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Anchor
escode
escode
Encounter Section code

XPath:section/templateID
Purpose:Identifies that this section is detailing encounter information.

The code element must:

  • be present

  • contain code and codeSystem attributes

    AttributeValuePurpose

    code

    Must have a value of 46240-8

    Identifies that this section is detailing encounter information

    codeSystem

    Must have a value of 2.16.840.1.1113883113883.6.1

    Identifies the LOINC coding system used to translate the identifier provided in the code attribute
    Note

    displayName and codeSystemName are not required for processing.

Code Block
languagexml
titleCode Example of Encounter Section code
collapsetrue
<section> 
	<templateID root=”2.16.840.1.113883.10.20.22.2.22.1”/> 
	<code code=”46240-8” codeSystem=”2.16.840.1.113883.6.1” codeSystemName=”LOINC” displayName=”HISTORY OF ENCOUNTERS”/> 
</section>
Warning

Processing of the code element will fail if it does not contain correctly populated code AND codeSystem attributes.

...

Anchor
eatemplate
eatemplate
Encounter Activity templateId

XPath:section/templateID
Purpose:Specifies which CCDA R2.1 template is being used to structure the encounter activity sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section describes an interaction between a patient and clinician. Interactions may include in-person encounters, telephone conversations, and email exchanges.

The templateID element must:

  • be present

  • contain a root attribute 

    AttributeValuePurpose
    rootMust have a value of 2.16.840.1.1113883113883.10.20.22.4.49Uniquely identifies the encounter activity sub-section template.
Code Block
languagexml
titleCode Example of Encounter Activity templateId
collapsetrue
<section> 
	<templateID root="2.16.840.1.113883.10.20.22.2.22.1"/> 
	<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF ENCOUNTERS"/> 
	<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
		</encounter> 
	</entry> 
</section> 
Warning

The entire encounters activity sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.49. The information provided in this section will not be processed and you will not receive any notification that this section was ignored.

...



Optional Elements
Anchor
optional
optional

This section details elements that are not required but if present, must contact certain information and be correct for accurate processing in Clinical Data Spaces (CDS). 

Anchor
eaeffective
eaeffective
Encounter Activity effectiveTime

XPath:section/entry/encounter/effectiveTime
Purpose:

Indicates when the encounter (that is, an interaction between a clinician and patient) took place.

If present, the effectiveTime element must:

contain a value OR nullFlavor attribute

AttributeValuePurpose

value

Must be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ]

Specifies when the specific interaction took place

nullFlavor

Must be one of the following:

  • ASKU - asked but unknown
  • MSK - masked (sensitivity/confidentiality reasons)
  • NA - not available, system down
  • NASK - not asked
  • NAV - not available
  • NI - no information
  • OTH - other
  • UNK - unknown
Indicates that an attribute was needed, but was not provided, and gives a reason for why the information is not present. In this case, it suggests the encounter took place, but it was not recorded when.
Code Block
languagexml
titleCode Example of Encounter Activity effectiveTime
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<effectiveTime value="20000407"/>
		</encounter> 
</entry>  
Warning

Processing of the effectiveTime element will fail if it does not contain a correctly populated value or nullFlavor attribute.

 

 

Anchor
eadischarge
eadischarge
Encounter Activity sdtc:dischargeDispositionCode

XPath:section/entry/encounter/effectiveTime
Purpose:

Indicates the current patient discharge status as it relates to this encounter

If present, the dischargeDispositionCode element must:

contain code AND codeSystem attributes

AttributeValuePurpose
code

Must include an alphanumeric string of any length.

Identifies the discharge status of the patient
codeSystem

Must be one of the following: 2.16.840.1.113883.6.301.5 OR
2.16.840.1.113883.12.112 

Identifies the coding system used to translate the identifier provided in the code attribute
Code Block
languagexml
titleCode Example of Encounter Activity sdtc:dischargeDispositionCode
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<sdtc:dischargeDispositionCode code="01" codeSystem"2.16.840.1.113883.3.88.12.80.33"/>
		</encounter> 
</entry>
Warning

Processing of the sdtc:dischargeDispositionCode element will fail if it does not contain correctly populated code and codeSystem attributes.

 

 

Anchor
eaperformer
eaperformer
Encounter Activity performer

XPath:section/entry/encounter/performer
Purpose:

Indicates the unique identifier of the clinician interacting with a patient in this specific encounter (for example, the site-specific alphanumerical ID for a community nurse visiting a patient at home)

If present, the performer element must:
  • have a child element of assignedEntity, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose
    root

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

    For example, OID: 2.16.840.1.1113883113883.x.xx.x  or  UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

    Uniquely identifies the performer of the current encounter

    extension

    Is optional and can include an alphanumeric string of any length

    Uniquely identifies the performer of the current encounter

Code Block
languagexml
titleCode Example of Encounter Activity performer
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<performer>
				<assignedEntity>
					<id extension="12345" root="2.16.840.1.113883.19.5"/>
				</assignedEntity>
			</performer>
		</encounter> 
</entry> 
Warning

The performer element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the performer element in the document header will be processed instead.

 

 

Anchor
sdlcode
sdlcode
Service Delivery Location code

XPath:section/entry/encounter/participant/participantRole/code
Purpose:

Indicates the type of healthcare service location where the encounter took place

If present, the code element must:
  • be contained within participant
  • have a parent element of participantRole
  • contain code and codeSystem attributes:

    AttributeValuePurpose
    code

    Must include an alphanumeric string of any length.

    Identifies the type of healthcare service location where the encounter took place for example, emergency ward, GP practice, outpatient clinic
    codeSystemMust include an alphanumeric string of any length, but typically in the following format: 2.16.840.1.1113883113883.X.XX.X.XIdentifies the coding system used to translate the identifier provided in the code attribute
    Note

    displayName or codeSystemName are not required for processing in Clinical Data Spaces.

    Note

    For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <code nullFlavor="UNK"/> or <code nullFlavor="OTH"/> is acceptable.

    If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Service Delivery code
collapsetrue
<entry typeCode="DRIVE">
	<encounter classCode="ENC" moodCode="EVN">
		<participant typeCode="LOC">
			<participantRole classCode="SDLOC">
				<templateId root="2.16.840.1.113883.10.20.22.4.32"/>	
				<code code="GACH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="General Acute Care Hospital"/>	
			</participantRole>
		</participant>
	</encounter>
</entry>
Warning

Processing of the code element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

 

Anchor
sdlplaying
sdlplaying
Service Delivery Location playingEntity

XPath:section/entry/encounter/participant/participantRole/playingEntity/name
Purpose:

Provides the name of the healthcare service location where the encounter took place

If present, the playingEntity element must:
  • be contained within participant
  • have a parent element of participantRole
  • contain a child element of name populated with alphanumeric text of any length
Code Block
languagexml
titleCode Example of Service Delivery Location playingEntity
collapsetrue
<entry>
	<encounter>
		<participant typeCode="LOC">
			<participantRole classCode="SDLOC">
				<templateId root="2.16.840.1.113883.10.20.22.4.32"/>	
				<playingEntity>
					<name>Good Health Clinic</name>
				</playingEntity>		
			</participantRole>
		</participant>
	</encounter>
</entry>
Warning

Processing of the playingEntity element will fail if it does not contain a correctly populated child element of name.

 

 

Anchor
sdltelecom
sdltelecom
Service Delivery Location telecom

XPath:section/entry/encounter/participant/participantRole/playingEntity/telecom
Purpose:

Provides the phone number of the healthcare service location where the encounter took place

If present, the playingEntity element must:
  • be contained within participant
  • have a parent element of participantRole
  • contain value and use attributes
AttributeValuePurpose
value

Must include an alphanumeric string of any length.

Identifies the phone number of the healthcare service location
use

Must include one of the following:

  • HP
  • HV
  • WP
  • MC
Identifies the type of phone number provided (for example, primary, vacation, work, mobile)
Code Block
languagexml
titleCode Example of Service Delivery Location telecom
collapsetrue
<section>
	<entry>
		<encounter>
			<participant typeCode="LOC">
				<participantRole classCode="SDLOC">
					<templateId root="2.16.840.1.113883.10.20.22.4.32"/>	
					<telecom nullFlavor="UNK"/>		
				</participantRole>
			</participant>
		</encounter>
	</entry>
</section>
Warning

Processing of the telecom element will fail if it does not contain correctly populated value AND use attributes.

 

 

Anchor
edtemplate
edtemplate
Encounter Diagnosis templateId

XPath:

section/entry/encounter/entryRelationship/act/templateId

Purpose:

Specifies which CCDA R2.1 template is being used to structure the encounter diagnosis sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section identifies relevant problems or diagnoses at the close of the encounter.

If present, the templateId element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR"
  • have a parent element of act
  • contain a root attribute

    AttributeValuePurpose

    root

    2.16.840.1.113883.10.20.22.4.80

    Uniquely identifies the encounter diagnosis sub-section template

Code Block
languagexml
titleCode Example of Encounter Diagnosis templateId
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.80" />
					</act>
			</entryRelationship>	
		</encounter> 
</entry> 
Warning

The entire encounter diagnosis sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.80.The information provided in this sub-section will not be processed and you will not receive any notification that this sub-section was ignored.

 

 

Anchor
edcode
edcode
Encounter Diagnosis code

XPath:

section/entry/encounter/entryRelationship/act/code

Purpose:

Identifies the particular type of problem or diagnosis made at the encounter.

If present, the code element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR", which has a templateId of 2.16.840.1.113883.10.20.22.4.80
  • have a parent element of act
  • contain code AND codeSystem attributes
AttributeValuePurpose

code

Must include an alphanumeric string of any length

Identifies the specific diagnosis in the coding system

codeSystem

Must include an alphanumeric string of any length, but typically in the following format: 2.16.840.1.113883.X.XX.X.X

Identifies the coding system used to translate the identifier provided in the code attribute

Note

displayName or codeSystemName are not required for processing in Clinical Data Spaces.

Code Block
languagexml
titleCode Example of Encounter Diagnosis code
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.80" />
							<code code="29308-4" displayName="Encounter Diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					</act>
			</entryRelationship>	
		</encounter> 
</entry> 
Warning

Processing of the code element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

 

Anchor
potemplate
potemplate
Problem Observation templateId

XPath:section/entry/encounter/entryRelationship/act/entryRelationship/observation/templateId
Purpose:

Specifies which CCDA R2.1 template is being used to structure the problem observation sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section represents a discrete observation about a patient's problem.

If present, the templateId element must:
  • be contained within an entryRelationship element with a typeCode attribute of "SUBJ"
  • have a parent element of observation
  • contain a root attribute

    AttributeValuePurpose

    root

    2.16.840.1.113883.10.20.22.4.4

    Uniquely identifies the problem observation sub-section template

Code Block
languagexml
titleCode Example of Problem Observation templateId
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.80" />
							<entryRelationship typeCode="SUBJ">
									<observation classCode="OBS" moodCode="EVN">
										<templateId root="2.16.840.1.113883.10.20.22.4.4" />
									</observation>
							</entryRelationship>
					</act>
			</entryRelationship>			
		</encounter> 
</entry> 
Warning

The entire problem observation sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.80.The information provided in this sub-section will not be processed and you will not receive any notification that this sub-section was ignored.

 

 

Anchor
poeffective
poeffective
Problem Observation effectiveTime

XPath:section/entry/encounter/entryRelationship/act/entryRelationship/observation/effectiveTime
Purpose:

Specifies the onset date, duration, and resolution date (if known) of the problem, as observed at a specific encounter.

If present, the effectiveTime element must:
  • be contained within an entryRelationship element with a typeCode attribute of "SUBJ", which has a templateId of 2.16.840.1.113883.10.20.22.4.4
  • have a parent element of observation
  • contain an attribute of xsi:type, value or nullFlavor

    AttributeValuePurpose
    xsi:type

    Must be populated with IVL_TS and effectiveTime must:

    1. have a low child element, which can be:
      • empty
      • have a nullFlavor attribute
      • have a value attribute indicating a specific date and time
    2. optionally have a high child element which can be:
      • empty
      • have a nullFlavor attribute
      • have a value attribute indicating a specific date and time
    Indicates the period over which the problem occurred. Low indicates the onset date (when the problem first occurred) and high specifies when the problem was known to be resolved. If high is not present, the problem is still active.
    valueMust be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ] where +/-ZZZZspecifies the offset from Coordinated Universal Time. Indicates the specific time a problem occurred
    nullFlavor

    Must be one of the following:

    • ASKU - asked but unknown
    • MSK - masked (for sensitivity or confidentiality reasons)
    • NA - not available, system down
    • NASK - not asked
    • NAV - not available
    • NI - no information
    • OTH - other
    • UNK - unknown 
    Indicates that an attribute was required, but was not provided, and gives a reason for why the information is not present. In this case, it suggests the problem occurred, but it was not recorded when.
Code Block
languagexml
titleCode Example of Problem Observation effectiveTime
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.80" />
							<entryRelationship typeCode="SUBJ">
									<observation classCode="OBS" moodCode="EVN">
										<templateId root="2.16.840.1.113883.10.20.22.4.4" />
										<effectiveTime>
												<low nullFlavor="UNK"/>
										</effectiveTime>
									</observation>
							</entryRelationship>
					</act>
			</entryRelationship>			
		</encounter> 
</entry> 
Warning

Processing of the effectiveTime element will fail if it does not contain correctly populated xsi:type, value OR nullFlavor attributes.

 

 

Anchor
povalue
povalue
Problem Observation value

XPath:section/entry/encounter/entryRelationship/act/entryRelationship/observation/value
Purpose:

Specifies the type of problem observed at the encounter

If present, the value element must:
  • be contained within an entryRelationship element with a typeCode attribute of "SUBJ", which has a templateId of 2.16.840.1.113883.10.20.22.4.4
  • have a parent element of observation
  • contain xsi:type, code and codeSystem attributes

    AttributeValuePurpose
    xsi:typeCDIndicates that the value element is providing code and codeSystem information

    code

    Must be an alphanumerical string of any length.

    Identifies the specific problem observed at the encounter

    codeSystemMust include an alphanumeric string of any length, but typically in the following format: 2.16.840.1.1113883113883.X.XX.X.XIdentifies the coding system used to translate the identifier provided in the code attribute
    Note

    displayName and codeSystemName are not required for processing

    Note

    For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <value nullFlavor="UNK"/> or <value nullFlavor="OTH"/> is acceptable.

    If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Problem Observation value
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.80" />
							<entryRelationship typeCode="SUBJ">
									<observation classCode="OBS" moodCode="EVN">
										<templateId root="2.16.840.1.113883.10.20.22.4.4" />
										<value xsi:type="CD" nullFlavor="UNK"/>
									</observation>
							</entryRelationship>
					</act>
			</entryRelationship>			
		</encounter> 
</entry> 
Warning

Processing of the value element will fail if it does not contain correctly populated xsi:type, code, and codeSystem attributes.

 

 

Anchor
pptemplate
pptemplate
Priority Preference templateId

XPath:section/entry/encounter/entryRelationship/act/entryRelationship/observation/entryRelationship/observation/templateId
Purpose:

Specifies which CCDA R2.1 template is being used to structure the priority preference sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section represents priority preference chosen by a patient or a care provider, relative to options for care or treatment, or the prioritization of concerns or problems.

If present, the templateId element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR"
  • have a parent element of observation
  • contain a root attribute

    AttributeValuePurpose

    root

    2.16.840.1.113883.10.20.22.4.143

    Uniquely identifies the priority preference sub-section

Code Block
languagexml
titleCode Example of Priority Preference templateId
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<code code="99241" displayName="Office consultation - 15 minutes" codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12" 	
			codeSystemVersion="4"/>
			<effectiveTime value="20010429"/>
			<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
							<entryRelationship typeCode="SUBJ">
									<observation classCode="OBS" moodCode="EVN">
										<entryRelationship typeCode="REFR">
											<observation>
												<templateId root="2.16.840.1.113883.10.20.22.4.143"/>
											</observation>
										</entryRelationship>
									</observation>
							</entryRelationship>
					</act>
			</entryRelationship>			
		</encounter> 
</entry> 
Warning

The entire priority preference sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.143.The information provided in this sub-section will not be processed and you will not receive any notification that this sub-section was ignored.

 

 

Anchor
ppvalue
ppvalue
Priority Preference value

XPath:section/entry/encounter/entryRelationship/act/entryRelationship/observation/value
Purpose:

Specifies the priority placed on the problem observed within this encounter

If present, the value element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR", which has a templateId of 2.16.840.1.113883.10.20.22.4.143
  • have a parent element of observation
  • contain xsi:type, code and codeSystem attributes

    AttributeValuePurpose
    xsi:typeCDIndicates that the value element is providing code and codeSystem information

    code

    Must be an alphanumerical string of any length. Could be one of the following:

    • 394849002 - High priority
    • 394848005 - Normal priority
    • 441808003 - Delayed priority

    Identifies the specific priority placed on the problem observed within this encounter

    codeSystemMust have a value of: 2.16.840.1.113883.6.96Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute
Note

displayName and codeSystemName are not required for processing

Note

For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <value nullFlavor="UNK"/> or <value nullFlavor="OTH"/> is acceptable.

If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Priority Preference value
collapsetrue
<entry typeCode="DRIV"> 
		<encounter classCode="ENC" moodCode="EVN"> 
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<code code="99241" displayName="Office consultation - 15 minutes" codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12" 	
			codeSystemVersion="4"/>
			<effectiveTime value="20010429"/>
			<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
							<entryRelationship typeCode="SUBJ">
									<observation classCode="OBS" moodCode="EVN">
										<entryRelationship typeCode="REFR">
											<observation>
												<templateId root="2.16.840.1.113883.10.20.22.4.143"/>
												<value xsi:type="CD" code="394848005" codeSystem="2.16.840.1.113883.6.96"/>
											</observation>
										</entryRelationship>
									</observation>
							</entryRelationship>
					</act>
			</entryRelationship>			
		</encounter> 
</entry>
Warning

Processing of the value element will fail if it does not contain correctly populated xsi:type,code, and codeSystem attributes.

 

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