CDA header

The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

• value @ root
• value @ root,

Unique identifier of this instance of the Patient Summary.

Determines the document type that is the "Patient Summary" document

This element can be here used either to provide the originally used document code if this IPS is the result of a transformation.

ClinicalDocument/title is used for display purposes.

Time of creation of the Patient Summary

Document Language CodeThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted

This attribute “represents an identifier that is common across all document revisions”.

In the case the IPS instance is generated as result of one or more transformations (translation/transcoding.html) the setId is supposed to remain unchanged across all those transformations.

Implementers are recommended to use this attribute.

Patient Identifiers: Primary Patient Identifier (Regional/National Health Id.html), Secondary Patient Identifier (Social/Insurance Number.html)

The patient address.When used for cross-border exchange the country address part has to be provided.

Subject's Country.The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

Subject's or Organization's State or Province

Subject's or Organization's City

Subject's or Organization's Postal Code

Subject's or Organization's Street Address Line

Patient’s telecom information : e.g. telephone number, e-mail address. If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.

Patient NameThe Alphabetic representation of the name SHALL be always provided

Patient's Family Name/Surname

Patient's Given Name

Patient's Gender

Patient's Date of Birth. The patient date of birth may be a partial date such as only the year.

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

The relationship between the patient and the guardian or other contact may be recorded in the element. 

If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.

Subject's Country.The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

Subject's or Organization's State or Province

Subject's or Organization's City

Subject's or Organization's Postal Code

Subject's or Organization's Street Address Line

Guardian’s telecom information: e.g. telephone number; e-mail address. If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.

Patient Guardian's Name

Patient Guardian's Family Name/Surname

Patient Guardian's Given Name

Patient’s languageThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted

The author/time element represents the start time of the author’s participation in the creation of the clinical document. 

Name of the person (e.g. the Healthcare Professional.html)  authoring this document

Author Identifier(s.html)

A code, which identifies the profession/competence/specialty of the author when it is a person.

If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.

Subject's Country.The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

Subject's or Organization's State or Province

Subject's or Organization's City

Subject's or Organization's Postal Code

Subject's or Organization's Street Address Line

Time of signing the document

Signature code

The entity that is responsible for the legal authentication of the CDA document

Unique identification of legal authenticator

Name of the legal authenticator

HP Family Name/Surname

HP Given Name

Organization the legal authenticator is acting for

Patient contacts or the Preferred Health Professional to contact in case of emergency.

• value @ root
• value @ root,

The   element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.

The element identifies the type of contact. 

Patient Contact's Name / Preferred HP's Name

Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname

Patient Contact's Given Name / Preferred HP's Given Name

Organization's Name

This element indicates the relationship between the patient and this participant.

Patient Contact's / Preferred HP's Address

Subject's Country.The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

Subject's or Organization's State or Province

Subject's or Organization's City

Subject's or Organization's Postal Code

Subject's or Organization's Street Address Line

Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail element is required.If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present

The documentationOf relationship in an International Patient Summary contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.

The main activity being described by a IPS is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision.html) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range.html).

For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the low value should represent the date when the treatment relationship between the patient and the GP started; and the high value the date of the latest care event.

It represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors

Healthcare provider ID number

It describes the professional role of the healthcare provider involved in the current or pertinent historical care of the patient.

Note: the proposed order of the sections hereafter indicated is not mandatory

• value @ profile

CDA header

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

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

• value @ root
• value @ 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.

Unique identifier of this instance of the Patient Summary.

Determines the document type that is the "Patient Summary" document

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.

A name or title for the code, under which the sending system shows the code value to its users.

Specifies additional codes that increase the specificity of the the primary code.

This element can be here used either to provide the originally used document code if this IPS is the result of a transformation.

ClinicalDocument/title is used for display purposes.

Time of creation of the Patient Summary

Document Language CodeThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted

This attribute “represents an identifier that is common across all document revisions”.

In the case the IPS instance is generated as result of one or more transformations (translation/transcoding.html) the setId is supposed to remain unchanged across all those transformations.

Implementers are recommended to use this attribute.

Patient Identifiers: Primary Patient Identifier (Regional/National Health Id.html), Secondary Patient Identifier (Social/Insurance Number.html)

The patient address.When used for cross-border exchange the country address part has to be provided.

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

A set of codes advising a system or user which address in a set of like addresses to select for a given purpose.

Subject's Country.The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's State or Province

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's City

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's Postal Code

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's Street Address Line

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Patient’s telecom information : e.g. telephone number, e-mail address. If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Patient NameThe Alphabetic representation of the name SHALL be always provided

Patient's Family Name/Surname

Patient's Given Name

Patient's Gender

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Specifies additional codes that increase the specificity of the the primary code.

Patient's Date of Birth. The patient date of birth may be a partial date such as only the year.

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

The relationship between the patient and the guardian or other contact may be recorded in the element. 

If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

A set of codes advising a system or user which address in a set of like addresses to select for a given purpose.

Subject's Country.The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's State or Province

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's City

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's Postal Code

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Subject's or Organization's Street Address Line

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Guardian’s telecom information: e.g. telephone number; e-mail address. If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Patient Guardian's Name

Patient Guardian's Family Name/Surname

Patient Guardian's Given Name

Patient’s languageThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted

The author/time element represents the start time of the author’s participation in the creation of the clinical document. 

Author Identifier(s.html)

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

A code, which identifies the profession/competence/specialty of the author when it is a person.

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.