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The Header section is the root XML element and is present in every CCDA document. It helps identify and classify documents via basic information about them as described in the following documentation.

This topic details the data elements that must be present in the Header section of a Continuity of Care Document (CCD) for it to be processed in data spaces (hosted in Data Engine).

(R) - Required elements for the Header section and its sub-sections to be processed correctly in the data spaces.

(O) - Optional elements that are processed if provided in correct format.

Required (R) elements that are children of an Optional (O) element are only required for the immediate parent element to be processed.

Header Section Details

Document Header Template ID

ClinicalDocument/templateId

Specifies which CCDA R2.1 template is being used to structure the document. R2.1 templates define the requirements, format, and structure of a CCD section.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical DocumentFirst templateIdrootMust be 2.16.840.1.113883.10.20.22.1.1

Defines constraints for, and conforms to, US Realm CDA document requirements. The presence of this particular templateId allows all other document, section and entry templateId's to only include a root attribute and not require an extension attribute.

Second templateIdrootMust be 2.16.840.1.113883.10.20.22.1.2Defines constraints for, and conforms to, document specific requirements.

Additional  templateId  elements may be present in the document header. Only the  templateId  elements documented here are required for processing in Clinical Data Spaces (CDS).

Document Header ID

ClinicalDocument/id

Determines the global unique identifier for the document, including information concerning the organization responsible for the document.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	<id root="2.16.840.1.113883.19" extension="999021"/> 
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical Documentidroot

Must be an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

For example:

  • OID: 2.16.840.1.113883.x.xx.x or 
  • UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

Uniquely identifies the document.

extensionMust be an alphanumeric string of any lengthThis attribute is optional. Uniquely identifies the document.

It is generally expected that all id elements include both a root and an extension, however for the purpose of processing in Clinical Data Spaces, a root is required and an extension is optional.

  • If only the root is present, the root acts as the identifier and is assumed to be globally unique. It is typically a hierarchical structure of numbers in the format of an OID (object identifier) or UUID (universally unique identifier).
  • If both the root and extension are present, the root acts as a namespace, and the extension is the unique identifier. Note that this is commonly used for registries where the registry is identified by the root (2.16.840.1.113883.2.18.2) and the extension is the unique identifier (for example, XYZ1234).

Document Header Code

ClinicalDocument/code

Specifies the particular type of document.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" displayName="Summarization of Episode Note" codeSystemName="LOINC"/>
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical DocumentcodecodeMust be 34133-9

 

codeSystemMust be 2.16.840.1.113883.6.1The unique numerical identifier for the Logical Observation Identifiers Names and Codes (LOINC) coding system. This system will be used to resolve the value in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the template section.

Document Header Effective Time

ClinicalDocument/effectiveTime

Specifies the time the document was created. Refer to How Effective Time values are processed for details on the different ways effectiveTime information can be processed.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
	<effectiveTime value="20050329171504+0500"/>
	...
</ClinicalDocument> 

Document Header Confidentiality Code

ClinicalDocument/confidentialityCode

Indicates the level of security that should be applied to this Continuity of Care Document (CCD). The level of security that should be applied is typically driven by the guidelines of the system that generated the CCD.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical Document
confidentialityCode
codeMust include an alphanumeric string of any length. The HL7-supported confidentiality coding system is typically used, where security levels are indicated as:
  • U - unrestricted
  • L - low
  • N - normal
  • - moderate
  • R - restricted
  • V - very restricted

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

 

 

codeSystemMust include an alphanumeric string of any length, typically in the following format: 2.16.840.1.113883.X.XX.X. The HL7-supported confidentiality coding system is indicated by 2.16.840.1.113883.5.25A numerical string that specifies which system will be used to translate the identifier provided in the code attribute.

Document Header Record Target

ClinicalDocument/recordTarget

Specifies the administrative and demographic data of the patient whose health information is captured in the CCD.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	<recordTarget>
		<patientRole>
			<id root="2.16.840.1.113883.19" extension="12345"/>
		</patientRole>
	</recordTarget>
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical Document
  • recordTarget
    • patientRole
      • id

root

Must be an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

For example:

  • OID: 2.16.840.1.113883.x.xx.x or 
  • UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

The unique identifier for the patient whose health information is captured in this document.

extensionCan be an alphanumeric string of any lengthThis attribute is optional. Part of the information that uniquely identifies the patient for this document.

Document Header Author

ClinicalDocument/author

Specifies information concerning the creator of the CCD. The author may be a device or a person. Refer to Assigned Author Element for more details on what information can be available for the author section.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	<author>
		<time value="199803"/>
		<assignedAuthor>
			<id root="2.16.840.1.113883.19.5" extension="KP00017"/>
		</assignedAuthor>
	</author>
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical Document
  • author
    • time
value

Must be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ] where +/-ZZZZ specifies the offset from Coordinated Universal Time.

Indicates the specific time

  • author
    • assignedAuthor
      • id

 
root

Must be an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

For example:

  • OID: 2.16.840.1.113883.x.xx.x or 
  • UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4
The unique identifier for the author of the document.
extension Can be an alphanumeric string of any lengthThis attribute is optional. Part of the information that uniquely identifies the author for this document.

Document Header Custodian

ClinicalDocument/custodian/assignedCustodian/representedCustodianOrganization

Indicates who is ultimately responsible for the information provided in the Continuity of Care Document.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	<custodian>
		<assignedCustodian>
			<representedCustodianOrganization>
				<id root="2.16.840.1.113883.19.5"/>
				<name>Good Health Clinic</name>
			</representedCustodianOrganization>
		</assignedCustodian>
	</custodian>
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical Document
  • custodian
    • assignedCustodian
      • representedCustodianOrganization
        • id
root

Must include an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

For example, OID: 2.16.840.1.1113883.x.xx.x  or  UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

The unique identifier for the custodian of the document.

extensionCan be an alphanumeric string of any lengthThis attribute is optional. Part of the information that uniquely identifies the custodian for this document.
  • custodian
    • assignedCustodian
      • representedCustodianOrganization
        • name
N/ACan be an alphanumeric string of any lengthThe name of the custodian organization.

Document Header Language Code

ClinicalDocument/languageCode

Indicates the primary language used in the document using language codes as defined in the ISO-639 standard.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/> 
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>  
	...
	<languageCode code="en-US"/>
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical Document
languageCode
code

Must include an alphanumeric string indicating the language, for example:

  • en-US represents US English
  • fr represents French

 

Document Header Informant

ClinicalDocument/informant

Indicates the identifier for an information source for any content within the document.

<ClinicalDocument>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
	<informant>
		<assignedEntity>
			<id root="2.16.840.1.113883.19.5" extension="KP00017"/>
			<code codeSystem="2.16.840.1.113883.5.110" codeSystemName="RoleClass" code="PAYOR" displayName="Payor Care"/>
			<assignedPerson>
				<name>
					<given>Harold</given>
					<family>Hippocrates</family>
				</name>
			</assignedPerson>
			<representedOrganization>
				<name>The DoctorsApart Physician Group</name>
			</representedOrganization>
		</assignedEntity>
	</informant>
	...
</ClinicalDocument>
SectionElementAttributeValueNotes
Clinical Document
  • informant
    • assignedEntity
      • id
root

Must be an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

For example:

  • OID: 2.16.840.1.113883.x.xx.x or 
  • UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

The unique identifier for the informant of the document.

extension Can be an alphanumeric string of any lengthThis attribute is optional. Part of the information that uniquely identifies the informant for this document.
  • informant
    • assignedEntity
      • code
codeMust be an alphanumerical string of any length 
codeSystemMust be 2.16.840.1.113883.x.xx.x 
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the template section.
  • informant
    • assignedEntity
      • assignedPerson
        • name
N/A

Contains the following child elements for different parts of the name:

  • given
  • family
  • prefix
  • suffix
Multiple <given> elements can be present.
  • informant
    • assignedEntity
      • representedOrganization
        • id
root

Must be an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

For example:

  • OID: 2.16.840.1.113883.x.xx.x or 
  • UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4
 
extensionCan an alphanumerical string of any length 
  • informant
    • assignedEntity
      • representedOrganization
        • name
N/AMust be an alphanumerical string of any lengthA human readable name of the organization.


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