hours. Overarching goals described in this section are not tied to a specific condition, problem, health concern, or intervention. Examples of overarching goals could be to minimize pain or dependence on others, or to walk a daughter down the aisle for her marriage. The plan may also indicate that patient education will be provided.
Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.
If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question
When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.
A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.
Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
Identifies the type as an HL7 Registered model
A character string as a unique identifier within the scope of the identifier root.
When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.
The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.
Specifies the code system that defines the code.
If applicable, a version descriptor defined specifically for the given code system.
A name or title for the code, under which the sending system shows the code value to its users.
The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.
The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.
The text or phrase used as the basis for the coding.
Specifies additional codes that increase the specificity of the the primary code.
A set of other concept descriptors that translate this concept descriptor into other code systems.
MAY contain zero or more [0..*] entry (CONF:1098-7726) such that it
The entry, if present, SHALL contain exactly one [1..1] Planned Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09) (CONF:1098-14751).
MAY contain zero or more [0..*] entry (CONF:1098-8805) such that it
MAY contain zero or more [0..*] entry (CONF:1098-8807) such that it
MAY contain zero or more [0..*] entry (CONF:1098-8809) such that it
MAY contain zero or more [0..*] entry (CONF:1098-8811) such that it
SHALL contain exactly one [1..1] Planned Medication Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09) (CONF:1098-30475).
If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
doseQuantity.unit.exists() implies administrationUnitCode.empty()
MAY contain zero or more [0..*] entry (CONF:1098-8813) such that it
The supply SHALL contain either 1 product or 1 device participant (@typeCode='DEV')
(product | participant.where(typeCode='DEV')).count() = 1
MAY contain zero or more [0..*] entry (CONF:1098-14695) such that it
MAY contain zero or more [0..*] entry (CONF:1098-29621) such that it
SHALL contain exactly one [1..1] Handoff Communication Participants (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.141) (CONF:1098-30868).
MAY contain zero or more [0..*] entry (CONF:1098-31841) such that it
SHALL contain exactly one [1..1] Nutrition Recommendation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.130) (CONF:1098-31864).
MAY contain zero or more [0..*] entry (CONF:1098-32353) such that it
SHALL contain exactly one [1..1] Planned Immunization Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.120) (CONF:1098-32354).
MAY contain zero or more [0..*] entry (CONF:1098-32887) such that it
SHALL contain exactly one [1..1] Goal Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.121) (CONF:1098-32888).
Drawn from concept domain DocumentSectionType