Header Attributes

This section describes attributes of the root ClinicalDocument class.

Table 5: Value set for ClinicalDocument.classCode (CNE)
Code / Definition
DOCCLIN [default] / A clinical document is a documentation of clinical observations and services, as defined above.
Table 6: Value set for ClinicalDocument.moodCode (CNE)
Code / Definition
EVN (event) [default] / An actual occurrence of an event (i.e., the documentation act already happened and is not just a request, intent, plan or promise to document).
ClinicalDocument.id

Represents the unique instance identifier of a clinical document.

ClinicalDocument.code

The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note). The value set is drawn from LOINC, and has a CWE coding strength.

Within the LOINC database, beginning with version 2.09, May 2003, document type codes are those that have a value of "DOC" in the Scale component. This subset of LOINC is included in the appendix (see LOINC Document Codes (§ B.2 )).

NOTE: The hierarchical relationship among LOINC document codes is in evolution. Per the LOINC version 2.14 (December 2004) manual: As soon as possible, the component terms used in the creation of the names of document type codes will be mapped to either the UMLS Metathesaurus or SNOMED CT. This mapping will help to establish the meaning of the terms and will allow aggregation and classification of document type codes based on definitions, computable relationships, and subsumption hierarchies that exist in the reference terminology.

ClinicalDocument.title

Represents the title of the document. It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of ClinicalDocument.code (e.g. a "consultation" or "progress note"). Where these display names are rendered to the clinician, or where the document has a unique title, the ClinicalDocument.title component should be used. In the example document in the appendix (see Sample Document (§ A.1 )), the value of ClinicalDocument.title = "Good Health Clinic Consultation Note".

ClinicalDocument.effectiveTime

Signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA.

ClinicalDocument.ConfidentialityCode

Confidentiality is a required contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value (as further described in CDA Context (§ 4.4 )).

Table 7: Value set for ClinicalDocument.confidentialityCode (CWE)
Code * / Definition
N (normal) (codeSystem 2.16.840.1.113883.5.25) / Normal confidentiality rules (according to good health care practice) apply. That is, only authorized individuals with a legitimate medical or business need may access this item.
R (restricted) (codeSystem 2.16.840.1.113883.5.25) / Restricted access, e.g. only to providers having a current care relationship to the patient.
V (very restricted) (codeSystem 2.16.840.1.113883.5.25) / Very restricted access as declared by the Privacy Officer of the record holder.
* The codeSystem value is included here because confidentialityCode is of type CE, and therefore must carry both a code and a codeSystem.
ClinicalDocument.languageCode

Specifies the human language of character data (whether they be in contents or attribute values). The values of the attribute are language identifiers as defined by the IETF (Internet Engineering Task Force) RFC 3066 for the Identification of Languages, ed. H. Alvestrand. 1995, which obsoletes RFC 1766. The HL7 code system for these values is "2.16.840.1.113883.6.121". Language is a contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value (as further described in CDA Context (§ 4.4 )).

ClinicalDocument.setId

Represents an identifier that is common across all document revisions.

ClinicalDocument.versionNumber

An integer value used to version successive replacement documents.

ClinicalDocument.completionCode

TBD[r1]

ClinicalDocument.copyTime (Deprecated)[r2]
Represents the time a document is released (i.e. copied or sent to a display device) from a document management system that maintains revision control over the document. Once valued, it cannot be changed. The intent is to give the viewer of the document some notion as to how long the document has been out of the safe context of its document management system.
Included for backwards compatibility with CDA, Release One. ClinicalDocument.copyTime has been deprecated because it is not part of the document at the time it is authenticated, but instead represents metadata about the document, applied at some variable time after authentication. Further use is discouraged.

[r1]Austin, please provide the description here.

[r2]Check with Austin to see if this should be removed. It was already deprecated in CDA R2.