Ancestor: HL7Connect.Cda.CDABase

The ClinicalDocument class is the entry point into the CDA R-MIM, and corresponds to the <ClinicalDocument> XML element that is the root element of a CDA document

A CDA document is logically broken up into a CDA Header and a CDA Body. The CDA Header is comprised of ClinicalDocument attributes, participants, and act relationships. The CDA Body is the target of the ClinicalDocument component act relationship.


HL7Connect.Cda.II id;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.CD code;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.ST title;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.TS effectiveTime;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.CD confidentialityCode;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.CS languageCode;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.II setId;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.INT versionNumber;
   l version="1.0" encoding="UTF-8"?>

HL7Connect.Cda.TS copyTime;
   l version="1.0" encoding="UTF-8"?>

IList<HL7Connect.Cda.RecordTarget> recordTarget;
   The recordTarget represents the medical record that this document belongs to.

A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated.

The recordTarget(s) of a document are stated in the header and propagate to nested content, where they cannot be overridden

IList<HL7Connect.Cda.Author> author;
   Represents the humans and/or machines that authored the document or section

HL7Connect.Cda.DataEnterer dataEnterer;
   Represents the participant who has transformed a dictated note into text.

IList<HL7Connect.Cda.Informant12> informant;
   An informant (or source of information) is a person that provides relevant information, such as the parent of a comatose patient who describes the patient's behavior prior to the onset of coma.

HL7Connect.Cda.Custodian custodian;
   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 or section

IList<HL7Connect.Cda.InformationRecipient> informationRecipient;
   Represents a recipient who should receive a copy of the document.

NOTE: The information recipient is an entity to whom a copy of a document is directed, at the time of document authorship. It is not the same as the cumulative set of persons to whom the document has subsequently been disclosed, over the life-time of the patient. Such a disclosure list would not be contained within the document, and it outside the scope of CDA.

HL7Connect.Cda.LegalAuthenticator legalAuthenticator;
   Represents a participant who has legally authenticated the document.

The CDA is a standard that specifies the structure of exchanged clinical documents. In the case where a local document is transformed into a CDA document for exchange, authentication occurs on the local document, and that fact is reflected in the exchanged CDA document. A CDA document can reflect the unauthenticated, authenticated, or legally authenticated state. The unauthenticated state exists when no authentication information has been recorded (i.e., it is the absence of being either authenticated or legally authenticated).

While electronic signatures are not captured in a CDA document, both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual. A legalAuthenticator has a required legalAuthenticator.time indicating the time of authentication, and a required legalAuthenticator.signatureCode, indicating that a signature has been obtained and is on file.

IList<HL7Connect.Cda.Authenticator> authenticator;
   Represents a participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document. An example would be a resident physician who sees a patient and dictates a note, then later signs it

IList<HL7Connect.Cda.Participant1> participant;
   Used to represent other participants not explicitly mentioned by other classes, that were somehow involved in the documented acts.

IList<HL7Connect.Cda.InFulfillmentOf> inFulfillmentOf;
   represents those orders that are fulfilled by this document. For instance, a provider orders an X-Ray. The X-Ray is performed. A radiologist reads the X-Ray and generates a report. The X-Ray order identifier is transmitted in the Order class, the performed X-Ray procedure is transmitted in the ServiceEvent class, and the ClinicalDocument.code would be valued with "Diagnostic Imaging Report".

IList<HL7Connect.Cda.DocumentationOf> documentationOf;
   represents the main Act, such as a colonoscopy or an appendectomy, being documented.

In some cases, the ServiceEvent is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is "History and Physical Report" and the procedure being documented is a "History and Physical" act. A ServiceEvent can further specialize the act inherent in the ClinicalDocument.code, such as where the ClinicalDocument.code is simply "Procedure Report" and the procedure was a "colonoscopy". If ServiceEvent is included, it must be equivalent to or further specialize the value inherent in the ClinicalDocument.code, and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

ServiceEvent.effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place.

IList<HL7Connect.Cda.RelatedDocument> relatedDocument;
   A conformant CDA document can have a single relatedDocument with typeCode "APND"; a single relatedDocument with typeCode "RPLC"; a single relatedDocument with typeCode "XFRM"; a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; or a combination of two relatedDocuments with typeCodes "XFRM" and "APND". No other combinations are allowed.

IList<HL7Connect.Cda.Authorization> authorization;
   references the consents associated with this document. The type of consent (e.g. a consent to perform the related ServiceEvent, a consent for the information contained in the document to be released to a third party) is conveyed in Consent.code. Consents referenced in the CDA Header have been finalized (Consent.statusCode must equal "completed") and should be on file.

HL7Connect.Cda.Component1 componentOf;
   represents the setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note.

In some cases, the setting of the encounter is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is "Diabetes Clinic Progress Note". The setting of an encounter can also be transmitted in the HealthCareFacility.code attribute. If HealthCareFacility.code is sent, it should be equivalent to or further specialize the value inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply "Clinic Progress Note" and the value of HealthCareFacility.code is "cardiology clinic"), and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

EncompassingEncounter.dischargeDispositionCode can be used to depict the disposition of the patient at the time of hospital discharge (e.g., discharged to home, expired, against medical advice, etc.).

HL7Connect.Cda.Component2 component;
   The CDA body. The body can be either an unstructured blob, or can be comprised of structured markup. Every CDA document has exactly one body, associated with the ClinicalDocument class through the component relationship.

string classCode;
   l version="1.0" encoding="UTF-8"?>

string moodCode;
   l version="1.0" encoding="UTF-8"?>


© Kestral Computing P/L 2000 - 2003. HL7Connect v2.00-063 generated on 30-Nov 2015.
Keywords: Code, ID, Component, title, author, classCode, effectiveTime, informant, languageCode, moodCode, participant, authenticator, authorization, componentOf, confidentialityCode, copyTime, custodian, dataEnterer, documentationOf, informationRecipient, inFulfillmentOf, legalAuthenticator, recordTarget, relatedDocument, setId, versionNumber, ClinicalDocument, HL7Connect.Cda.ClinicalDocument