Document - Health Level Seven International - Homepage Defects... · Web viewBirth Defects Events ReportNovember 20Page 415 Birth Defects Events Report November 20 Table of Contents

Birth Defects Events ReportNovember 20

Birth Defects Events Report November 20 Page 1

Table of Contents1 DOCUMENT.....................................................................................................................20

1.1 Birth Defects Event Report Document (NEW) - Draft...............................................201.2 US Realm Header - Published..................................................................................35

2 SECTIONS.......................................................................................................................542.1 Birth Defects Diagnosis Section (entries required) (NEW) - Draft...........................542.2 Family History Section - Published..........................................................................562.3 General Status - NB BD IG Specific Constraints (NEW) - Draft................................572.4 General Status Section - Published.........................................................................582.5 Labor and Delivery Events Section (NEW) - Draft...................................................602.6 Medications Administered Section - Published.......................................................652.7 Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW) - Draft

662.8 Medications Section - LD BD IG Specific Constraints - Draft...................................672.9 Medications Section (entries optional) - Published.................................................692.10 Medications Section (entries required) - Published................................................702.11 Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) - Draft 722.12 Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) - Draft

732.13 Mother's History and Physical Section (NEW) - Draft..............................................742.14 Mothers Social History Section (NEW) - Draft.........................................................762.15 Newborn Delivery Information Section (NEW) - Draft.............................................772.16 Payers Section - Published.....................................................................................812.17 Physical Exam - LD BD IG Specific - Draft...............................................................832.18 Physical Exam - NB BD IG Specific Constraints (NEW) - Draft.................................842.19 Physical Exam Section - Published.........................................................................852.20 Plan of Care Section - Published.............................................................................872.21 Plan of Care Section - Birth Defects IG Specific Constraints (NEW) - Draft.............902.22 Prior Pregnancy History Section (NEW) - Draft.......................................................912.23 Problem Section (entries optional) - Published.......................................................932.24 Problem Section (entries required) - Published.......................................................942.25 Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) - Draft 962.26 Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) - Draft 972.27 Procedures Section - LD BD IG Specific - Draft.......................................................98


2.28 Procedures Section (entries optional) - Published................................................1012.29 Procedures Section (entries required) - Published................................................1032.30 Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) - Draft 1052.31 Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) - Draft

1062.32 Results Section (entries optional) - Published.......................................................1082.33 Results Section (entries required) - Published......................................................1092.34 Social History Section - Published.........................................................................1112.35 Vital Signs Section - LD BD IG Specific - Draft......................................................1132.36 Vital Signs Section - NB BD IG Specific Constraints (NEW) - Draft........................1142.37 Vital Signs Section (entries optional) - Published..................................................1152.38 Vital Signs Section (entries required) - Published.................................................116

3 ENTRIES........................................................................................................................1183.1 Admission to NICU - Draft......................................................................................1183.2 Age Observation - Published.................................................................................1203.3 Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period - Draft 1223.4 Antibiotic Administration Procedure - Draft...........................................................1243.5 Antibiotics - Draft..................................................................................................1263.6 Apgar at 10 minute - Draft....................................................................................1293.7 Apgar at 5 minutes - Draft.....................................................................................1303.8 Assisted Ventilation [required immediately following delivery] - Draft..................1313.9 Assisted Ventilation for 6 or more hours - Draft....................................................1343.10 Birth Defect Diagnosis Observation - Draft...........................................................1373.11 Birth Defects Diagnosis Concern Act - Draft.........................................................1433.12 Birth head circumference - Draft..........................................................................1463.13 Birth height - Draft...............................................................................................1473.14 Birth Outcome - Draft...........................................................................................1493.15 Birth weight - Draft...............................................................................................1523.16 Cause of Death - Draft..........................................................................................1533.17 CCD Result observation - Draft.............................................................................1563.18 Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor] - Draft

1573.19 Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor] - Draft

1593.20 Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor] - Draft 161


3.21 Characteristics of Labor and Delivery: Augmentation of Labor - Draft..................1633.22 Characteristics of Labor and Delivery: Augmentation of Labor - Medication - Draft1653.23 Characteristics of labor and delivery: Induction of labor - Draft...........................1663.24 Characteristics of Labor and Delivery: Meconium Staining - Draft........................1683.25 Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery] - Draft..............................................................1693.26 Coverage Activity - Published...............................................................................1713.27 Date of Death - Draft............................................................................................1733.28 Date of Last Live Birth - Draft...............................................................................1753.29 Drug Vehicle - Published......................................................................................1773.30 Estimate of Gestation - Draft................................................................................1783.31 Estimated Date of Delivery - Published................................................................1803.32 Family History Death Observation - Published......................................................1813.33 Family History Observation - Published................................................................1833.34 Family History Organizer - Published....................................................................1863.35 Gestational age - Draft.........................................................................................1893.36 Health Status Observation - Published.................................................................1903.37 Highest Pressure Ulcer Stage - Published.............................................................1923.38 Immunization Medication Information - Published................................................1943.39 Indication - Published...........................................................................................1963.40 Indication - BxDefects IG Specific Constraint - Draft.............................................1983.41 Infant Living at Time of Report? - Draft................................................................1993.42 Instructions - Published........................................................................................2013.43 Karyotype Determination - Draft..........................................................................2033.44 Location of Death - Draft......................................................................................2053.45 Maternal Morbidity - Admission to Intensive Care [unit] - Draft............................2073.46 Maternal Morbidity: [Third or fourth degree] perineal laceration - Draft...............2093.47 Maternal Morbidity: Maternal Transfusion - Draft.................................................2113.48 Maternal Morbidity: Ruptured Uterus - Draft........................................................2133.49 Maternal Morbidity: Unplanned Hysterectomy - Draft..........................................2153.50 Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery] - Draft

2173.51 Maternal Risk Factors - Draft................................................................................2193.52 Medication Activity - Published.............................................................................2213.53 Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) - Draft......2273.54 Medication Dispense - Published..........................................................................228


3.55 Medication Information - Published......................................................................2313.56 Medication Supply Order - Published....................................................................2333.57 Method of Delivery: [Final] Route and Method of Delivery - Draft........................2353.58 Method of Delivery: Fetal Presentation [at birth] - Draft.......................................2373.59 Method of Delivery: Trial of Labor Attempted - Draft............................................2403.60 Mother's Weight at Delivery - Draft......................................................................2423.61 Newborn given Surfactant replacement therapy? - Draft.....................................2443.62 Number of Fetal Deaths - Draft............................................................................2473.63 Number of Pressure Ulcers Observation - Published.............................................2483.64 Obstetric Procedures: Cervical Cerclage - Draft...................................................2513.65 Obstetric Procedures: Tocolysis - Draft.................................................................2523.66 Onset of Labor: Precipitous Labor - Draft.............................................................2533.67 Onset of Labor: Premature Rupture - Draft...........................................................2553.68 Onset of Labor: Prolonged Labor - Draft...............................................................2563.69 Other Pregnancy Outcome - Draft........................................................................2583.70 Place of Birth (type or birthing place) - Draft........................................................2603.71 Plan of Care Activity Act - Published.....................................................................2633.72 Plan of Care Activity Encounter - Published..........................................................2633.73 Plan of Care Activity Encounter - Birth Defects IG Specific Constraints - Draft.....2643.74 Plan of Care Activity Observation - Published.......................................................2653.75 Plan of Care Activity Procedure - Published..........................................................2663.76 Plan of Care Activity Substance Administration - Published..................................2673.77 Plan of Care Activity Supply - Published...............................................................2683.78 Plurality (The number of babies resulting from a single pregnancy) - Draft.........2693.79 Policy Activity - Published.....................................................................................2713.80 Precondition for Substance Administration - Published........................................2773.81 Pregnancy Observation - Published......................................................................2783.82 Pregnancy Outcome - Draft..................................................................................2803.83 Pressure Ulcer Observation - Published................................................................2823.84 Problem Concern Act (Condition) - Published.......................................................2873.85 Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) - Draft. .2893.86 Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) - Draft.............2913.87 Problem Observation - Published..........................................................................2923.88 Problem Observation (V2) - Birth Defect IG Specific - Draft..................................2963.89 Problem Status - Published...................................................................................2973.90 Procedure Activity Act - Published........................................................................299


3.91 Procedure Activity Observation - Published..........................................................3043.92 Procedure Activity Procedure - Published.............................................................3093.93 Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) - Draft3143.94 Product Instance - Published................................................................................3163.95 Rank of Birth (Birth Order / Set Order) - Draft......................................................3183.96 Reaction Observation - Published.........................................................................3203.97 Result Observation - Published.............................................................................3233.98 Result Organizer - Published................................................................................3263.99 Seizure or Serious Neurologic Dysfunction - Draft................................................3273.100 Service Delivery Location - Published...................................................................3293.101 Severity Observation - Published..........................................................................3313.102 Significant Birth Injury - Draft...............................................................................3333.103 Smoking Status Observation - Published..............................................................3363.104 Social History Observation - Published.................................................................3383.105 Specify number of infants in this delivery born alive when not single birth - Draft3403.106 Suspected Neonatal Sepsis - Draft.......................................................................3423.107 Tobacco Use - Published.......................................................................................3453.108 Vital Sign Observation - Published........................................................................3463.109 Vital Signs Organizer - Published..........................................................................348

4 UNSPECIFIED................................................................................................................3514.1 Participant - Father - Draft......................................................................................3514.2 Participant - Mother - Draft.....................................................................................3534.3 US Realm Address (AD.US.FIELDED) - Published.....................................................3554.4 US Realm Address (AD.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) - Draft3574.5 US Realm Patient Name (PTN.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) - Draft 3594.6 US Realm Person Name (PN.US.FIELDED) - Published.............................................360

5 TEMPLATE IDS IN THIS GUIDE.......................................................................................361

6 VALUE SETS IN THIS GUIDE..........................................................................................375

7 CODE SYSTEMS IN THIS GUIDE.....................................................................................414

Table of Figures

Figure 1: US Realm Header..............................................................................................................40


Figure 2: effectiveTime with Time Zone...........................................................................................40Figure 3: Family History Section.......................................................................................................44Figure 4: General Status Section Example........................................................................................46Figure 5: Age Observation Example...............................................................................................109Figure 6: Drug Vehicle Example.....................................................................................................165Figure 7: Estimated Date of Delivery Example...............................................................................168Figure 8: Family History Death Observation Example.....................................................................170Figure 9: Family History Observation Example...............................................................................173Figure 10: Family History Organizer Example.................................................................................176Figure 11: Health Status Observation Example..............................................................................179Figure 12: Highest Pressure Ulcer Stage Example..........................................................................181Figure 13: Immunization Medication Information Example.............................................................183Figure 14: Number of Pressure Ulcers Example..............................................................................237Figure 15: Precondition for Substance Administration Example.....................................................265Figure 16: Pregnancy Observation Example...................................................................................267Figure 17: Product Instance Example.............................................................................................304Figure 18: Service Delivery Location Example................................................................................318Figure 19: US Realm Address Example...........................................................................................343

Table of Tables

Table 1: Birth Defects Event Report Document (NEW) Contexts...................................................20Table 2: Birth Defects Event Report Document (NEW) Constraints Overview...............................21Table 3: US Realm Header Constraints Overview.........................................................................35Table 4: Birth Defects Diagnosis Section (entries required) (NEW) Contexts................................53Table 5: Birth Defects Diagnosis Section (entries required) (NEW) Constraints Overview............54Table 6: Family History Section Contexts.....................................................................................55Table 7: Family History Section Constraints Overview..................................................................55Table 8: General Status - NB BD IG Specific Constraints (NEW) Contexts.....................................56Table 9: General Status - NB BD IG Specific Constraints (NEW) Constraints Overview.................57Table 10: General Status Section Constraints Overview.................................................................58Table 11: Labor and Delivery Events Section (NEW) Contexts........................................................59Table 12: Labor and Delivery Events Section (NEW) Constraints Overview....................................60Table 13: Medications Administered Section Contexts...................................................................64


Table 14: Medications Administered Section Constraints Overview................................................64Table 15: Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW)

Contexts.................................................................................................................................... 65Table 16: Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW)

Constraints Overview................................................................................................................65Table 17: Medications Section - LD BD IG Specific Constraints Contexts........................................66Table 18: Medications Section - LD BD IG Specific Constraints Constraints Overview....................67Table 19: Medications Section (entries optional) Contexts.............................................................68Table 20: Medications Section (entries optional) Constraints Overview..........................................69Table 21: Medications Section (entries required) Contexts.............................................................69Table 22: Medications Section (entries required) Constraints Overview.........................................70Table 23: Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)

Contexts.................................................................................................................................... 71Table 24: Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)

Constraints Overview................................................................................................................71Table 25: Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)

Contexts.................................................................................................................................... 72Table 26: Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)

Constraints Overview................................................................................................................72Table 27: Mother's History and Physical Section (NEW) Contexts...................................................73Table 28: Mother's History and Physical Section (NEW) Constraints Overview...............................74Table 29: Mothers Social History Section (NEW) Contexts..............................................................75Table 30: Mothers Social History Section (NEW) Constraints Overview..........................................75Table 31: Newborn Delivery Information Section (NEW) Contexts..................................................76Table 32: Newborn Delivery Information Section (NEW) Constraints Overview..............................77Table 33: Payers Section Contexts.................................................................................................80Table 34: Payers Section Constraints Overview..............................................................................81Table 35: Physical Exam - LD BD IG Specific Contexts....................................................................82Table 36: Physical Exam - LD BD IG Specific Constraints Overview................................................82Table 37: Physical Exam - NB BD IG Specific Constraints (NEW) Contexts......................................83Table 38: Physical Exam - NB BD IG Specific Constraints (NEW) Constraints Overview..................83Table 39: Physical Exam Section Contexts.....................................................................................84Table 40: Physical Exam Section Constraints Overview..................................................................85Table 41: Plan of Care Section Contexts.........................................................................................86Table 42: Plan of Care Section Constraints Overview.....................................................................87


Table 43: Plan of Care Section - Birth Defects IG Specific Constraints (NEW) Contexts..................89Table 44: Plan of Care Section - Birth Defects IG Specific Constraints (NEW) Constraints Overview

................................................................................................................................................. 89Table 45: Prior Pregnancy History Section (NEW) Contexts............................................................90Table 46: Prior Pregnancy History Section (NEW) Constraints Overview........................................91Table 47: Problem Section (entries optional) Contexts...................................................................92Table 48: Problem Section (entries optional) Constraints Overview...............................................93Table 49: Problem Section (entries required) Contexts..................................................................93Table 50: Problem Section (entries required) Constraints Overview...............................................94Table 51: Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)

Contexts.................................................................................................................................... 95Table 52: Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)

Constraints Overview................................................................................................................95Table 53: Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) Contexts

................................................................................................................................................. 96Table 54: Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)

Constraints Overview................................................................................................................96Table 55: Procedures Section - LD BD IG Specific Contexts............................................................97Table 56: Procedures Section - LD BD IG Specific Constraints Overview........................................98Table 57: Procedures Section (entries optional) Contexts............................................................100Table 58: Procedures Section (entries optional) Constraints Overview.........................................101Table 59: Procedures Section (entries required) Contexts............................................................102Table 60: Procedures Section (entries required) Constraints Overview........................................103Table 61: Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)

Contexts..................................................................................................................................104Table 62: Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)

Constraints Overview..............................................................................................................105Table 63: Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)

Contexts..................................................................................................................................105Table 64: Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)

Constraints Overview..............................................................................................................106Table 65: Results Section (entries optional) Contexts..................................................................107Table 66: Results Section (entries optional) Constraints Overview...............................................108Table 67: Results Section (entries required) Contexts..................................................................108Table 68: Results Section (entries required) Constraints Overview..............................................109Table 69: Social History Section Contexts....................................................................................110


Table 70: Social History Section Constraints Overview.................................................................111Table 71: Vital Signs Section - LD BD IG Specific Contexts...........................................................112Table 72: Vital Signs Section - LD BD IG Specific Constraints Overview.......................................112Table 73: Vital Signs Section - NB BD IG Specific Constraints (NEW) Contexts.............................113Table 74: Vital Signs Section - NB BD IG Specific Constraints (NEW) Constraints Overview.........113Table 75: Vital Signs Section (entries optional) Contexts.............................................................114Table 76: Vital Signs Section (entries optional) Constraints Overview..........................................115Table 77: Vital Signs Section (entries required) Contexts.............................................................115Table 78: Vital Signs Section (entries required) Constraints Overview.........................................116Table 79: Admission to NICU Contexts.........................................................................................117Table 80: Admission to NICU Constraints Overview......................................................................118Table 81: Age Observation Contexts............................................................................................119Table 82: Age Observation Constraints Overview.........................................................................120Table 83: Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period Contexts....121Table 84: Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period Constraints

Overview.................................................................................................................................122Table 85: Antibiotic Administration Procedure Contexts...............................................................123Table 86: Antibiotic Administration Procedure Constraints Overview...........................................124Table 87: Antibiotics Contexts......................................................................................................125Table 88: Antibiotics Constraints Overview..................................................................................126Table 89: Apgar at 10 minute Contexts........................................................................................128Table 90: Apgar at 10 minute Constraints Overview....................................................................128Table 91: Apgar at 5 minutes Contexts........................................................................................129Table 92: Apgar at 5 minutes Constraints Overview.....................................................................130Table 93: Assisted Ventilation [required immediately following delivery] Contexts......................130Table 94: Assisted Ventilation [required immediately following delivery] Constraints Overview. .131Table 95: Assisted Ventilation for 6 or more hours Contexts........................................................133Table 96: Assisted Ventilation for 6 or more hours Constraints Overview....................................134Table 97: Birth Defect Diagnosis Observation Contexts...............................................................136Table 98: Birth Defect Diagnosis Observation Constraints Overview............................................137Table 99: Birth Defects Diagnosis Concern Act Contexts..............................................................142Table 100: Birth Defects Diagnosis Concern Act Constraints Overview..........................................144Table 101: Birth head circumference Contexts...............................................................................145


Table 102: Birth head circumference Constraints Overview...........................................................146Table 103: Birth height Contexts....................................................................................................146Table 104: Birth height Constraints Overview................................................................................147Table 105: Birth Outcome Contexts................................................................................................148Table 106: Birth Outcome Constraints Overview............................................................................149Table 107: Birth weight Contexts...................................................................................................151Table 108: Birth weight Constraints Overview................................................................................151Table 109: Cause of Death Contexts..............................................................................................152Table 110: Cause of Death Constraints Overview...........................................................................153Table 111: CCD Result observation Constraints Overview..............................................................155Table 112: Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor]

Contexts..................................................................................................................................156Table 113: Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor]

Constraints Overview..............................................................................................................157Table 114: Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor]

Contexts..................................................................................................................................158Table 115: Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor]

Constraints Overview..............................................................................................................159Table 116: Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor]

Contexts..................................................................................................................................160Table 117: Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor]

Constraints Overview..............................................................................................................161Table 118: Characteristics of Labor and Delivery: Augmentation of Labor Contexts......................162Table 119: Characteristics of Labor and Delivery: Augmentation of Labor Constraints Overview...163Table 120: Characteristics of Labor and Delivery: Augmentation of Labor - Medication Contexts. .164Table 121: Characteristics of Labor and Delivery: Augmentation of Labor - Medication Constraints

Overview.................................................................................................................................164Table 122: Characteristics of labor and delivery: Induction of labor Contexts................................165Table 123: Characteristics of labor and delivery: Induction of labor Constraints Overview............166Table 124: Characteristics of Labor and Delivery: Meconium Staining Contexts............................167Table 125: Characteristics of Labor and Delivery: Meconium Staining Constraints Overview.........167Table 126: Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung

maturation received by the mother prior to delivery] Contexts..............................................168Table 127: Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung

maturation received by the mother prior to delivery] Constraints Overview...........................169Table 128: Coverage Activity Contexts...........................................................................................170


Table 129: Coverage Activity Constraints Overview.......................................................................171Table 130: Date of Death Contexts................................................................................................172Table 131: Date of Death Constraints Overview.............................................................................173Table 132: Date of Last Live Birth Contexts....................................................................................174Table 133: Date of Last Live Birth Constraints Overview................................................................175Table 134: Drug Vehicle Contexts..................................................................................................176Table 135: Drug Vehicle Constraints Overview...............................................................................176Table 136: Estimate of Gestation Contexts....................................................................................177Table 137: Estimate of Gestation Constraints Overview.................................................................178Table 138: Estimated Date of Delivery Contexts............................................................................179Table 139: Estimated Date of Delivery Constraints Overview.........................................................179Table 140: Family History Death Observation Contexts.................................................................180Table 141: Family History Death Observation Constraints Overview..............................................181Table 142: Family History Observation Contexts............................................................................182Table 143: Family History Observation Constraints Overview........................................................183Table 144: Family History Organizer Contexts................................................................................185Table 145: Family History Organizer Constraints Overview............................................................186Table 146: Gestational age Contexts..............................................................................................188Table 147: Gestational age Constraints Overview..........................................................................189Table 148: Health Status Observation Contexts.............................................................................189Table 149: Health Status Observation Constraints Overview..........................................................190Table 150: Highest Pressure Ulcer Stage Contexts.........................................................................191Table 151: Highest Pressure Ulcer Stage Constraints Overview.....................................................192Table 152: Immunization Medication Information Contexts............................................................193Table 153: Immunization Medication Information Constraints Overview........................................194Table 154: Indication Contexts.......................................................................................................195Table 155: Indication Constraints Overview...................................................................................196Table 156: Indication - BxDefects IG Specific Constraint Contexts.................................................197Table 157: Indication - BxDefects IG Specific Constraint Constraints Overview..............................198Table 158: Infant Living at Time of Report? Contexts.....................................................................198Table 159: Infant Living at Time of Report? Constraints Overview.................................................199Table 160: Instructions Contexts....................................................................................................200Table 161: Instructions Constraints Overview................................................................................201


Table 162: Karyotype Determination Contexts...............................................................................202Table 163: Karyotype Determination Constraints Overview...........................................................203Table 164: Location of Death Contexts...........................................................................................204Table 165: Location of Death Constraints Overview.......................................................................205Table 166: Maternal Morbidity - Admission to Intensive Care [unit] Contexts.................................206Table 167: Maternal Morbidity - Admission to Intensive Care [unit] Constraints Overview.............207Table 168: Maternal Morbidity: [Third or fourth degree] perineal laceration Contexts...................208Table 169: Maternal Morbidity: [Third or fourth degree] perineal laceration Constraints Overview209Table 170: Maternal Morbidity: Maternal Transfusion Contexts......................................................210Table 171: Maternal Morbidity: Maternal Transfusion Constraints Overview..................................211Table 172: Maternal Morbidity: Ruptured Uterus Contexts.............................................................212Table 173: Maternal Morbidity: Ruptured Uterus Constraints Overview.........................................213Table 174: Maternal Morbidity: Unplanned Hysterectomy Contexts...............................................214Table 175: Maternal Morbidity: Unplanned Hysterectomy Constraints Overview...........................215Table 176: Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery]

Contexts..................................................................................................................................216Table 177: Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery]

Constraints Overview..............................................................................................................217Table 178: Maternal Risk Factors Contexts.....................................................................................218Table 179: Maternal Risk Factors Constraints Overview.................................................................219Table 180: Medication Activity Contexts.........................................................................................220Table 181: Medication Activity Constraints Overview.....................................................................222Table 182: Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) Contexts..........226Table 183: Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) Constraints

Overview.................................................................................................................................227Table 184: Medication Dispense Contexts......................................................................................227Table 185: Medication Dispense Constraints Overview..................................................................228Table 186: Medication Information Contexts..................................................................................230Table 187: Medication Information Constraints Overview...............................................................231Table 188: Medication Supply Order Contexts................................................................................232Table 189: Medication Supply Order Constraints Overview............................................................233Table 190: Method of Delivery: [Final] Route and Method of Delivery Contexts.............................234Table 191: Method of Delivery: [Final] Route and Method of Delivery Constraints Overview.........235Table 192: Method of Delivery: Fetal Presentation [at birth] Contexts...........................................236


Table 193: Method of Delivery: Fetal Presentation [at birth] Constraints Overview........................237Table 194: Method of Delivery: Trial of Labor Attempted Contexts................................................239Table 195: Method of Delivery: Trial of Labor Attempted Constraints Overview.............................240Table 196: Mother's Weight at Delivery Contexts...........................................................................241Table 197: Mother's Weight at Delivery Constraints Overview.......................................................242Table 198: Newborn given Surfactant replacement therapy? Contexts..........................................243Table 199: Newborn given Surfactant replacement therapy? Constraints Overview......................244Table 200: Number of Fetal Deaths Contexts.................................................................................246Table 201: Number of Fetal Deaths Constraints Overview.............................................................246Table 202: Number of Pressure Ulcers Observation Contexts.........................................................247Table 203: Number of Pressure Ulcers Observation Constraints Overview.....................................248Table 204: Obstetric Procedures: Cervical Cerclage Contexts........................................................250Table 205: Obstetric Procedures: Cervical Cerclage Constraints Overview....................................250Table 206: Obstetric Procedures: Tocolysis Contexts.....................................................................251Table 207: Obstetric Procedures: Tocolysis Constraints Overview..................................................251Table 208: Onset of Labor: Precipitous Labor Contexts..................................................................252Table 209: Onset of Labor: Precipitous Labor Constraints Overview...............................................253Table 210: Onset of Labor: Premature Rupture Constraints Overview............................................254Table 211: Onset of Labor: Prolonged Labor Contexts....................................................................255Table 212: Onset of Labor: Prolonged Labor Constraints Overview................................................256Table 213: Other Pregnancy Outcome Contexts.............................................................................257Table 214: Other Pregnancy Outcome Constraints Overview.........................................................258Table 215: Place of Birth (type or birthing place) Contexts............................................................259Table 216: Place of Birth (type or birthing place) Constraints Overview.........................................260Table 217: Plan of Care Activity Act Contexts.................................................................................262Table 218: Plan of Care Activity Act Constraints Overview.............................................................262Table 219: Plan of Care Activity Encounter Contexts......................................................................262Table 220: Plan of Care Activity Encounter Constraints Overview..................................................263Table 221: Plan of Care Activity Encounter - Birth Defects IG Specific Constraints Contexts..........263Table 222: Plan of Care Activity Encounter - Birth Defects IG Specific Constraints Constraints

Overview.................................................................................................................................264Table 223: Plan of Care Activity Observation Contexts...................................................................264Table 224: Plan of Care Activity Observation Constraints Overview...............................................265


Table 225: Plan of Care Activity Procedure Contexts......................................................................265Table 226: Plan of Care Activity Procedure Constraints Overview..................................................266Table 227: Plan of Care Activity Substance Administration Contexts.............................................266Table 228: Plan of Care Activity Substance Administration Constraints Overview..........................267Table 229: Plan of Care Activity Supply Contexts...........................................................................267Table 230: Plan of Care Activity Supply Constraints Overview.......................................................268Table 231: Plurality (The number of babies resulting from a single pregnancy) Contexts..............268Table 232: Plurality (The number of babies resulting from a single pregnancy) Constraints Overview

............................................................................................................................................... 269Table 233: Policy Activity Contexts.................................................................................................270Table 234: Policy Activity Constraints Overview.............................................................................271Table 235: Precondition for Substance Administration Contexts....................................................276Table 236: Precondition for Substance Administration Constraints Overview.................................277Table 237: Pregnancy Observation Contexts..................................................................................277Table 238: Pregnancy Observation Constraints Overview..............................................................278Table 239: Pregnancy Outcome Contexts.......................................................................................279Table 240: Pregnancy Outcome Constraints Overview...................................................................280Table 241: Pressure Ulcer Observation Contexts............................................................................281Table 242: Pressure Ulcer Observation Constraints Overview........................................................282Table 243: Problem Concern Act (Condition) Contexts...................................................................286Table 244: Problem Concern Act (Condition) Constraints Overview...............................................287Table 245: Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) Contexts.......288Table 246: Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) Constraints

Overview.................................................................................................................................289Table 247: Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) Contexts..................290Table 248: Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) Constraints Overview

............................................................................................................................................... 290Table 249: Problem Observation Contexts.....................................................................................291Table 250: Problem Observation Constraints Overview..................................................................292Table 251: Problem Observation (V2) - Birth Defect IG Specific Contexts.......................................295Table 252: Problem Observation (V2) - Birth Defect IG Specific Constraints Overview...................295Table 253: Problem Status Contexts...............................................................................................296Table 254: Problem Status Constraints Overview...........................................................................297Table 255: Procedure Activity Act Contexts....................................................................................298


Table 256: Procedure Activity Act Constraints Overview................................................................299Table 257: Procedure Activity Observation Contexts......................................................................303Table 258: Procedure Activity Observation Constraints Overview..................................................304Table 259: Procedure Activity Procedure Contexts.........................................................................308Table 260: Procedure Activity Procedure Constraints Overview.....................................................309Table 261: Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) Contexts

............................................................................................................................................... 313Table 262: Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW)

Constraints Overview..............................................................................................................314Table 263: Product Instance Contexts............................................................................................315Table 264: Product Instance Constraints Overview........................................................................316Table 265: Rank of Birth (Birth Order / Set Order) Contexts...........................................................317Table 266: Rank of Birth (Birth Order / Set Order) Constraints Overview.......................................318Table 267: Reaction Observation Contexts.....................................................................................319Table 268: Reaction Observation Constraints Overview.................................................................320Table 269: Result Observation Contexts.........................................................................................322Table 270: Result Observation Constraints Overview.....................................................................323Table 271: Result Organizer Contexts............................................................................................325Table 272: Result Organizer Constraints Overview.........................................................................325Table 273: Seizure or Serious Neurologic Dysfunction Contexts.....................................................326Table 274: Seizure or Serious Neurologic Dysfunction Constraints Overview.................................327Table 275: Service Delivery Location Contexts...............................................................................328Table 276: Service Delivery Location Constraints Overview...........................................................329Table 277: Severity Observation Contexts.....................................................................................330Table 278: Severity Observation Constraints Overview..................................................................331Table 279: Significant Birth Injury Contexts....................................................................................332Table 280: Significant Birth Injury Constraints Overview................................................................333Table 281: Smoking Status Observation Contexts..........................................................................335Table 282: Smoking Status Observation Constraints Overview......................................................336Table 283: Social History Observation Contexts.............................................................................337Table 284: Social History Observation Constraints Overview.........................................................338Table 285: Specify number of infants in this delivery born alive when not single birth Contexts. . .339Table 286: Specify number of infants in this delivery born alive when not single birth Constraints

Overview.................................................................................................................................340


Table 287: Suspected Neonatal Sepsis Contexts............................................................................341Table 288: Suspected Neonatal Sepsis Constraints Overview........................................................342Table 289: Tobacco Use Contexts..................................................................................................344Table 290: Tobacco Use Constraints Overview...............................................................................344Table 291: Vital Sign Observation Contexts....................................................................................345Table 292: Vital Sign Observation Constraints Overview................................................................346Table 293: Vital Signs Organizer Contexts......................................................................................347Table 294: Vital Signs Organizer Constraints Overview..................................................................348Table 295: Participant - Father Contexts........................................................................................350Table 296: Participant - Father Constraints Overview.....................................................................351Table 297: Participant - Mother Contexts.......................................................................................352Table 298: Participant - Mother Constraints Overview....................................................................353Table 299: US Realm Address (AD.US.FIELDED) Contexts..............................................................354Table 300: US Realm Address (AD.US.FIELDED) Constraints Overview...........................................355Table 301: US Realm Address (AD.US.FIELDED) - Birth Defects IG Specific Constraints (NEW)

Constraints Overview..............................................................................................................356Table 302: US Realm Patient Name (PTN.US.FIELDED) - Birth Defects IG Specific Constraints (NEW)

Constraints Overview..............................................................................................................358Table 303: US Realm Person Name (PN.US.FIELDED) Constraints Overview...................................359Table 304: Template List................................................................................................................360Table 305: Template Containments................................................................................................368Table 306: Administrative Gender (HL7 V3)...................................................................................374Table 307: Race..............................................................................................................................374Table 308: EthnicityGroup..............................................................................................................375Table 309: HL7 BasicConfidentialityKind........................................................................................375Table 310: Marital Status................................................................................................................375Table 311: Religious Affiliation.......................................................................................................376Table 312: ResponsibleParty..........................................................................................................376Table 313: Language......................................................................................................................377Table 314: Telecom Use (US Realm Header)..................................................................................377Table 315: PostalCode....................................................................................................................377Table 316: Country.........................................................................................................................378Table 317: LanguageAbilityMode....................................................................................................378Table 318: LanguageAbilityProficiency...........................................................................................378


Table 319: INDRoleclassCodes.......................................................................................................379Table 320: Healthcare Provider Taxonomy (HIPAA)........................................................................379Table 321: NullValues_UNK_NI_NA..................................................................................................380Table 322: AgePQ_UCUM................................................................................................................380Table 323: Antibiotic Administration Procedure..............................................................................380Table 324: Apgar 10 minutes post birth.........................................................................................381Table 325: Apgar 5 minutes post birth...........................................................................................381Table 326: Assisted Ventilation Minutes After Birth (NCHS)............................................................381Table 327: Assisted Ventilation More Than Six Hours (NCHS).........................................................381Table 328: Birth Defects Laterality at Diagnosis.............................................................................382Table 329: ProblemAct statusCode.................................................................................................382Table 330: Birth head circumference..............................................................................................382Table 331: Birth Outcome (VPD).....................................................................................................383Table 332: Birth weight..................................................................................................................383Table 333: IV Medication Administration........................................................................................383Table 334: Augmentation of Labor - Medication.............................................................................384Table 335: Meconium Staining.......................................................................................................384Table 336: Glucocortico Steroids....................................................................................................385Table 337: Problem Type................................................................................................................385Table 338: Problem........................................................................................................................386Table 339: Family Member Value Set.............................................................................................387Table 340: HealthStatus.................................................................................................................387Table 341: Vaccine Administered Value Set...................................................................................388Table 342: Patient Education..........................................................................................................388Table 343: Karyotype Determination..............................................................................................389Table 344: ICU Care (NCHS)...........................................................................................................389Table 345: Fourth Degree Perineal Laceration................................................................................390Table 346: Pregnancy Risk Factors (NCHS).....................................................................................391Table 347: MoodCodeEvnInt...........................................................................................................391Table 348: Medication Route FDA...................................................................................................392Table 349: Body Site......................................................................................................................393Table 350: Medication Product Form Value Set..............................................................................394Table 351: UnitsOfMeasureCaseSensitive......................................................................................395


Table 352: Medication Fill Status....................................................................................................395Table 353: Medication Clinical Drug Name Value Set.....................................................................396Table 354: Route Method of Delivery - Trial of Labor......................................................................397Table 355: Mother’s Delivery Weight..............................................................................................397Table 356: Newborn Receiving Surfactant Replacement Therapy..................................................397Table 357: Pressure Ulcer Stage.....................................................................................................398Table 358: Tocolysis.......................................................................................................................398Table 359: Precipitous Labor..........................................................................................................398Table 360: Birthplace Setting (NCHS).............................................................................................399Table 361: Birth or Delivery Occurred (NCHS)................................................................................399Table 362: Planned moodCode (Act/Encounter/Procedure)............................................................399Table 363: Planned moodCode (Observation)................................................................................400Table 364: Planned moodCode (SubstanceAdministration/Supply).................................................400Table 365: Birth Plurality of Delivery..............................................................................................400Table 366: HL7FinanciallyResponsiblePartyType............................................................................401Table 367: Coverage Role Type......................................................................................................401Table 368: Health Insurance Type..................................................................................................402Table 369: Pressure Point...............................................................................................................403Table 370: TargetSite Qualifiers.....................................................................................................403Table 371: Problem Status.............................................................................................................404Table 372: ProcedureAct statusCode..............................................................................................404Table 373: Act Priority....................................................................................................................404Table 374: Result Status.................................................................................................................405Table 375: HealthcareServiceLocation...........................................................................................406Table 376: Problem Severity..........................................................................................................407Table 377: Social History Type.......................................................................................................408Table 378: Neonatal Sepsis............................................................................................................409Table 379: Tobacco Use.................................................................................................................410Table 380: Vital Sign Result............................................................................................................410Table 381: PostalAddressUse.........................................................................................................411Table 382: StateValueSet...............................................................................................................411Table 383: City...............................................................................................................................412Table 384: Code Systems...............................................................................................................413



1 DOCUMENTThe Birth Defects Event Report contains a record of a patient’s encounter for diagnosis and/or treatment of Birth Defects.

1.1 Birth Defects Event Report Document (NEW) - Draft[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.14:27Oct2014 (open)]

Table 1: Birth Defects Event Report Document (NEW) Contexts

Contained By: Contains:Birth Defects Diagnosis Section (entries required) (NEW)Family History SectionLabor and Delivery Events Section (NEW)Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW)Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)Mother's History and Physical Section (NEW)Newborn Delivery Information Section (NEW)Participant - FatherParticipant - MotherPayers SectionPlan of Care Section - Birth Defects IG Specific Constraints (NEW)Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)Results Section (entries required)Vital Signs Section (entries required)


Table 2: Birth Defects Event Report Document (NEW) Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.14:27Oct2014)templateId 1..1 SHALL 1137-

33@root 1..1 SHALL 1137-

342.16.840.1.113883.10.14.1

@extension 1..1 SHALL 1137-44

id 1..1 SHALL 1137-722

code 1..1 SHALL 1137-36

@nullFlavor 0..0 SHALL 1137-45

@code 1..1 SHALL 1137-39

2.16.840.1.113883.6.1 (LOINC) = 75609-8

title 1..1 SHALL 1137-40

effectiveTime 1..1 SHALL 1137-46


confidentialityCode 1..1 SHALL 1137-339

2.16.840.1.113883.5.25 (ConfidentialityCode)

setId 1..1 SHALL 1137-333

versionNumber 1..1 SHALL 1137-334

recordTarget 1..* SHALL 1137-48

patientRole 1..1 SHALL 1137-49

id 1..1 SHALL 1137-340

@root 1..1 SHALL 1137-342

2.16.840.1.113883.10.14.1

id 1..* SHALL 1137-343


@root 1..1 SHALL 1137-906

addr 1..* SHALL 1137-50

telecom 0..* SHOULD

1137-353


patient 1..1 SHALL 1137-52

name 1..* SHALL 1137-57


administrativeGenderCode 1..1 SHALL 1137-58

2.16.840.1.113883.1.11.1 (Administrative Gender (HL7 V3))


birthTime 1..1 SHALL 1137-60


raceCode 1..1 SHALL 1137-748

2.16.840.1.113883.1.11.14914 (Race)

sdtc:raceCode 0..* SHOULD

1137-348

2.16.840.1.113883.1.11.14914 (Race)

@code 1..1 SHALL 1137-905

ethnicGroupCode 1..1 SHALL 1137-749

2.16.840.1.114222.4.11.837 (EthnicityGroup)

guardian 1..* SHALL 1137-70


@classCode 1..1 SHALL 1137-72

GUARD

code 1..1 SHALL 1137-73


@code 1..1 SHALL 1137-75

2.16.840.1.113883.5.111 (RoleCode)

@codeSystem 1..1 SHALL 1137-77

2.16.840.1.113883.5.111

@displayName 1..1 SHALL 1137-76

2.16.840.1.113883.5.111 (RoleCode)

addr 1..* SHALL 1137-78

@use 1..1 SHALL 1137-79

telecom 1..* SHALL 1137-80

@use 1..1 SHALL 1137-81


guardianPerson 1..1 SHALL 1137-82


name 1..* SHALL 1137-84

birthplace 1..1 SHALL 1137-62


place 1..1 SHALL 1137-64


addr 1..1 SHALL 1137-66


country 1..1 SHALL 1137-68

state 1..1 SHALL 1137-69

providerOrganization 0..1 MAY 1137-85

id 1..1 SHALL 1137-355

@root 1..1 SHALL 1137-356

2.16.840.1.113883.4.6


id 1..1 SHALL 1137-357

@root 1..1 SHALL 1137-359


name 1..1 SHALL 1137-354

addr 1..1 SHALL 1137-908



city 1..1 SHALL 1137-911

postalCode 0..1 SHOUL 1137-


D 912


streetAddressLine 0..1 SHOULD

1137-913

author 1..* SHALL 1137-102

assignedAuthor 1..1 SHALL 1137-103

addr 1..* SHALL 1137-104

US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2

assignedPerson 1..1 SHALL 1137-105



assignedAuthoringDevice 1..1 SHALL 1137-754

manufacturerModelName 0..1 SHOULD

1137-755

softwareName 1..1 SHALL 1137-756

custodian 1..1 SHALL 1137-107

assignedCustodian 1..1 SHALL 1137-108

representedCustodianOrganization

1..1 SHALL 1137-109

addr 1..1 SHALL 1137-110

participant 0..1 SHOULD

1137-890

Participant - Mother (identifier: urn:hl7ii:2.16.840.1.113883.10.14.33:27Oct2014

@nullFlavor 0..1 MAY 1137-907


1137-903

Participant - Father (identifier: urn:hl7ii:2.16.840.1.113883.10.14.34:27Oct2014

relatedDocument 0..* MAY 1137-365

@typeCode 1..1 SHALL 1137-366

2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RPLC

componentOf 1..1 SHALL 1137-86

encompassingEncounter 1..1 SHALL 1137-87



encounterParticipant 0..* MAY 1137-89



REF

assignedEntity 1..1 SHALL 1137-91

id 1..* SHALL 1137-92

@root 1..1 SHALL 1137-93

2.16.840.1.113883.4.6


id 1..1 SHALL 1137-94

@root 1..1 SHALL 1137-95


assignedPerson 0..1 SHOULD

1137-96

name 1..1 SHALL 1137-97

component 1..1 SHALL 1137-98

structuredBody 1..1 SHALL 1137-99



section 1..1 SHALL 1137-101

Birth Defects Diagnosis Section (entries required) (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.2:27Oct2014




Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.1


4.6:27Oct2014




Payers Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.18



Plan of Care Section - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.12:27Oct2014



Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.9:27Oct2014



Results Section (entries required) (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.3.1



Vital Signs Section (entries required) (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.4.1



Newborn Delivery Information Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.17:27Oct2014



Labor and Delivery Events Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.25:27Oct2014



Mother's History and Physical Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.30:27Oct2014




Family History Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.15



Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.14:27Oct2014



Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.16:27Oct2014



1. Conforms to US Realm Header template (identifier: urn:oid:2.16.840.1.113883.10.20.22.1.1).

2. SHALL contain exactly one [1..1] templateId (CONF:1137-33) such that ita. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.14.1"

(CONF:1137-34).b. SHALL contain exactly one [1..1] @extension (CONF:1137-44).

3. SHALL contain exactly one [1..1] id (CONF:1137-722).a. This id SHALL be a globally unique identifier for the document (CONF:1137-723).

4. SHALL contain exactly one [1..1] code (CONF:1137-36).a. This code SHALL contain [0..0] @nullFlavor (CONF:1137-45).b. This code SHALL contain exactly one [1..1] @code="75609-8" Birth Defects Events

Report (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-39).5. SHALL contain exactly one [1..1] title (CONF:1137-40).6. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-46).

a. This effectiveTime SHALL contain [0..0] @nullFlavor (CONF:1137-47).7. SHALL contain exactly one [1..1] confidentialityCode (CodeSystem:

ConfidentialityCode 2.16.840.1.113883.5.25) (CONF:1137-339).8. SHALL contain exactly one [1..1] setId (CONF:1137-333).9. SHALL contain exactly one [1..1] versionNumber (CONF:1137-334).


10. SHALL contain at least one [1..*] recordTarget (CONF:1137-48) such that ita. SHALL contain exactly one [1..1] patientRole (CONF:1137-49).

i. This patientRole SHALL contain exactly one [1..1] id (CONF:1137-340) such that itNote: This field SHALL be used for Social Security Number (SSN).

1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.14.1" (CONF:1137-342).Note: This root OID is assigning authority for Social Security Number (SSN).

ii. This patientRole SHALL contain at least one [1..*] id (CONF:1137-343) such that itNote: This field SHALL be used for Medical Record Number (MRN).

1. SHALL contain [0..0] @nullFlavor (CONF:1137-750).2. SHALL contain exactly one [1..1] @root (CONF:1137-906).3. This field SHALL be used for Medical Record Number (MRN)

(CONF:1137-344).iii. This patientRole SHALL contain at least one [1..*] addr (CONF:1137-50).

Note: SHALL provide ALL addresses for that patient over time. In other words, ALL historical and current addresses where patient has or is residing SHALL be provided.

1. The content of addr SHALL be a conformant to US Realm Address (AD.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.35:27Oct2014) (CONF:1137-735).

iv. This patientRole SHOULD contain zero or more [0..*] telecom (CONF:1137-353).

v. This patientRole SHALL contain exactly one [1..1] patient (CONF:1137-52).1. This patient SHALL contain at least one [1..*] name (CONF:1137-57).

a. Such names SHALL contain [0..0] @nullFlavor (CONF:1137-345).

b. The content of name SHALL be a conformant to US Realm Patient Name (PTN.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.36:27Oct2014) (CONF:1137-747).

2. This patient SHALL contain exactly one [1..1] administrativeGenderCode (ValueSet: Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1) (CONF:1137-58).

a. This administrativeGenderCode SHALL contain [0..0] @nullFlavor (CONF:1137-59).

3. This patient SHALL contain exactly one [1..1] birthTime (CONF:1137-60).

a. This birthTime SHALL contain [0..0] @nullFlavor (CONF:1137-61).


conf:1137-50

conf:1137-342

b. SHALL be precise to day (CONF:1137-346).4. This patient SHALL contain exactly one [1..1] raceCode, which

SHALL be selected from ValueSet Race 2.16.840.1.113883.1.11.14914 (CONF:1137-748).

5. This patient SHOULD contain zero or more [0..*] sdtc:raceCode, which SHALL be selected from ValueSet Race 2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:1137-348) such that it

a. SHALL contain exactly one [1..1] @code (CONF:1137-905).6. This patient SHALL contain exactly one [1..1] ethnicGroupCode,

which SHALL be selected from ValueSet EthnicityGroup 2.16.840.1.114222.4.11.837 (CONF:1137-749).

7. This patient SHALL contain at least one [1..*] guardian (CONF:1137-70).

a. Such guardians SHALL contain [0..0] @nullFlavor (CONF:1137-71).

b. Such guardians SHALL contain exactly one [1..1] @classCode="GUARD" (CONF:1137-72).

c. Such guardians SHALL contain exactly one [1..1] code (CONF:1137-73).

i. This code SHALL contain [0..0] @nullFlavor (CONF:1137-74).

ii. This code SHALL contain exactly one [1..1] @code (CodeSystem: RoleCode 2.16.840.1.113883.5.111) (CONF:1137-75).

iii. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.111" HL7 Role code (CONF:1137-77).

iv. This code SHALL contain exactly one [1..1] @displayName (CodeSystem: RoleCode 2.16.840.1.113883.5.111) (CONF:1137-76).

d. Such guardians SHALL contain at least one [1..*] addr (CONF:1137-78).

i. Such addrs SHALL contain exactly one [1..1] @use (CONF:1137-79).

e. Such guardians SHALL contain at least one [1..*] telecom (CONF:1137-80).

i. Such telecoms SHALL contain exactly one [1..1] @use (CONF:1137-81).

f. Such guardians SHALL contain exactly one [1..1] guardianPerson (CONF:1137-82).

i. This guardianPerson SHALL contain [0..0] @nullFlavor (CONF:1137-83).

ii. This guardianPerson SHALL contain at least one [1..*] name (CONF:1137-84).


8. This patient SHALL contain exactly one [1..1] birthplace (CONF:1137-62).

a. This birthplace SHALL contain [0..0] @nullFlavor (CONF:1137-63).

b. This birthplace SHALL contain exactly one [1..1] place (CONF:1137-64).

i. This place SHALL contain [0..0] @nullFlavor (CONF:1137-65).

ii. This place SHALL contain exactly one [1..1] addr (CONF:1137-66).

1. This addr SHALL contain [0..0] @nullFlavor (CONF:1137-67).

2. This addr SHALL contain exactly one [1..1] country (CONF:1137-68).

3. This addr SHALL contain exactly one [1..1] state (CONF:1137-69).

9. This patient SHOULD contain zero or one 0..1] sdtc:deceasedInd. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedInd element (CONF:1137-350).

10. This patient SHOULD contain zero or one 0..1] sdtc:deceasedTime. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedTime element (CONF:1137-351).

vi. This patientRole MAY contain zero or one [0..1] providerOrganization (CONF:1137-85).

1. The providerOrganization, if present, SHALL contain exactly one [1..1] id (CONF:1137-355) such that it

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" NPI (CONF:1137-356).

b. SHALL contain exactly one [1..1] @extension (CONF:1137-358).NOTE: Should contain NPI of the organization.

2. The providerOrganization, if present, SHALL contain exactly one [1..1] id (CONF:1137-357) such that it

a. SHALL contain exactly one [1..1] @root (CONF:1137-359).Note: OID should not be equal to '2.16.840.1.113883.4.6' and extension should contain Organization OID.

b. SHALL contain exactly one [1..1] @extension (CONF:1137-360).NOTE: Should contain OID of the Organization.

3. The providerOrganization, if present, SHALL contain exactly one [1..1] name (CONF:1137-354).


conf:1137-360

conf:1137-360

conf:1137-359

conf:1137-358

conf:1137-358

4. The providerOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1137-908).

a. This addr SHALL contain exactly one [1..1] country (CONF:1137-909).

b. This addr SHALL contain exactly one [1..1] state (CONF:1137-910).

c. This addr SHALL contain exactly one [1..1] city (CONF:1137-911).

d. This addr SHOULD contain zero or one [0..1] postalCode (CONF:1137-912).

e. This addr SHOULD contain zero or one [0..1] streetAddressLine (CONF:1137-913).

11. SHALL contain at least one [1..*] author (CONF:1137-102) such that ita. SHALL contain exactly one [1..1] assignedAuthor (CONF:1137-103).

i. This assignedAuthor SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1137-104).

1. The content SHALL be a conformant US Realm Address (AD.US.FIELDED) (V2) (CONF:1137-363).

ii. This assignedAuthor SHALL contain exactly one [1..1] assignedPerson (CONF:1137-105).

12. SHALL contain at least one [1..*] author (CONF:1137-752) such that ita. SHALL contain exactly one [1..1] assignedAuthor (CONF:1137-753).

i. This assignedAuthor SHALL contain exactly one [1..1] assignedAuthoringDevice (CONF:1137-754).

1. This assignedAuthoringDevice SHOULD contain zero or one [0..1] manufacturerModelName (CONF:1137-755).

2. This assignedAuthoringDevice SHALL contain exactly one [1..1] softwareName (CONF:1137-756).

13. SHALL contain exactly one [1..1] custodian (CONF:1137-107).a. This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:1137-

108).i. This assignedCustodian SHALL contain exactly one [1..1]

representedCustodianOrganization (CONF:1137-109).1. This representedCustodianOrganization SHALL contain exactly one

[1..1] addr (CONF:1137-110).a. The content SHALL be a conformant US Realm Address

(AD.US.FIELDED) (V2) (CONF:1137-364).14. SHOULD contain zero or one [0..1] Participant - Mother (identifier:

urn:hl7ii:2.16.840.1.113883.10.14.33:27Oct2014) (CONF:1137-890) such that ita. MAY contain zero or one [0..1] @nullFlavor (CONF:1137-907).

15. SHOULD contain zero or one [0..1] Participant - Father (identifier: urn:hl7ii:2.16.840.1.113883.10.14.34:27Oct2014) (CONF:1137-903).

16. MAY contain zero or more [0..*] relatedDocument (CONF:1137-365).


a. The relatedDocument, if present, SHALL contain exactly one [1..1] @typeCode="RPLC" replace (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-366).

b. If versionNumber/@value is greater than 1, a relatedDocument element SHALL be present where the value of @typeCode SHALL be RPLC (replace) and the value of parentDocument/id SHALL be populated with the ClinicalDocument/id of the document being replaced. In all cases (regardless of the version number), values of APND and XFRM SHALL NOT be used for relatedDocument/@typeCode (CONF:1137-367).

17. SHALL contain exactly one [1..1] componentOf (CONF:1137-86).Note: This element records the provider that referred the patient to the reporting facility.

a. This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:1137-87).Note: This element SHALL be provided in the header of the CDA document in the event the patient was referred to this ambulatory healthcare provider.

i. This encompassingEncounter SHALL contain zero or one [0..1] @nullFlavor (CONF:1137-88).

ii. This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1137-89) such that itNote: Used to specify Provider Referred From Details.

1. MAY contain zero or one [0..1] @nullFlavor (CONF:1137-368).2. SHALL contain exactly one [1..1] @typeCode="REF" (CONF:1137-

90).3. SHALL contain exactly one [1..1] assignedEntity (CONF:1137-91).

a. This assignedEntity SHALL contain at least one [1..*] id (CONF:1137-92) such that it

i. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1137-93).

ii. SHALL contain exactly one [1..1] @extension (CONF:1137-369).

b. This assignedEntity SHALL contain exactly one [1..1] id (CONF:1137-94) such that itNote: This would be the Facility OID in extension where root!='2.16.840.1.113883.4.6.

i. SHALL contain exactly one [1..1] @root (CONF:1137-95).

ii. SHALL contain exactly one [1..1] @extension (CONF:1137-370).

c. This assignedEntity SHOULD contain zero or one [0..1] assignedPerson (CONF:1137-96).

i. The assignedPerson, if present, SHALL contain exactly one [1..1] name (CONF:1137-97).

18. SHALL contain exactly one [1..1] component (CONF:1137-98).


conf:1137-87

conf:1137-86

a. This component SHALL contain exactly one [1..1] structuredBody (CONF:1137-99).

i. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-100) such that it

1. SHALL contain [0..0] @nullFlavor (CONF:1137-376).2. SHALL contain exactly one [1..1] Birth Defects Diagnosis

Section (entries required) (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.2:27Oct2014) (CONF:1137-101).

a. This section SHALL contain [0..0] @nullFlavor (CONF:1137-377).

ii. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-371) such that it

1. SHALL contain exactly one [1..1] Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.6:27Oct2014) (CONF:1137-372).

iii. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-373) such that it

1. SHALL contain exactly one [1..1] Payers Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.18) (CONF:1137-385).

iv. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-386) such that it

1. SHALL contain exactly one [1..1] Plan of Care Section - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.12:27Oct2014) (CONF:1137-388).

v. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-387) such that it

1. SHALL contain exactly one [1..1] Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.9:27Oct2014) (CONF:1137-389).

vi. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-390) such that it

1. SHALL contain exactly one [1..1] Results Section (entries required) (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.3.1) (CONF:1137-392).

vii. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-391) such that it

1. SHALL contain exactly one [1..1] Vital Signs Section (entries required) (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.4.1) (CONF:1137-393).


viii.This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-394) such that it

1. SHALL contain exactly one [1..1] Newborn Delivery Information Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.17:27Oct2014) (CONF:1137-395).

ix. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-396) such that it

1. SHALL contain exactly one [1..1] Labor and Delivery Events Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.25:27Oct2014) (CONF:1137-397).

x. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-398) such that it

1. SHALL contain exactly one [1..1] Mother's History and Physical Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.30:27Oct2014) (CONF:1137-399).

xi. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-400) such that it

1. SHALL contain exactly one [1..1] Family History Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.15) (CONF:1137-401).

xii. This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-374) such that it

1. SHALL contain exactly one [1..1] Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.14:27Oct2014) (CONF:1137-384).

xiii.This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-375) such that it

1. SHALL contain exactly one [1..1] Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.16:27Oct2014) (CONF:1137-381).

xiv.This structuredBody SHALL contain exactly one [1..1] component (CONF:1137-470) such that it

1. SHALL contain exactly one [1..1] Cytogenetics Section (urn:oid:2.16.840.1.113883.10.20.20.1.4) (CONF:1137-904).

xv. This structuredBody SHALL NOT contain [0..0] any other section than those identified above (CONF:1137-751).


1.2 US Realm Header - Published[ClinicalDocument: identifier urn:oid:2.16.840.1.113883.10.20.22.1.1 (open)]

This section describes constraints that apply to the header for all documents within the scope of this implementation guide. Header constraints specific to each document type are described in the appropriate document-specific section below.


Table 3: US Realm Header Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value

ClinicalDocument (identifier: urn:oid:2.16.840.1.113883.10.20.22.1.1)realmCode 1..1 SHALL 81-

16791US

typeId 1..1 SHALL 81-5361

@root 1..1 SHALL 81-5250

2.16.840.1.113883.1.3


POCD_HD000040

templateId 1..1 SHALL 81-5252

@root 1..1 SHALL 81-10036

2.16.840.1.113883.10.20.22.1.1

id 1..1 SHALL 81-5363

code 1..1 SHALL 81-5253



confidentialityCode 1..1 SHALL 81-5259

2.16.840.1.113883.1.11.16926 (HL7 BasicConfidentialityKind)

languageCode 1..1 SHALL 81-5372

2.16.840.1.113883.1.11.11526 (Language)

setId 0..1 MAY 81-5261

versionNumber 0..1 MAY 81-5264

recordTarget 1..* SHALL 81-5266

patientRole 1..1 SHALL 81-5267

id 1..* SHALL 81-5268

addr 1..* SHALL 81-5271


@use 0..1 SHOULD

81-5375

2.16.840.1.113883.11.20.9.20 (Telecom Use (US Realm Header))

patient 1..1 SHALL 81-5283

name 1..* SHALL 81-


5284




birthTime 1..1 SHALL 81-5298

maritalStatusCode 0..1 SHOULD

81-5303

2.16.840.1.113883.1.11.12212 (Marital Status)

religiousAffiliationCode 0..1 MAY 81-5317

2.16.840.1.113883.1.11.19185 (Religious Affiliation)

raceCode 0..1 MAY 81-5322

2.16.840.1.113883.1.11.14914 (Race)

sdtc:raceCode 0..* MAY 81-7263

2.16.840.1.113883.1.11.14914 (Race)

ethnicGroupCode 0..1 MAY 81-5323

2.16.840.1.114222.4.11.837 (EthnicityGroup)

guardian 0..* MAY 81-5325

code 0..1 SHOULD

81-5326

2.16.840.1.113883.1.11.19830 (ResponsibleParty)

addr 0..* SHOULD

81-5359

telecom 0..* MAY 81-5382

@use 0..1 SHOULD

81-7993


guardianPerson 1..1 SHALL 81-5385

name 1..* SHALL 81-5386

birthplace 0..1 MAY 81-5395

place 1..1 SHALL 81-5396

addr 1..1 SHALL 81-5397

country 0..1 SHOULD

81-5404

2.16.840.1.113883.3.88.12.80.63 (Country)

postalCode 0..1 MAY 81-5403

2.16.840.1.113883.3.88.12.80.2 (PostalCode)

languageCommunication 0..* SHOULD

81-5406

languageCode 1..1 SHALL 81-5407

2.16.840.1.113883.1.11.11526 (Language)

modeCode 0..1 MAY 81-5409

2.16.840.1.113883.1.11.12249 (LanguageAbilityMode)

proficiencyLevelCode 0..1 SHOULD

81-9965

2.16.840.1.113883.1.11.12199 (LanguageAbilityProficiency)


preferenceInd 0..1 MAY 81-5414

providerOrganization 0..1 MAY 81-5416

id 1..* SHALL 81-5417

@root 0..1 SHOULD

81-16820

2.16.840.1.113883.4.6

name 1..* SHALL 81-5419


@use 0..1 SHOULD

81-7994


addr 1..* SHALL 81-5422


time 1..1 SHALL 81-5445


id 1..* SHALL 81-5449

code 0..1 SHOULD

81-16787

@code 1..1 SHALL 81-16788

2.16.840.1.114222.4.11.1066 (Healthcare Provider Taxonomy (HIPAA))

addr 1..* SHALL 81-5452


@use 0..1 SHOULD

81-7995


assignedPerson 0..1 SHOULD

81-5430

name 1..* SHALL 81-16789

assignedAuthoringDevice 0..1 SHOULD

81-16783

manufacturerModelName 1..1 SHALL 81-16784

softwareName 1..1 SHALL 81-16785

dataEnterer 0..1 MAY 81-


5441



id 1..* SHALL 81-5443

@root 0..1 SHOULD

81-16821

2.16.840.1.113883.4.6

addr 1..* SHALL 81-5460


@use 0..1 SHOULD

81-7996



name 1..* SHALL 81-5470

informant 0..* MAY 81-8001


id 1..* SHALL 81-9945

addr 1..* SHALL 81-8220


name 1..* SHALL 81-8222

informant 0..* MAY 81-26467

relatedEntity 1..1 SHALL 81-26468

custodian 1..1 SHALL 81-5519

assignedCustodian 1..1 SHALL 81-5520

representedCustodianOrganization

1..1 SHALL 81-5521

id 1..* SHALL 81-5522

@root 0..1 SHOULD

81-16822

2.16.840.1.113883.4.6

name 1..1 SHALL 81-5524

telecom 1..1 SHALL 81-5525


@use 0..1 SHOULD

81-7998


addr 1..1 SHALL 81-5559

informationRecipient 0..* MAY 81-5565

intendedRecipient 1..1 SHALL 81-5566

informationRecipient 0..1 MAY 81-5567

name 1..* SHALL 81-5568

receivedOrganization 0..1 MAY 81-5577

name 1..1 SHALL 81-5578

legalAuthenticator 0..1 SHOULD

81-5579

time 1..1 SHALL 81-5580

signatureCode 1..1 SHALL 81-5583

@code 1..1 SHALL 81-5584

2.16.840.1.113883.5.89 (Participationsignature) = S


id 1..* SHALL 81-5586

@root 0..1 MAY 81-16823

2.16.840.1.113883.4.6

code 0..1 MAY 81-17000


addr 1..* SHALL 81-5589


@use 0..1 SHOULD

81-7999



name 1..* SHALL 81-5598

authenticator 0..* MAY 81-5607

time 1..1 SHALL 81-


5608


signatureCode 1..1 SHALL 81-5610

@code 1..1 SHALL 81-5611

2.16.840.1.113883.5.89 (Participationsignature) = S


id 1..* SHALL 81-5613

@root 0..1 SHOULD

81-16824

2.16.840.1.113883.4.6

code 0..1 MAY 81-16825

@code 0..1 MAY 81-16826


addr 1..* SHALL 81-5616


@use 0..1 SHOULD

81-8000



name 1..* SHALL 81-5625

participant 0..* MAY 81-10003

time 0..1 MAY 81-10004

inFulfillmentOf 0..* MAY 81-9952

order 1..1 SHALL 81-9953

id 1..* SHALL 81-9954

documentationOf 0..* MAY 81-14835

serviceEvent 1..1 SHALL 81-14836


low 1..1 SHALL 81-14838

performer 0..* SHOULD

81-14839


2.16.840.1.113883.5.90 (HL7ParticipationType)


functionCode 0..1 MAY 81-16818

@codeSystem 0..1 SHOULD

81-16819

2.16.840.1.113883.5.88 (participationFunction)


id 1..* SHALL 81-14846

@root 0..1 SHOULD

81-14847

2.16.840.1.113883.4.6

code 0..1 SHOULD

81-14842

@code 1..1 SHALL 81-14843

2.16.840.1.113883.6.101 (Healthcare Provider Taxonomy (HIPAA))

authorization 0..* MAY 81-16792

consent 1..1 SHALL 81-16793

id 0..* MAY 81-16794

code 0..1 MAY 81-16795

statusCode 1..1 SHALL 81-16797

@code 1..1 SHALL 81-16798

2.16.840.1.113883.5.6 (HL7ActClass) = completed

componentOf 0..1 MAY 81-9955

encompassingEncounter 1..1 SHALL 81-9956

id 1..* SHALL 81-9959


1. SHALL contain exactly one [1..1] realmCode="US" (CONF:81-16791).2. SHALL contain exactly one [1..1] typeId (CONF:81-5361).

a. This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" (CONF:81-5250).

b. This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:81-5251).

3. SHALL contain exactly one [1..1] templateId (CONF:81-5252) such that ita. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1"

(CONF:81-10036).4. SHALL contain exactly one [1..1] id (CONF:81-5363).


a. This id SHALL be a globally unique identifier for the document (CONF:81-9991).5. SHALL contain exactly one [1..1] code (CONF:81-5253).

a. This code SHALL specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:81-9992).

6. SHALL contain exactly one [1..1] title (CONF:81-5254).a. Can either be a locally defined name or the display name corresponding to

clinicalDocument/code (CONF:81-5255).7. SHALL contain exactly one [1..1] effectiveTime (CONF:81-5256).

a. The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:81-16865).

8. SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC 2010-04-21 (CONF:81-5259).

9. SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language 2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:81-5372).

10. MAY contain zero or one [0..1] setId (CONF:81-5261).a. If setId is present versionNumber SHALL be present (CONF:81-6380).

11. MAY contain zero or one [0..1] versionNumber (CONF:81-5264).a. If versionNumber is present setId SHALL be present (CONF:81-6387).

12. SHALL contain at least one [1..*] recordTarget (CONF:81-5266).a. Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:81-

5267).i. This patientRole SHALL contain at least one [1..*] id (CONF:81-5268).ii. This patientRole SHALL contain at least one [1..*] addr (CONF:81-5271).

1. The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:81-10412).

iii. This patientRole SHALL contain at least one [1..*] telecom (CONF:81-5280).1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL

be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:81-5375).

iv. This patientRole SHALL contain exactly one [1..1] patient (CONF:81-5283).1. This patient SHALL contain at least one [1..*] name (CONF:81-5284).

a. The content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1) (CONF:81-10411).

2. This patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC (CONF:81-6394).

3. This patient SHALL contain exactly one [1..1] birthTime (CONF:81-5298).


a. SHALL be precise to year (CONF:81-5299).b. SHOULD be precise to day (CONF:81-5300).

4. This patient SHOULD contain zero or one [0..1] maritalStatusCode, which SHALL be selected from ValueSet Marital Status 2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:81-5303).

5. This patient MAY contain zero or one [0..1] religiousAffiliationCode, which SHALL be selected from ValueSet Religious Affiliation 2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:81-5317).

6. This patient MAY contain zero or one [0..1] raceCode, which SHALL be selected from ValueSet Race 2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:81-5322).Note: To record additional raceCode, use the extension element sdtc:raceCode.

7. This patient MAY contain zero or more [0..*] sdtc:raceCode, which SHALL be selected from ValueSet Race 2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:81-7263).

8. This patient MAY contain zero or one [0..1] ethnicGroupCode, which SHALL be selected from ValueSet EthnicityGroup 2.16.840.1.114222.4.11.837 DYNAMIC (CONF:81-5323).

9. This patient MAY contain zero or more [0..*] guardian (CONF:81-5325).

a. The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet ResponsibleParty 2.16.840.1.113883.1.11.19830 DYNAMIC (CONF:81-5326).

b. The guardian, if present, SHOULD contain zero or more [0..*] addr (CONF:81-5359).

i. The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:81-10413).

c. The guardian, if present, MAY contain zero or more [0..*] telecom (CONF:81-5382).

i. The telecom, if present, SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:81-7993).

d. The guardian, if present, SHALL contain exactly one [1..1] guardianPerson (CONF:81-5385).

i. This guardianPerson SHALL contain at least one [1..*] name (CONF:81-5386).

1. The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED)


(2.16.840.1.113883.10.20.22.5.1.1) (CONF:81-10414).

10. This patient MAY contain zero or one [0..1] birthplace (CONF:81-5395).

a. The birthplace, if present, SHALL contain exactly one [1..1] place (CONF:81-5396).

i. This place SHALL contain exactly one [1..1] addr (CONF:81-5397).

1. This addr SHOULD contain zero or one [0..1] country, which SHALL be selected from ValueSet Country 2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:81-5404).

2. This addr MAY contain zero or one [0..1] postalCode, which SHALL be selected from ValueSet PostalCode 2.16.840.1.113883.3.88.12.80.2 DYNAMIC (CONF:81-5403).

3. If country is US, this addr SHOULD contain zero or 1 [0..1] state, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.1 StateValueSet DYNAMIC (CONF:81-5402).

11. This patient SHOULD contain zero or more [0..*] languageCommunication (CONF:81-5406).

a. The languageCommunication, if present, SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language 2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:81-5407).

b. The languageCommunication, if present, MAY contain zero or one [0..1] modeCode, which SHALL be selected from ValueSet LanguageAbilityMode 2.16.840.1.113883.1.11.12249 DYNAMIC (CONF:81-5409).

c. The languageCommunication, if present, SHOULD contain zero or one [0..1] proficiencyLevelCode, which SHALL be selected from ValueSet LanguageAbilityProficiency 2.16.840.1.113883.1.11.12199 DYNAMIC (CONF:81-9965).

d. The languageCommunication, if present, MAY contain zero or one [0..1] preferenceInd (CONF:81-5414).

v. This patientRole MAY contain zero or one [0..1] providerOrganization (CONF:81-5416).

1. The providerOrganization, if present, SHALL contain at least one [1..*] id (CONF:81-5417).

a. Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:81-16820).

2. The providerOrganization, if present, SHALL contain at least one [1..*] name (CONF:81-5419).


3. The providerOrganization, if present, SHALL contain at least one [1..*] telecom (CONF:81-5420).

a. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:81-7994).

4. The providerOrganization, if present, SHALL contain at least one [1..*] addr (CONF:81-5422).

a. The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:81-10415).

13. SHALL contain at least one [1..*] author (CONF:81-5444).a. Such authors SHALL contain exactly one [1..1] time (CONF:81-5445).

i. The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:81-16866).

b. Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:81-5448).i. This assignedAuthor SHALL contain at least one [1..*] id (CONF:81-5449).

1. If this assignedAuthor is an assignedPerson, the id SHOULD contain zero to one 0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:81-26469).

ii. This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:81-16787).

1. The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:81-16788).

iii. This assignedAuthor SHALL contain at least one [1..*] addr (CONF:81-5452).

1. The content SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:81-16871).

iv. This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:81-5428).

1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:81-7995).

v. This assignedAuthor SHOULD contain zero or one [0..1] assignedPerson (CONF:81-5430).

1. The assignedPerson, if present, SHALL contain at least one [1..*] name (CONF:81-16789).

a. The content SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:81-16872).


vi. This assignedAuthor SHOULD contain zero or one [0..1] assignedAuthoringDevice (CONF:81-16783).

1. The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] manufacturerModelName (CONF:81-16784).

2. The assignedAuthoringDevice, if present, SHALL contain exactly one [1..1] softwareName (CONF:81-16785).

vii. There SHALL be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:81-16790).

14. MAY contain zero or one [0..1] dataEnterer (CONF:81-5441).a. The dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity

(CONF:81-5442).i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-5443).

1. Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:81-16821).

ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:81-5460).1. The content of addr SHALL be a conformant US Realm Address

(AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:81-10417).

iii. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:81-5466).


iv. This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:81-5469).

1. This assignedPerson SHALL contain at least one [1..*] name (CONF:81-5470).

a. The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1) (CONF:81-10418).

v. This assignedEntity MAY contain zero or one 0..1] code which SHOULD be selected from coding system NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101 (CONF:81-9944).

An informant can contain either an assignedEntity or a relatedEntity. The constraints here apply to assignedEntity.

15. MAY contain zero or more [0..*] informant (CONF:81-8001) such that ita. SHALL contain exactly one [1..1] assignedEntity (CONF:81-8002).

i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-9945).1. If assignedEntity/id is a provider then this id, SHOULD include zero

or one 0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:81-9946).

ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:81-8220).



iii. This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:81-8221).



iv. This assignedEntity MAY contain zero or one 0..1] code which SHOULD be selected from coding system NUCC Health Care Provider Taxonomy 2.16.840.1.113883.6.101 (CONF:81-9947).

An informant can contain either an assignedEntity or a relatedEntity. This template does not place any constraints on a relatedEntity.

16. MAY contain zero or more [0..*] informant (CONF:81-26467) such that ita. SHALL contain exactly one [1..1] relatedEntity (CONF:81-26468).

17. SHALL contain exactly one [1..1] custodian (CONF:81-5519).a. This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:81-

5520).i. This assignedCustodian SHALL contain exactly one [1..1]

representedCustodianOrganization (CONF:81-5521).1. This representedCustodianOrganization SHALL contain at least one

[1..*] id (CONF:81-5522).a. Such ids SHOULD contain zero or one [0..1]

@root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:81-16822).

2. This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:81-5524).

3. This representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:81-5525).

a. This telecom SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:81-7998).

4. This representedCustodianOrganization SHALL contain exactly one [1..1] addr (CONF:81-5559).

a. The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:81-10421).

18. MAY contain zero or more [0..*] informationRecipient (CONF:81-5565).a. The informationRecipient, if present, SHALL contain exactly one [1..1]

intendedRecipient (CONF:81-5566).


i. This intendedRecipient MAY contain zero or one [0..1] informationRecipient (CONF:81-5567).

1. The informationRecipient, if present, SHALL contain at least one [1..*] name (CONF:81-5568).


ii. This intendedRecipient MAY contain zero or one [0..1] receivedOrganization (CONF:81-5577).

1. The receivedOrganization, if present, SHALL contain exactly one [1..1] name (CONF:81-5578).

19. SHOULD contain zero or one [0..1] legalAuthenticator (CONF:81-5579).a. The legalAuthenticator, if present, SHALL contain exactly one [1..1] time

(CONF:81-5580).i. The content SHALL be a conformant US Realm Date and Time

(DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:81-16873).b. The legalAuthenticator, if present, SHALL contain exactly one [1..1]

signatureCode (CONF:81-5583).i. This signatureCode SHALL contain exactly one [1..1] @code="S"

(CodeSystem: Participationsignature 2.16.840.1.113883.5.89 STATIC) (CONF:81-5584).

c. The legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:81-5585).

i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-5586).1. Such ids MAY contain zero or one [0..1]


ii. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066 STATIC (CONF:81-17000).

iii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:81-5589).1. The content of addr SHALL be a conformant US Realm Address


iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:81-5595).


v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:81-5597).




20. MAY contain zero or more [0..*] authenticator (CONF:81-5607).a. The authenticator, if present, SHALL contain exactly one [1..1] time (CONF:81-

5608).i. The content SHALL be a conformant US Realm Date and Time

(DTM.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) (CONF:81-16874).b. The authenticator, if present, SHALL contain exactly one [1..1] signatureCode

(CONF:81-5610).i. This signatureCode SHALL contain exactly one [1..1] @code="S"

(CodeSystem: Participationsignature 2.16.840.1.113883.5.89 STATIC) (CONF:81-5611).

c. The authenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:81-5612).

i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-5613).1. Such ids SHOULD contain zero or one [0..1]


ii. This assignedEntity MAY contain zero or one [0..1] code (CONF:81-16825).1. The code, if present, MAY contain zero or one [0..1] @code, which

SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066 STATIC (CONF:81-16826).

iii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:81-5616).1. The content of addr SHALL be a conformant US Realm Address


iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:81-5622).


v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:81-5624).



In general, many types of participant are possible. When participant/@typeCode is IND (individual), associatedEntity/@classCode must be from the specified value set, unless this requirement is overridden by the document type's header.

21. MAY contain zero or more [0..*] participant (CONF:81-10003) such that it


a. MAY contain zero or one [0..1] time (CONF:81-10004).b. Such participants, if present, SHALL contain associatedEntity/associatedPerson or

associatedEntity/scopingOrganization (CONF:81-10006).c. Unless otherwise specified by the document specific header constraints, when

participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:81-10007).

22. MAY contain zero or more [0..*] inFulfillmentOf (CONF:81-9952).a. The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:81-

9953).i. This order SHALL contain at least one [1..*] id (CONF:81-9954).

23. MAY contain zero or more [0..*] documentationOf (CONF:81-14835).a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent

(CONF:81-14836).i. This serviceEvent SHALL contain exactly one [1..1] effectiveTime

(CONF:81-14837).1. This effectiveTime SHALL contain exactly one [1..1] low (CONF:81-

14838).ii. This serviceEvent SHOULD contain zero or more [0..*] performer (CONF:81-

14839).1. The performer, if present, SHALL contain exactly one [1..1]

@typeCode (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-14840).

a. The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors (CONF:81-16753).

2. The performer, if present, MAY contain zero or one [0..1] functionCode (CONF:81-16818).

a. The functionCode, if present, SHOULD contain zero or one [0..1] @codeSystem, which SHOULD be selected from CodeSystem participationFunction (2.16.840.1.113883.5.88) STATIC (CONF:81-16819).

3. The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:81-14841).

a. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-14846).

i. Such ids SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:81-14847).


b. This assignedEntity SHOULD contain zero or one [0..1] code (CONF:81-14842).

i. The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from CodeSystem Healthcare Provider Taxonomy (HIPAA) (2.16.840.1.113883.6.101) STATIC (CONF:81-14843).

24. MAY contain zero or more [0..*] authorization (CONF:81-16792) such that ita. SHALL contain exactly one [1..1] consent (CONF:81-16793).

i. This consent MAY contain zero or more [0..*] id (CONF:81-16794).ii. This consent MAY contain zero or one [0..1] code (CONF:81-16795).

1. The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code (CONF:81-16796).

iii. This consent SHALL contain exactly one [1..1] statusCode (CONF:81-16797).

1. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-16798).

25. MAY contain zero or one [0..1] componentOf (CONF:81-9955).a. The componentOf, if present, SHALL contain exactly one [1..1]

encompassingEncounter (CONF:81-9956).i. This encompassingEncounter SHALL contain at least one [1..*] id

(CONF:81-9959).ii. This encompassingEncounter SHALL contain exactly one [1..1]

effectiveTime (CONF:81-9958).


Figure 1: US Realm Header

<realmCode code="US"/><typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/><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 extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/><code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/><title>Community Health and Hospitals: Health Summary</title><effectiveTime value="201209150000-0400"/><confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/><languageCode code="en-US"/><setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/><versionNumber value="1"/>

Figure 2: effectiveTime with Time Zone

<effectiveTime value=”201107061227-08”/>


2 SECTIONS

2.1 Birth Defects Diagnosis Section (entries required) (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.2:27Oct2014 (open)]

Table 4: Birth Defects Diagnosis Section (entries required) (NEW) Contexts

Contained By: Contains:Birth Defects Event Report Document (NEW) (required)

Birth Defects Diagnosis Concern Act

Note: This template is modeled based on C-CDA R2 "Problem Section (entries required) (V2)" template.This is the key section for the Ambulatory Healthcare Provider Birth Defects Event Report and, therefore, SHALL NOT be null. (In other words, the Birth Defects Diagnosis Section SHALL be provided and NO nullFlavor is allowed).


Table 5: Birth Defects Diagnosis Section (entries required) (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.14.2:27Oct2014)templateId 1..1 SHALL 1137-

111@root 1..1 SHALL 1137-

1122.16.840.1.113883.10.14.2


27Oct2014

code 1..1 SHALL 1137-113

@code 1..1 SHALL 1137-114

2.16.840.1.113883.6.1 (LOINC) = xxxxx-x


2.16.840.1.113883.6.1

@codeSystemName 1..1 SHALL 1137-402

LOINC


text 1..1 SHALL 1137-117

entry 1..* SHALL 1137-118


act 1..1 SHALL 1137-120

Birth Defects Diagnosis Concern Act (identifier: urn:hl7ii:2.16.840.1.113883.10.14.3:27Oct2014


(CONF:1137-112).b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1466).

2. SHALL contain exactly one [1..1] code (CONF:1137-113).a. This code SHALL contain exactly one [1..1] @code="xxxxx-x" Birth Defects

Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-114).b. This code SHALL contain exactly one [1..1]

@codeSystem="2.16.840.1.113883.6.1" (CONF:1137-115).c. This code SHALL contain exactly one [1..1] @codeSystemName="LOINC"

(CONF:1137-402).3. SHALL contain exactly one [1..1] title (CONF:1137-116).4. SHALL contain exactly one [1..1] text (CONF:1137-117).5. SHALL contain at least one [1..*] entry (CONF:1137-118) such that it


a. SHALL contain [0..0] @nullFlavor (CONF:1137-119).b. SHALL contain exactly one [1..1] Birth Defects Diagnosis Concern Act

(identifier: urn:hl7ii:2.16.840.1.113883.10.14.3:27Oct2014) (CONF:1137-120).

2.2 Family History Section - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.15 (open)]

Table 6: Family History Section Contexts


Family History Organizer

This section contains data defining the patient’s genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient’s healthcare risk profile.

Table 7: Family History Section Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.15)templateId 1..1 SHALL 81-

7932@root 1..1 SHALL 81-

103882.16.840.1.113883.10.20.22.2.15

code 1..1 SHALL 81-15469

@code 1..1 SHALL 81-15470

2.16.840.1.113883.6.1 (LOINC) = 10157-6


text 1..1 SHALL 81-7935

entry 0..* MAY 81-7955

organizer 1..1 SHALL 81-15471

Family History Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.45


(CONF:81-10388).2. SHALL contain exactly one [1..1] code (CONF:81-15469).

a. This code SHALL contain exactly one [1..1] @code="10157-6" Family History (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15470).


3. SHALL contain exactly one [1..1] title (CONF:81-7934).4. SHALL contain exactly one [1..1] text (CONF:81-7935).5. MAY contain zero or more [0..*] entry (CONF:81-7955) such that it

a. SHALL contain exactly one [1..1] Family History Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.45) (CONF:81-15471).

Figure 3: Family History Section

<section> <templateId root="2.16.840.1.113883.10.20.22.2.15"/>  <code code="10157-6" codeSystem="2.16.840.1.113883.6.1"/> <title>Family history</title> <text> ... </text> <entry typeCode="DRIV"> <organizer moodCode="EVN" classCode="CLUSTER"> <templateId root="2.16.840.1.113883.10.20.22.4.45"/>  ... </organizer> </entry></section>

2.3 General Status - NB BD IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.23:27Oct2014 (open)]

Table 8: General Status - NB BD IG Specific Constraints (NEW) Contexts

Contained By: Contains:Physical Exam - NB BD IG Specific Constraints (NEW) (required)

Apgar at 10 minuteApgar at 5 minutes


Table 9: General Status - NB BD IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


830@root 1..1 SHALL 1137-

8312.16.840.1.113883.10.14.23


27Oct2014

entry 1..1 SHALL 1137-832

observation 1..1 SHALL 1137-833

Apgar at 5 minutes (identifier: urn:oid:2.16.840.1.113883.10.20.17.3.5



Apgar at 10 minute (identifier: urn:hl7ii:2.16.840.1.113883.10.14.41:27Oct2014

1. Conforms to General Status Section template (identifier: urn:oid:2.16.840.1.113883.10.20.2.5).



3. SHALL contain exactly one [1..1] entry (CONF:1137-832) such that ita. SHALL contain exactly one [1..1] Apgar at 5 minutes (identifier:

urn:oid:2.16.840.1.113883.10.20.17.3.5) (CONF:1137-833).4. SHALL contain exactly one [1..1] entry (CONF:1137-834) such that it

a. SHALL contain exactly one [1..1] Apgar at 10 minute (identifier: urn:hl7ii:2.16.840.1.113883.10.14.41:27Oct2014) (CONF:1137-835).

2.4 General Status Section - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.2.5 (open)]

The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.


Table 10: General Status Section Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.2.5)templateId 1..1 SHALL 81-

7985@root 1..1 SHALL UID 81-

104572.16.840.1.113883.10.20.2.5

code 1..1 SHALL 81-15472

@code 1..1 SHALL 81-15473

10210-3


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


text 1..1 SHALL 81-7988

1. SHALL contain exactly one [1..1] templateId (CONF:81-7985) such that ita. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.2.5"


a. This code SHALL contain exactly one [1..1] @code="10210-3" General Status (CONF:81-15473).

b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:81-26477).

3. SHALL contain exactly one [1..1] title (CONF:81-7987).4. SHALL contain exactly one [1..1] text (CONF:81-7988).

Figure 4: General Status Section Example

<section> <templateId root="2.16.840.1.113883.10.20.2.5" /> <code code="10210-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="GENERAL STATUS" /> <title>GENERAL STATUS</title> <text> <paragraph>Alert and in good spirits, no acute distress. </paragraph> </text></section>


2.5 Labor and Delivery Events Section (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.25:27Oct2014 (open)]

Table 11: Labor and Delivery Events Section (NEW) Contexts


Characteristics of Labor and Delivery: Meconium StainingMaternal Morbidity - Admission to Intensive Care [unit]Maternal Morbidity: [Third or fourth degree] perineal lacerationMaternal Morbidity: Ruptured UterusMedications Section - LD BD IG Specific ConstraintsMethod of Delivery: Fetal Presentation [at birth]Number of Fetal DeathsOnset of Labor: Precipitous LaborOnset of Labor: Prolonged LaborPhysical Exam - LD BD IG SpecificPlurality (The number of babies resulting from a single pregnancy)Pregnancy OutcomeProcedures Section - LD BD IG SpecificSpecify number of infants in this delivery born alive when not single birth


Table 12: Labor and Delivery Events Section (NEW) Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


201@root 1..1 SHALL 1137-

2022.16.840.1.113883.10.14.25


27Oct2014

id 1..1 SHALL 1137-203

@root 1..1 SHALL 1137-204

@extension 0..1 SHOULD

1137-205

code 1..1 SHALL 1137-206

@code 1..1 SHALL 1137-207

57074-7


2.16.840.1.113883.6.1 (LOINC)


Labor and delivery process


text 1..1 SHALL 1137-211

entry 0..1 SHOULD

1137-1245


Plurality (The number of babies resulting from a single pregnancy) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.81:27Oct2014

entry 0..1 SHOULD

1137-1247


Specify number of infants in this delivery born alive when not single birth (identifier: urn:hl7ii:2.16.840.1.113883.10.14.86:27Oct2014

entry 0..1 SHOULD

1137-1249


Number of Fetal Deaths (identifier: urn:hl7ii:2.16.840.1.113883.10.14.73:27Oct2014

entry 1..1 SHALL 1137-


1251



Maternal Morbidity - Admission to Intensive Care [unit] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.61:27Oct2014

entry 1..1 SHALL 1137-1253


Method of Delivery: Fetal Presentation [at birth] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.69:27Oct2014

entry 1..1 SHALL 1137-1255


Characteristics of Labor and Delivery: Meconium Staining (identifier: urn:hl7ii:2.16.840.1.113883.10.14.53:27Oct2014

entry 1..1 SHALL 1137-1257


Maternal Morbidity: [Third or fourth degree] perineal laceration (identifier: urn:hl7ii:2.16.840.1.113883.10.14.62:27Oct2014

entry 1..1 SHALL 1137-1259


Maternal Morbidity: Ruptured Uterus (identifier: urn:hl7ii:2.16.840.1.113883.10.14.64:27Oct2014

entry 1..1 SHALL 1137-1260


Onset of Labor: Precipitous Labor (identifier: urn:hl7ii:2.16.840.1.113883.10.14.76:27Oct2014

entry 1..1 SHALL 1137-1263


Onset of Labor: Prolonged Labor (identifier: urn:hl7ii:2.16.840.1.113883.10.14.78:27Oct2014

entry 1..1 SHALL 1137-1265


Pregnancy Outcome (identifier: urn:hl7ii:2.16.840.1.113883.10.14.82:27Oct2014




Physical Exam - LD BD IG Specific (identifier: urn:hl7ii:2.16.840.1.113883.10.14.26:27Oct2014



Procedures Section - LD BD IG Specific (identifier: urn:hl7ii:2.16.840.1.113883.10.14.28:27Oct2014



Medications Section - LD BD IG Specific Constraints (identifier: urn:hl7ii:2.16.840.1.113883.10.14.29:27Oct2014



2. SHALL contain exactly one [1..1] id (CONF:1137-203).a. This id SHALL contain exactly one [1..1] @root (CONF:1137-204).b. This id SHOULD contain zero or one [0..1] @extension (CONF:1137-205).

3. SHALL contain exactly one [1..1] code (CONF:1137-206).a. This code SHALL contain exactly one [1..1] @code="57074-7" Labor and delivery

process (CONF:1137-207).b. This code SHALL contain exactly one [1..1] @codeSystem (CodeSystem: LOINC

2.16.840.1.113883.6.1 STATIC) (CONF:1137-208).c. This code SHALL contain exactly one [1..1] @displayName="Labor and delivery

process" (CONF:1137-209).4. SHALL contain exactly one [1..1] title (CONF:1137-210).5. SHALL contain exactly one [1..1] text (CONF:1137-211).6. SHOULD contain zero or one [0..1] entry (CONF:1137-1245) such that it

a. SHALL contain exactly one [1..1] Plurality (The number of babies resulting from a single pregnancy) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.81:27Oct2014) (CONF:1137-1246).

7. SHOULD contain zero or one [0..1] entry (CONF:1137-1247) such that ita. SHALL contain exactly one [1..1] Specify number of infants in this

delivery born alive when not single birth (identifier: urn:hl7ii:2.16.840.1.113883.10.14.86:27Oct2014) (CONF:1137-1248).

8. SHOULD contain zero or one [0..1] entry (CONF:1137-1249) such that ita. SHALL contain exactly one [1..1] Number of Fetal Deaths (identifier:

urn:hl7ii:2.16.840.1.113883.10.14.73:27Oct2014) (CONF:1137-1250).9. SHALL contain exactly one [1..1] entry (CONF:1137-1251) such that it


a. SHALL contain exactly one [1..1] Maternal Morbidity - Admission to Intensive Care [unit] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.61:27Oct2014) (CONF:1137-1252).

10. SHALL contain exactly one [1..1] entry (CONF:1137-1253) such that ita. SHALL contain exactly one [1..1] Method of Delivery: Fetal Presentation

[at birth] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.69:27Oct2014) (CONF:1137-1254).

11. SHALL contain exactly one [1..1] entry (CONF:1137-1255) such that ita. SHALL contain exactly one [1..1] Characteristics of Labor and Delivery:

Meconium Staining (identifier: urn:hl7ii:2.16.840.1.113883.10.14.53:27Oct2014) (CONF:1137-1256).

12. SHALL contain exactly one [1..1] entry (CONF:1137-1257) such that ita. SHALL contain exactly one [1..1] Maternal Morbidity: [Third or fourth

degree] perineal laceration (identifier: urn:hl7ii:2.16.840.1.113883.10.14.62:27Oct2014) (CONF:1137-1258).

13. SHALL contain exactly one [1..1] entry (CONF:1137-1259) such that ita. SHALL contain exactly one [1..1] Maternal Morbidity: Ruptured Uterus


14. SHALL contain exactly one [1..1] entry (CONF:1137-1260) such that ita. SHALL contain exactly one [1..1] Onset of Labor: Precipitous Labor


15. SHALL contain exactly one [1..1] entry (CONF:1137-1263) such that ita. SHALL contain exactly one [1..1] Onset of Labor: Prolonged Labor


16. SHALL contain exactly one [1..1] entry (CONF:1137-1265) such that ita. SHALL contain exactly one [1..1] Pregnancy Outcome (identifier:

urn:hl7ii:2.16.840.1.113883.10.14.82:27Oct2014) (CONF:1137-1266).17. SHALL contain exactly one [1..1] component (CONF:1137-868) such that it

a. SHALL contain exactly one [1..1] Physical Exam - LD BD IG Specific (identifier: urn:hl7ii:2.16.840.1.113883.10.14.26:27Oct2014) (CONF:1137-869).

18. SHALL contain exactly one [1..1] component (CONF:1137-214) such that ita. SHALL contain exactly one [1..1] Procedures Section - LD BD IG Specific


19. SHALL contain exactly one [1..1] component (CONF:1137-218) such that ita. SHALL contain exactly one [1..1] Medications Section - LD BD IG Specific

Constraints (identifier: urn:hl7ii:2.16.840.1.113883.10.14.29:27Oct2014) (CONF:1137-219).


2.6 Medications Administered Section - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.38 (open)]

Table 13: Medications Administered Section Contexts

Contained By: Contains:Medication Activity

The Medications Administered section defines medications and fluids administered during the procedure, encounter, or other activity excluding anesthetic medications. This guide recommends anesthesia medications be documented as described in the section on Anesthesia.

Table 14: Medications Administered Section Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


8152@root 1..1 SHALL 81-

104052.16.840.1.113883.10.20.22.2.38

code 1..1 SHALL 81-15383

@code 1..1 SHALL 81-15384

2.16.840.1.113883.6.1 (LOINC) = 29549-3


text 1..1 SHALL 81-8155

entry 0..* MAY 81-8156

substanceAdministration 1..1 SHALL 81-15499

Medication Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.16



a. This code SHALL contain exactly one [1..1] @code="29549-3" Medications Administered (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15384).

3. SHALL contain exactly one [1..1] title (CONF:81-8154).4. SHALL contain exactly one [1..1] text (CONF:81-8155).5. MAY contain zero or more [0..*] entry (CONF:81-8156).


a. The entry, if present, SHALL contain exactly one [1..1] Medication Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.16) (CONF:81-15499).

2.7 Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.16:27Oct2014 (open)]

Table 15: Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW) Contexts


Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW)

This template provides Birth defects-specific information in addition to the C-CDA R2 template "Medications Administered Section (V2)". It requires a Medication Activity (V2) – Birth Defects IG Specific Constraints template to be used.The Medication Administered Section captures medications given to the patient during the encounter.

Table 16: Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


915@root 1..1 SHALL 1137-

9162.16.840.1.113883.10.14.16


27Oct2014



Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.15:27Oct2014

1. Conforms to Medications Administered Section template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.38).



3. SHALL contain at least one [1..*] entry (CONF:1137-917) such that it


a. SHALL contain exactly one [1..1] Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.15:27Oct2014) (CONF:1137-918).

2.8 Medications Section - LD BD IG Specific Constraints - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.29:27Oct2014 (open)]

Table 17: Medications Section - LD BD IG Specific Constraints Contexts

Contained By: Contains:Labor and Delivery Events Section (NEW) (required) Characteristics of Labor and Delivery: [Epidural or

spinal] Anesthesia [during labor]Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor]Characteristics of Labor and Delivery: Augmentation of Labor - MedicationCharacteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery]


Table 18: Medications Section - LD BD IG Specific Constraints Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1118@root 1..1 SHALL 1137-

11192.16.840.1.113883.10.14.29


27Oct2014

id 1..* SHALL 1137-1120

@root 1..1 SHALL 1137-1121

entry 0..1 SHOULD

1137-1122


Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.49:27Oct2014

entry 0..1 SHOULD

1137-1312


Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.54:27Oct2014

entry 0..1 SHOULD

1137-1314


Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.48:27Oct2014

entry 0..1 SHOULD

1137-1316


Characteristics of Labor and Delivery: Augmentation of Labor - Medication (identifier: urn:hl7ii:2.16.840.1.113883.10.14.51:27Oct2014


1. Conforms to Medications Section (entries required) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.1.1).



3. SHALL contain at least one [1..*] id (CONF:1137-1120) such that ita. SHALL contain exactly one [1..1] @root (CONF:1137-1121).

4. SHOULD contain zero or one [0..1] entry (CONF:1137-1122) such that ita. SHALL contain exactly one [1..1] Characteristics of Labor and Delivery:

Antibiotics [received by the mother during labor] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.49:27Oct2014) (CONF:1137-1123).


Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.54:27Oct2014) (CONF:1137-1313).


[Epidural or spinal] Anesthesia [during labor] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.48:27Oct2014) (CONF:1137-1315).


Augmentation of Labor - Medication (identifier: urn:hl7ii:2.16.840.1.113883.10.14.51:27Oct2014) (CONF:1137-1327).

2.9 Medications Section (entries optional) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.1 (open)]

Table 19: Medications Section (entries optional) Contexts


The Medications section defines a patient's current medications and pertinent medication history. At a minimum, the currently active medications are to be listed, with an entire medication history as an option. The section may also include a patient's prescription and dispense history.This section requires that there be either an entry indicating the subject is not known to be on any medications, or that there be entries summarizing the subject's medications.


Table 20: Medications Section (entries optional) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7791@root 1..1 SHALL 81-

104322.16.840.1.113883.10.20.22.2.1

code 1..1 SHALL 81-15385

@code 1..1 SHALL 81-15386

2.16.840.1.113883.6.1 (LOINC) = 10160-0


text 1..1 SHALL 81-7794

entry 0..* SHOULD

81-7795





a. This code SHALL contain exactly one [1..1] @code="10160-0" History of medication use (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15386).

3. SHALL contain exactly one [1..1] title (CONF:81-7793).4. SHALL contain exactly one [1..1] text (CONF:81-7794).5. SHOULD contain zero or more [0..*] entry (CONF:81-7795) such that it

a. SHALL contain exactly one [1..1] Medication Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.16) (CONF:81-15984).

b. If medication use is unknown, the appropriate nullFlavor MAY be present (see unknown information in Section 1) (CONF:81-10076).

2.10Medications Section (entries required) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.1.1 (open)]

Table 21: Medications Section (entries required) Contexts



The Medications section defines a patient's current medications and pertinent medication history. At a minimum, the currently active medications are to be listed, with an entire medication history as an option. The section may also include a patient's prescription and dispense history.This section requires that there be either an entry indicating the subject is not known to be on any medications, or that there be entries summarizing the subject's medications.

Table 22: Medications Section (entries required) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.1.1)templateId 1..1 SHALL 81-

7568@root 1..1 SHALL 81-

104332.16.840.1.113883.10.20.22.2.1.1

code 1..1 SHALL 81-15387

@code 1..1 SHALL 81-15388

2.16.840.1.113883.6.1 (LOINC) = 10160-0


text 1..1 SHALL 81-7571




1. Conforms to Medications Section (entries optional) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.1).

2. SHALL contain exactly one [1..1] templateId (CONF:81-7568) such that ita. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.1.1"


a. This code SHALL contain exactly one [1..1] @code="10160-0" History of medication use (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15388).

4. SHALL contain exactly one [1..1] title (CONF:81-7570).5. SHALL contain exactly one [1..1] text (CONF:81-7571).6. SHALL contain at least one [1..*] entry (CONF:81-7572) such that it

a. SHALL contain exactly one [1..1] Medication Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.16) (CONF:81-15500).

b. If medication use is unknown, the appropriate nullFlavor MAY be present (see unknown information in Section 1) (CONF:81-10077).


2.11Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.14:27Oct2014 (open)]

Table 23: Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) Contexts



This template provides Birth Defects-specific information in addition to the C-CDA R2 template "Medications Section (V2)". It requires a Medication Activity (V2) – Birth Defects IG Specific Constraints template to be used.The Medications Section captures medications taken by a patient.

Table 24: Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


924@root 1..1 SHALL 1137-

9252.16.840.1.113883.10.14.14


27Oct2014



Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.15:27Oct2014




3. SHALL contain at least one [1..*] entry (CONF:1137-926) such that ita. SHALL contain exactly one [1..1] Medication Activity (V2) - Birth Defects

IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.15:27Oct2014) (CONF:1137-927).


2.12Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.24:27Oct2014 (open)]

Table 25: Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) Contexts

Contained By: Contains:Newborn Delivery Information Section (NEW) (required)

AntibioticsNewborn given Surfactant replacement therapy?

This template provides Newborn-specific information in addition to the C-CDA R2 template "Medications Section (V2)". It requires a Medication Activity (V2) – Newborn Specific Constraints template to be used.The Medications Section captures medications taken by a patient.

Table 26: Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


838@root 1..1 SHALL 1137-

8392.16.840.1.113883.10.14.24


27Oct2014



Antibiotics (identifier: urn:hl7ii:2.16.840.1.113883.10.14.40:27Oct2014



Newborn given Surfactant replacement therapy? (identifier: urn:hl7ii:2.16.840.1.113883.10.14.72:27Oct2014




3. SHALL contain at least one [1..*] entry (CONF:1137-840) such that it


a. SHALL contain exactly one [1..1] Antibiotics (identifier: urn:hl7ii:2.16.840.1.113883.10.14.40:27Oct2014) (CONF:1137-841).

4. SHALL contain at least one [1..*] entry (CONF:1137-856) such that ita. SHALL contain exactly one [1..1] Newborn given Surfactant replacement

therapy? (identifier: urn:hl7ii:2.16.840.1.113883.10.14.72:27Oct2014) (CONF:1137-857).

2.13Mother's History and Physical Section (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.30:27Oct2014 (open)]

Table 27: Mother's History and Physical Section (NEW) Contexts


Mothers Social History Section (NEW)Prior Pregnancy History Section (NEW)

Used for Social History and Pregnancy History.


Table 28: Mother's History and Physical Section (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1328@root 1..1 SHALL 1137-

13312.16.840.1.113883.10.14.30


27Oct2014

code 1..1 SHALL 1137-1329

@code 1..1 SHALL 1137-1332

text 1..1 SHALL 1137-1333

subject 1..1 SHALL 1137-1334

component 0..1 SHOULD

1137-1330


Prior Pregnancy History Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.31:27Oct2014

component 0..1 SHOULD

1137-1336

section 0..1 SHOULD

1137-1337

Mothers Social History Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.32:27Oct2014



2. SHALL contain exactly one [1..1] code (CONF:1137-1329) such that ita. SHALL contain exactly one [1..1] @code (CONF:1137-1332).

3. SHALL contain exactly one [1..1] text (CONF:1137-1333).4. SHALL contain exactly one [1..1] subject (CONF:1137-1334).

NOTE: Shall contain Mothers details.5. SHOULD contain zero or one [0..1] component (CONF:1137-1330) such that it

a. SHALL contain exactly one [1..1] Prior Pregnancy History Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.31:27Oct2014) (CONF:1137-1335).

6. SHOULD contain zero or one [0..1] component (CONF:1137-1336) such that it


conf:1137-1334

a. SHOULD contain zero or one [0..1] Mothers Social History Section (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.32:27Oct2014) (CONF:1137-1337).

2.14Mothers Social History Section (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.32:27Oct2014 (open)]

Table 29: Mothers Social History Section (NEW) Contexts

Contained By: Contains:Mother's History and Physical Section (NEW) (optional)

Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period

Table 30: Mothers Social History Section (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1338@root 1..1 SHALL 1137-

13392.16.840.1.113883.10.14.32


27Oct2014

entry 0..* SHOULD

1137-1340


Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period (identifier: urn:hl7ii:2.16.840.1.113883.10.14.38:27Oct2014

1. Conforms to Social History Section template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.17).



3. SHOULD contain zero or more [0..*] entry (CONF:1137-1340) such that ita. SHALL contain exactly one [1..1] Alcohol Intake (glasses/week) Alcohol

intake within the pregnancy period (identifier: urn:hl7ii:2.16.840.1.113883.10.14.38:27Oct2014) (CONF:1137-1353).


2.15Newborn Delivery Information Section (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.17:27Oct2014 (open)]

This template is modeled based on C-CDA R2 "Problem Section (entries required) (V2)" template. This is the key section for the Ambulatory Healthcare Provider Birth Defects Event Report and, therefore, SHALL NOT be null. (In other words, the Birth Defects Diagnosis Section SHALL be provided and NO nullFlavor is allowed).

Table 31: Newborn Delivery Information Section (NEW) Contexts


Admission to NICUBirth OutcomeCause of DeathDate of DeathGestational ageInfant Living at Time of Report?Location of DeathMedications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)Physical Exam - NB BD IG Specific Constraints (NEW)Place of Birth (type or birthing place)Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)Rank of Birth (Birth Order / Set Order)Significant Birth Injury

The Birth Defects Diagnosis Section is the most critical section in the Birth Defects Event Report. The information in this section includes: the date the Birth Defect was first diagnosed; laterality (which of a paired organ contains the birth defect); the diagnostic confirmation; etc at diagnosis. These data elements are necessary for public health central birth defect registries.


Table 32: Newborn Delivery Information Section (NEW) Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


715@nullFlavor 0..0 SHALL 1137-

719@root 1..1 SHALL 1137-

7162.16.840.1.113883.10.14.17


1137-717

27Oct2014

id 1..1 SHALL 1137-186

@root 1..1 SHALL 1137-187


1137-188

code 1..1 SHALL 1137-4 2.16.840.1.113883.6.1 (LOINC) = 57075-4

title 1..1 SHALL 1137-5text 1..1 SHALL 1137-6entry 1..* SHALL 1137-

693@typeCode 1..1 SHALL 1137-

695DRIV


Significant Birth Injury (identifier: urn:hl7ii:2.16.840.1.113883.10.14.85:27Oct2014



Admission to NICU (identifier: urn:hl7ii:2.16.840.1.113883.10.14.37:27Oct2014



Birth Outcome (identifier: urn:hl7ii:2.16.840.1.113883.10.14.45:27Oct2014

entry 0..1 SHOULD

1137-701


Rank of Birth (Birth Order / Set Order) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.83:27Oct2014

entry 0..1 SHOULD

1137-703


Place of Birth (type or birthing place) (identifier:


urn:hl7ii:2.16.840.1.113883.10.14.80:27Oct2014



observation 0..1 SHOULD

1137-706

Infant Living at Time of Report? (identifier: urn:hl7ii:2.16.840.1.113883.10.14.58:27Oct2014



Cause of Death (identifier: urn:hl7ii:2.16.840.1.113883.10.14.46:27Oct2014



1137-710

Location of Death (identifier: urn:hl7ii:2.16.840.1.113883.10.14.60:27Oct2014



1137-712

Date of Death (identifier: urn:hl7ii:2.16.840.1.113883.10.14.55:27Oct2014



Gestational age (identifier: urn:oid:2.16.840.1.113883.10.20.17.3.3



Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.18:27Oct2014



Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.19:27Oct2014



Physical Exam - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.21:27Oct2014

component 1..1 SHALL 1137-


858section 1..1 SHALL 1137-

859Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.24:27Oct2014

1. SHALL contain exactly one [1..1] templateId (CONF:1137-715) such that ita. SHALL contain [0..0] @nullFlavor (CONF:1137-719).b. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.14.17"

(CONF:1137-716).c. SHOULD contain zero or one [0..1] @extension="27Oct2014" (CONF:1137-717).

2. SHALL contain exactly one [1..1] id (CONF:1137-186).a. This id SHALL contain exactly one [1..1] @root (CONF:1137-187).b. This id SHOULD contain zero or one [0..1] @extension (CONF:1137-188).

3. SHALL contain exactly one [1..1] code="57075-4" NB delivery info NB (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:1137-4).


a. SHALL contain exactly one [1..1] @typeCode="DRIV" Is Derived From (CONF:1137-695).

b. SHALL contain exactly one [1..1] Significant Birth Injury (identifier: urn:hl7ii:2.16.840.1.113883.10.14.85:27Oct2014) (CONF:1137-694).

7. SHALL contain exactly one [1..1] entry (CONF:1137-697) such that ita. SHALL contain exactly one [1..1] Admission to NICU (identifier:


a. SHALL contain exactly one [1..1] Birth Outcome (identifier: urn:hl7ii:2.16.840.1.113883.10.14.45:27Oct2014) (CONF:1137-700).

9. SHOULD contain zero or one [0..1] entry (CONF:1137-701) such that ita. SHALL contain exactly one [1..1] Rank of Birth (Birth Order / Set Order)


10. SHOULD contain zero or one [0..1] entry (CONF:1137-703) such that ita. SHALL contain exactly one [1..1] Place of Birth (type or birthing place)


11. SHALL contain exactly one [1..1] entry (CONF:1137-705) such that ita. SHOULD contain zero or one [0..1] Infant Living at Time of Report?


12. SHALL contain exactly one [1..1] entry (CONF:1137-707) such that it


a. SHALL contain exactly one [1..1] Cause of Death (identifier: urn:hl7ii:2.16.840.1.113883.10.14.46:27Oct2014) (CONF:1137-708).

13. SHALL contain exactly one [1..1] entry (CONF:1137-709) such that ita. SHOULD contain zero or one [0..1] Location of Death (identifier:


a. SHOULD contain zero or one [0..1] Date of Death (identifier: urn:hl7ii:2.16.840.1.113883.10.14.55:27Oct2014) (CONF:1137-712).

15. SHALL contain exactly one [1..1] entry (CONF:1137-713) such that ita. SHALL contain exactly one [1..1] Gestational age (identifier:

urn:oid:2.16.840.1.113883.10.20.17.3.3) (CONF:1137-714).16. SHALL contain exactly one [1..1] component (CONF:1137-814) such that it

a. SHALL contain exactly one [1..1] Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.18:27Oct2014) (CONF:1137-815).

17. SHALL contain exactly one [1..1] component (CONF:1137-195) such that ita. SHALL contain exactly one [1..1] Problem Section (entries required) (V2) -

NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.19:27Oct2014) (CONF:1137-200).

18. SHALL contain exactly one [1..1] component (CONF:1137-836) such that ita. SHALL contain exactly one [1..1] Physical Exam - NB BD IG Specific

Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.21:27Oct2014) (CONF:1137-837).

19. SHALL contain exactly one [1..1] component (CONF:1137-858) such that ita. SHALL contain exactly one [1..1] Medications Section (entries required)

(V2) - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.24:27Oct2014) (CONF:1137-859).

2.16Payers Section - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.18 (open)]

Table 33: Payers Section Contexts


Coverage Activity

The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care.Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient’s pertinent current payment sources should be listed.


The sources of payment are represented as a Coverage Activity, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by preference. The Coverage Activity has a sequence number that represents the preference order. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded.

Table 34: Payers Section Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7924@root 1..1 SHALL 81-

104342.16.840.1.113883.10.20.22.2.18

code 1..1 SHALL 81-15395

@code 1..1 SHALL 81-15396

2.16.840.1.113883.6.1 (LOINC) = 48768-6


text 1..1 SHALL 81-7927

entry 0..* SHOULD

81-7959

act 1..1 SHALL 81-15501

Coverage Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.60



a. This code SHALL contain exactly one [1..1] @code="48768-6" Payers (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15396).


a. SHALL contain exactly one [1..1] Coverage Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.60) (CONF:81-15501).


2.17Physical Exam - LD BD IG Specific - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.26:27Oct2014 (open)]

Table 35: Physical Exam - LD BD IG Specific Contexts

Contained By: Contains:Labor and Delivery Events Section (NEW) (required) Vital Signs Section - LD BD IG Specific

Table 36: Physical Exam - LD BD IG Specific Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


860@root 1..1 SHALL 1137-

8612.16.840.1.113883.10.14.26


27Oct2014



Vital Signs Section - LD BD IG Specific (identifier: urn:hl7ii:2.16.840.1.113883.10.14.27:27Oct2014

1. Conforms to Physical Exam Section template (identifier: urn:oid:2.16.840.1.113883.10.20.2.10).



3. SHALL contain exactly one [1..1] component (CONF:1137-862) such that ita. SHALL contain exactly one [1..1] Vital Signs Section - LD BD IG Specific



2.18Physical Exam - NB BD IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.21:27Oct2014 (open)]

Table 37: Physical Exam - NB BD IG Specific Constraints (NEW) Contexts


General Status - NB BD IG Specific Constraints (NEW)Vital Signs Section - NB BD IG Specific Constraints (NEW)

Table 38: Physical Exam - NB BD IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


816@root 1..1 SHALL 1137-

8172.16.840.1.113883.10.14.21


27Oct2014



Vital Signs Section - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.22:27Oct2014



General Status - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.23:27Oct2014

1. Conforms to Physical Exam Section template (identifier: urn:oid:2.16.840.1.113883.10.20.2.10).



3. SHALL contain exactly one [1..1] component (CONF:1137-818) such that ita. SHALL contain exactly one [1..1] Vital Signs Section - NB BD IG Specific



4. SHALL contain exactly one [1..1] component (CONF:1137-828) such that ita. SHALL contain exactly one [1..1] General Status - NB BD IG Specific


2.19Physical Exam Section - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.2.10 (open)]

Table 39: Physical Exam Section Contexts

Contained By: Contains:Highest Pressure Ulcer StageNumber of Pressure Ulcers ObservationPressure Ulcer Observation

The Physical Exam section includes direct observations made by the clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient’s body. This section includes only observations made by the examining clinician using inspection, palpation, auscultation, and percussion; it does not include laboratory or imaging findings. The exam may be limited to pertinent body systems based on the patient’s chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically. The Physical Exam section may contain multiple nested subsections: Vital Signs, General Status, and those listed in the Additional Physical Examination Subsections appendix.


Table 40: Physical Exam Section Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.2.10)templateId 1..1 SHALL 81-

7806@root 1..1 SHALL UID 81-

104652.16.840.1.113883.10.20.2.10

code 1..1 SHALL 81-15397

@code 1..1 SHALL 81-15398

2.16.840.1.113883.6.1 (LOINC) = 29545-1


text 1..1 SHALL 81-7809

entry 0..* MAY 81-17094


Pressure Ulcer Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.70

entry 0..* MAY 81-17096


Number of Pressure Ulcers Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.76

entry 0..* MAY 81-17098


Highest Pressure Ulcer Stage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.77

1. SHALL contain exactly one [1..1] templateId (CONF:81-7806) such that ita. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.2.10"


a. This code SHALL contain exactly one [1..1] @code="29545-1" Physical Findings (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15398).


a. SHALL contain exactly one [1..1] Pressure Ulcer Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.70) (CONF:81-17095).


6. MAY contain zero or more [0..*] entry (CONF:81-17096) such that ita. SHALL contain exactly one [1..1] Number of Pressure Ulcers Observation

(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.76) (CONF:81-17097).7. MAY contain zero or more [0..*] entry (CONF:81-17098) such that it

a. SHALL contain exactly one [1..1] Highest Pressure Ulcer Stage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.77) (CONF:81-17099).

2.20Plan of Care Section - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.10 (open)]

Table 41: Plan of Care Section Contexts

Contained By: Contains:InstructionsPlan of Care Activity ActPlan of Care Activity EncounterPlan of Care Activity ObservationPlan of Care Activity ProcedurePlan of Care Activity Substance AdministrationPlan of Care Activity Supply

The Plan of Care section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only, which are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education will be provided.


Table 42: Plan of Care Section Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


7723@root 1..1 SHALL 81-

104352.16.840.1.113883.10.20.22.2.10

code 1..1 SHALL 81-14749

@code 1..1 SHALL 81-14750

2.16.840.1.113883.6.1 (LOINC) = 18776-5


text 1..1 SHALL 81-7725

entry 0..* MAY 81-7726


Plan of Care Activity Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.39

entry 0..* MAY 81-8805


Plan of Care Activity Encounter (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.40

entry 0..* MAY 81-8807


Plan of Care Activity Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.44

entry 0..* MAY 81-8809


Plan of Care Activity Procedure (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.41

entry 0..* MAY 81-8811


Plan of Care Activity Substance Administration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.42

entry 0..* MAY 81-8813


Plan of Care Activity Supply (identifier:


urn:oid:2.16.840.1.113883.10.20.22.4.43

entry 0..* MAY 81-14695

act 1..1 SHALL 81-16751

Instructions (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.20



a. This code SHALL contain exactly one [1..1] @code="18776-5" Plan of Care (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-14750).


a. SHALL contain exactly one [1..1] Plan of Care Activity Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.39) (CONF:81-14751).

6. MAY contain zero or more [0..*] entry (CONF:81-8805) such that ita. SHALL contain exactly one [1..1] Plan of Care Activity Encounter


a. SHALL contain exactly one [1..1] Plan of Care Activity Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.44) (CONF:81-14753).

8. MAY contain zero or more [0..*] entry (CONF:81-8809) such that ita. SHALL contain exactly one [1..1] Plan of Care Activity Procedure


a. SHALL contain exactly one [1..1] Plan of Care Activity Substance Administration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.42) (CONF:81-14755).

10. MAY contain zero or more [0..*] entry (CONF:81-8813) such that ita. SHALL contain exactly one [1..1] Plan of Care Activity Supply (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.43) (CONF:81-14756).11. MAY contain zero or more [0..*] entry (CONF:81-14695) such that it

a. SHALL contain exactly one [1..1] Instructions (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.20) (CONF:81-16751).


2.21Plan of Care Section - Birth Defects IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.12:27Oct2014 (open)]

Table 43: Plan of Care Section - Birth Defects IG Specific Constraints (NEW) Contexts


Plan of Care Activity Encounter - Birth Defects IG Specific Constraints

This template provides birth defects-specific information in addition to the C-CDA R2 template "Plan of Care Section". Conformance has been changed to “SHALL” for Plan of Care Encounter - Birth Defects IG Specific Constraints.

Table 44: Plan of Care Section - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


966@root 1..1 SHALL 1137-

9672.16.840.1.113883.10.14.12


encounter 1..1 SHALL 1137-969

Plan of Care Activity Encounter - Birth Defects IG Specific Constraints (identifier: urn:hl7ii:2.16.840.1.113883.10.14.13:27Oct2014

1. Conforms to Plan of Care Section template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.10).


(CONF:1137-967).3. SHALL contain at least one [1..*] entry (CONF:1137-968) such that it

a. SHALL contain exactly one [1..1] Plan of Care Activity Encounter - Birth Defects IG Specific Constraints (identifier: urn:hl7ii:2.16.840.1.113883.10.14.13:27Oct2014) (CONF:1137-969).


2.22Prior Pregnancy History Section (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.31:27Oct2014 (open)]

Table 45: Prior Pregnancy History Section (NEW) Contexts

Contained By: Contains:Mother's History and Physical Section (NEW) (optional)

Date of Last Live BirthEstimate of GestationMaternal Risk FactorsOther Pregnancy Outcome

The pregnancy history section contains entries describing the patient's prior pregnancy history.


Table 46: Prior Pregnancy History Section (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1377@root 1..1 SHALL 1137-

13782.16.840.1.113883.10.14.31


27Oct2014

code 1..1 SHALL 1137-1379

@code 1..1 SHALL 1137-1380

2.16.840.1.113883.6.1 (LOINC) = 57073-9


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Prenatal events

text 1..1 SHALL 1137-1384

entry 1..* SHALL 1137-1425


Maternal Risk Factors (identifier: urn:hl7ii:2.16.840.1.113883.10.14.67:27Oct2014

entry 0..1 SHOULD

1137-1427


Date of Last Live Birth (identifier: urn:hl7ii:2.16.840.1.113883.10.14.56:27Oct2014

entry 0..1 SHOULD

1137-1428


Estimate of Gestation (identifier: urn:hl7ii:2.16.840.1.113883.10.14.57:27Oct2014

entry 0..1 SHOULD

1137-1444


Other Pregnancy Outcome (identifier: urn:hl7ii:2.16.840.1.113883.10.14.79:27Oct2014


(CONF:1137-1378).


b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1462).2. SHALL contain exactly one [1..1] code (CONF:1137-1379) such that it

a. SHALL contain exactly one [1..1] @code="57073-9" to specify Prenatal events (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1380).

b. SHALL contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1381).

c. SHALL contain exactly one [1..1] @codeSystemName="LOINC" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1382).

d. SHALL contain exactly one [1..1] @displayName="Prenatal events" (CONF:1137-1383).

3. SHALL contain exactly one [1..1] text (CONF:1137-1384).4. SHALL contain at least one [1..*] entry (CONF:1137-1425) such that it

a. SHALL contain exactly one [1..1] Maternal Risk Factors (identifier: urn:hl7ii:2.16.840.1.113883.10.14.67:27Oct2014) (CONF:1137-1426).

5. SHOULD contain zero or one [0..1] entry (CONF:1137-1427) such that ita. SHALL contain exactly one [1..1] Date of Last Live Birth (identifier:

urn:hl7ii:2.16.840.1.113883.10.14.56:27Oct2014) (CONF:1137-1429).6. SHOULD contain zero or one [0..1] entry (CONF:1137-1428) such that it

a. SHALL contain exactly one [1..1] Estimate of Gestation (identifier: urn:hl7ii:2.16.840.1.113883.10.14.57:27Oct2014) (CONF:1137-1430).

7. SHOULD contain zero or one [0..1] entry (CONF:1137-1444) such that ita. SHALL contain exactly one [1..1] Other Pregnancy Outcome (identifier:

urn:hl7ii:2.16.840.1.113883.10.14.79:27Oct2014) (CONF:1137-1445).

2.23Problem Section (entries optional) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.5 (open)]

Table 47: Problem Section (entries optional) Contexts

Contained By: Contains:Problem Concern Act (Condition)

This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed.


Table 48: Problem Section (entries optional) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7877@root 1..1 SHALL 81-

104402.16.840.1.113883.10.20.22.2.5

code 1..1 SHALL 81-15407

@code 1..1 SHALL 81-15408

2.16.840.1.113883.6.1 (LOINC) = 11450-4


text 1..1 SHALL 81-7880

entry 0..* SHOULD

81-7881

act 1..1 SHALL 81-15505

Problem Concern Act (Condition) (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.3



a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem List (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15408).

3. SHALL contain exactly one [1..1] title (CONF:81-7879).4. SHALL contain exactly one [1..1] text (CONF:81-7880).5. SHOULD contain zero or more [0..*] entry (CONF:81-7881).

a. The entry, if present, SHALL contain exactly one [1..1] Problem Concern Act (Condition) (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.3) (CONF:81-15505).

2.24Problem Section (entries required) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.5.1 (open)]

Table 49: Problem Section (entries required) Contexts

Contained By: Contains:Problem Concern Act (Condition)


This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed.

Table 50: Problem Section (entries required) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


9179@root 1..1 SHALL 81-

104412.16.840.1.113883.10.20.22.2.5.1

code 1..1 SHALL 81-15409

@code 1..1 SHALL 81-15410

2.16.840.1.113883.6.1 (LOINC) = 11450-4


text 1..1 SHALL 81-9182


act 1..1 SHALL 81-15506

Problem Concern Act (Condition) (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.3

1. Conforms to Problem Section (entries optional) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.5).



a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem List (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15410).

4. SHALL contain exactly one [1..1] title (CONF:81-9181).5. SHALL contain exactly one [1..1] text (CONF:81-9182).6. SHALL contain at least one [1..*] entry (CONF:81-9183).

a. Such entries SHALL contain exactly one [1..1] Problem Concern Act (Condition) (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.3) (CONF:81-15506).


2.25Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.6:27Oct2014 (open)]

Table 51: Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) Contexts


Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW)

This template defines Birth Defect Report-specific constraints to C-CDA R2.0 Problem Section (entries required) (V2). This template defines Birth Defect Report-specific constraints to C-CDA R2.0 Problem Section (entries required) (V2). It requires a Problem Concern Act (V2) - Birth Defects IG Specific Constraints template to be used.The Problem Section captures the patient’s pre-existing and/or concurrent medical conditions, which influence treatment decisions and patient outcomes. Consideration of comorbid conditions is important when evaluating patient survival and other outcomes.

Table 52: Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


928@root 1..1 SHALL 1137-

9292.16.840.1.113883.10.14.6


act 1..1 SHALL 1137-931

Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.7:27Oct2014

1. Conforms to Problem Section (entries required) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.5.1).



a. SHALL contain exactly one [1..1] Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.7:27Oct2014) (CONF:1137-931).


2.26Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.19:27Oct2014 (open)]

Table 53: Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) Contexts


Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW)

Table 54: Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


758@root 1..1 SHALL 1137-

7592.16.840.1.113883.10.14.19


27Oct2014


act 1..1 SHALL 1137-761

Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.20:27Oct2014

1. Conforms to Problem Section (entries required) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.5.1).



3. SHALL contain at least one [1..*] entry (CONF:1137-760) such that ita. SHALL contain exactly one [1..1] Problem Concern Act (V2) - NB BD IG

Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.20:27Oct2014) (CONF:1137-761).


2.27Procedures Section - LD BD IG Specific - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.28:27Oct2014 (open)]

Table 55: Procedures Section - LD BD IG Specific Contexts

Contained By: Contains:Labor and Delivery Events Section (NEW) (required) Characteristics of Labor and Delivery: [Epidural or

Spinal] Anesthesia [during labor]Characteristics of Labor and Delivery: Augmentation of LaborCharacteristics of labor and delivery: Induction of laborMaternal Morbidity: Maternal TransfusionMaternal Morbidity: Unplanned HysterectomyMaternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery]Method of Delivery: [Final] Route and Method of DeliveryMethod of Delivery: Trial of Labor AttemptedObstetric Procedures: Cervical CerclageObstetric Procedures: Tocolysis


Table 56: Procedures Section - LD BD IG Specific Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


993@root 1..1 SHALL 1137-

9942.16.840.1.113883.10.14.28


27Oct2014

entry 0..1 SHOULD

1137-995

procedure 1..1 SHALL 1137-996

Maternal Morbidity: Unplanned Hysterectomy (identifier: urn:hl7ii:2.16.840.1.113883.10.14.65:27Oct2014

entry 0..1 SHOULD

1137-1100


Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.66:27Oct2014

entry 0..1 SHOULD

1137-1101


Maternal Morbidity: Maternal Transfusion (identifier: urn:hl7ii:2.16.840.1.113883.10.14.63:27Oct2014

entry 0..1 SHOULD

1137-1104


Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.47:27Oct2014

entry 0..1 SHOULD

1137-1106


Characteristics of labor and delivery: Induction of labor (identifier: urn:hl7ii:2.16.840.1.113883.10.14.52:27Oct2014

entry 0..1 SHOULD

1137-1108


Characteristics of Labor and Delivery: Augmentation of Labor (identifier: urn:hl7ii:2.16.840.1.113883.10.14.50:27Oct2014


entry 0..1 SHOULD

1137-1110


Obstetric Procedures: Cervical Cerclage (identifier: urn:hl7ii:2.16.840.1.113883.10.14.74:27Oct2014

entry 0..1 SHOULD

1137-1111


Obstetric Procedures: Tocolysis (identifier: urn:hl7ii:2.16.840.1.113883.10.14.75:27Oct2014

entry 0..1 SHOULD

1137-1114


Method of Delivery: [Final] Route and Method of Delivery (identifier: urn:hl7ii:2.16.840.1.113883.10.14.68:27Oct2014

entry 0..1 SHOULD

1137-1116


Method of Delivery: Trial of Labor Attempted (identifier: urn:hl7ii:2.16.840.1.113883.10.14.70:27Oct2014

1. Conforms to Procedures Section (entries required) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.7.1).



3. SHOULD contain zero or one [0..1] entry (CONF:1137-995) such that ita. SHALL contain exactly one [1..1] Maternal Morbidity: Unplanned

Hysterectomy (identifier: urn:hl7ii:2.16.840.1.113883.10.14.65:27Oct2014) (CONF:1137-996).

4. SHOULD contain zero or one [0..1] entry (CONF:1137-1100) such that ita. SHALL contain exactly one [1..1] Maternal Morbidity: Unplanned

Operat[ing]ion [room procedure following delivery] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.66:27Oct2014) (CONF:1137-1102).

5. SHOULD contain zero or one [0..1] entry (CONF:1137-1101) such that ita. SHALL contain exactly one [1..1] Maternal Morbidity: Maternal Transfusion


6. SHOULD contain zero or one [0..1] entry (CONF:1137-1104) such that it


a. SHALL contain exactly one [1..1] Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.47:27Oct2014) (CONF:1137-1105).

7. SHOULD contain zero or one [0..1] entry (CONF:1137-1106) such that ita. SHALL contain exactly one [1..1] Characteristics of labor and delivery:

Induction of labor (identifier: urn:hl7ii:2.16.840.1.113883.10.14.52:27Oct2014) (CONF:1137-1107).


Augmentation of Labor (identifier: urn:hl7ii:2.16.840.1.113883.10.14.50:27Oct2014) (CONF:1137-1109).

9. SHOULD contain zero or one [0..1] entry (CONF:1137-1110) such that ita. SHALL contain exactly one [1..1] Obstetric Procedures: Cervical Cerclage


10. SHOULD contain zero or one [0..1] entry (CONF:1137-1111) such that ita. SHALL contain exactly one [1..1] Obstetric Procedures: Tocolysis


11. SHOULD contain zero or one [0..1] entry (CONF:1137-1114) such that ita. SHALL contain exactly one [1..1] Method of Delivery: [Final] Route and

Method of Delivery (identifier: urn:hl7ii:2.16.840.1.113883.10.14.68:27Oct2014) (CONF:1137-1115).

12. SHOULD contain zero or one [0..1] entry (CONF:1137-1116) such that ita. SHALL contain exactly one [1..1] Method of Delivery: Trial of Labor

Attempted (identifier: urn:hl7ii:2.16.840.1.113883.10.14.70:27Oct2014) (CONF:1137-1117).

2.28Procedures Section (entries optional) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.7 (open)]

Table 57: Procedures Section (entries optional) Contexts

Contained By: Contains:Procedure Activity ActProcedure Activity ObservationProcedure Activity Procedure

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section is intended to include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for


procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change).The length of an encounter is documented in the documentationOf/encompassingEncounter/effectiveTime and length of service in documentationOf/ServiceEvent/effectiveTime.

Table 58: Procedures Section (entries optional) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


6270@root 1..1 SHALL 81-

62712.16.840.1.113883.10.20.22.2.7

code 1..1 SHALL 81-15423

@code 1..1 SHALL 81-15424

2.16.840.1.113883.6.1 (LOINC) = 47519-4


text 1..1 SHALL 81-6273

entry 0..* MAY 81-6274


Procedure Activity Procedure (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.14

entry 0..1 MAY 81-6278


Procedure Activity Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.13

entry 0..1 MAY 81-8533

act 1..1 SHALL 81-15511

Procedure Activity Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.12



a. This code SHALL contain exactly one [1..1] @code="47519-4" History of Procedures (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15424).



a. SHALL contain exactly one [1..1] Procedure Activity Procedure (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.14) (CONF:81-15509).

6. MAY contain zero or one [0..1] entry (CONF:81-6278) such that ita. SHALL contain exactly one [1..1] Procedure Activity Observation

(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.13) (CONF:81-15510).7. MAY contain zero or one [0..1] entry (CONF:81-8533) such that it

a. SHALL contain exactly one [1..1] Procedure Activity Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.12) (CONF:81-15511).

2.29Procedures Section (entries required) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.7.1 (open)]

Table 59: Procedures Section (entries required) Contexts

Contained By: Contains:Procedure Activity ActProcedure Activity ObservationProcedure Activity Procedure

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section may contain all procedures for the period of time being summarized, but should include notable procedures. The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change).


Table 60: Procedures Section (entries required) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7891@root 1..1 SHALL 81-

104472.16.840.1.113883.10.20.22.2.7.1

code 1..1 SHALL 81-15425

@code 1..1 SHALL 81-15426

2.16.840.1.113883.6.1 (LOINC) = 47519-4


text 1..1 SHALL 81-7894

entry 0..* MAY 81-7895



entry 0..* MAY 81-8017


Procedure Activity Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.13

entry 0..* MAY 81-8019

act 1..1 SHALL 81-15514

Procedure Activity Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.12

1. Conforms to Procedures Section (entries optional) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.7).



a. This code SHALL contain exactly one [1..1] @code="47519-4" History of Procedures (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15426).



a. SHALL contain exactly one [1..1] Procedure Activity Procedure (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.14) (CONF:81-15512).

7. MAY contain zero or more [0..*] entry (CONF:81-8017) such that ita. SHALL contain exactly one [1..1] Procedure Activity Observation


a. SHALL contain exactly one [1..1] Procedure Activity Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.12) (CONF:81-15514).

9. There SHALL be at least one procedure, observation or act entry conformant to Procedure Activity Procedure template, Procedure Activity Observation template or Procedure Activity Act template in the Procedure Section (CONF:81-8021).

2.30Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.9:27Oct2014 (open)]

Table 61: Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) Contexts


Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW)

This template provides birth defects-specific information in addition to the C-CDA R2 template "Procedures Section (entries required) (V2)". It requires a Procedure Activity Procedure (V2) - Birth Defects IG Specific Constraints template to be used.The Procedures Section contains information about interventional, surgical, diagnostic, or treatments. This information is used to evaluate Birth defect treatment and outcomes and access to care.

Table 62: Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


950@root 1..1 SHALL 1137-

9522.16.840.1.113883.10.14.9



Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.10:27Oct2014





a. SHALL contain exactly one [1..1] Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) (identifier: urn:hl7ii:2.16.840.1.113883.10.14.10:27Oct2014) (CONF:1137-953).

2.31Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.18:27Oct2014 (open)]

Table 63: Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) Contexts


Antibiotic Administration ProcedureAssisted Ventilation [required immediately following delivery]Assisted Ventilation for 6 or more hoursKaryotype Determination

This template provides newborn-specific information in addition to the C-CDA R2 template "Procedures Section (entries required) (V2)".


Table 64: Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


772@root 1..1 SHALL 1137-

7732.16.840.1.113883.10.14.18


27Oct2014

entry 0..1 SHOULD

1137-774


Antibiotic Administration Procedure (identifier: urn:hl7ii:2.16.840.1.113883.10.14.39:27Oct2014



Karyotype Determination (identifier: urn:hl7ii:2.16.840.1.113883.10.14.59:27Oct2014



Assisted Ventilation [required immediately following delivery] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.42:27Oct2014



Assisted Ventilation for 6 or more hours (identifier: urn:hl7ii:2.16.840.1.113883.10.14.43:27Oct2014




3. SHOULD contain zero or one [0..1] entry (CONF:1137-774) such that ita. SHALL contain exactly one [1..1] Antibiotic Administration Procedure



4. SHALL contain exactly one [1..1] entry (CONF:1137-788) such that ita. SHALL contain exactly one [1..1] Karyotype Determination (identifier:


a. SHALL contain exactly one [1..1] Assisted Ventilation [required immediately following delivery] (identifier: urn:hl7ii:2.16.840.1.113883.10.14.42:27Oct2014) (CONF:1137-791).

6. SHALL contain exactly one [1..1] entry (CONF:1137-792) such that ita. SHALL contain exactly one [1..1] Assisted Ventilation for 6 or more hours


2.32Results Section (entries optional) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.3 (open)]

Table 65: Results Section (entries optional) Contexts

Contained By: Contains:Result Organizer

The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented.Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.


Table 66: Results Section (entries optional) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7116@root 1..1 SHALL 81-

91362.16.840.1.113883.10.20.22.2.3

code 1..1 SHALL 81-15431

@code 1..1 SHALL 81-15432

2.16.840.1.113883.6.1 (LOINC) = 30954-2


text 1..1 SHALL 81-7118

entry 0..* SHOULD

81-7119


Result Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.1



a. This code SHALL contain exactly one [1..1] @code="30954-2" Relevant diagnostic tests and/or laboratory data (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15432).


a. SHALL contain exactly one [1..1] Result Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.1) (CONF:81-15515).

2.33Results Section (entries required) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.3.1 (open)]

Table 67: Results Section (entries required) Contexts


Result Organizer


The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented.Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.

Table 68: Results Section (entries required) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7108@root 1..1 SHALL 81-

91372.16.840.1.113883.10.20.22.2.3.1

code 1..1 SHALL 81-15433

@code 1..1 SHALL 81-15434

2.16.840.1.113883.6.1 (LOINC) = 30954-2


text 1..1 SHALL 81-7111



Result Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.1

1. Conforms to Results Section (entries optional) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.3).




a. This code SHALL contain exactly one [1..1] @code="30954-2" Relevant diagnostic tests and/or laboratory data (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15434).


a. SHALL contain exactly one [1..1] Result Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.1) (CONF:81-15516).

2.34Social History Section - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.17 (open)]

Table 69: Social History Section Contexts

Contained By: Contains:Pregnancy ObservationSmoking Status ObservationSocial History ObservationTobacco Use

This section contains data defining the patient’s occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation. Social history can have significant influence on a patient’s physical, psychological and emotional health and wellbeing so should be considered in the development of a complete record.


Table 70: Social History Section Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7936@root 1..1 SHALL 81-

104492.16.840.1.113883.10.20.22.2.17

code 1..1 SHALL 81-14819

@code 1..1 SHALL 81-14820

2.16.840.1.113883.6.1 (LOINC) = 29762-2


text 1..1 SHALL 81-7939

entry 0..* MAY 81-7953


Social History Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.38

entry 0..* MAY 81-9132


Pregnancy Observation (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.8

entry 0..* SHOULD

81-14823


Smoking Status Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.78

entry 0..* MAY 81-16816


Tobacco Use (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.85



a. This code SHALL contain exactly one [1..1] @code="29762-2" Social History (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-14820).

3. SHALL contain exactly one [1..1] title (CONF:81-7938).


4. SHALL contain exactly one [1..1] text (CONF:81-7939).5. MAY contain zero or more [0..*] entry (CONF:81-7953) such that it

a. SHALL contain exactly one [1..1] Social History Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.38) (CONF:81-14821).

6. MAY contain zero or more [0..*] entry (CONF:81-9132) such that ita. SHALL contain exactly one [1..1] Pregnancy Observation (identifier:

urn:oid:2.16.840.1.113883.10.20.15.3.8) (CONF:81-14822).7. SHOULD contain zero or more [0..*] entry (CONF:81-14823) such that it

a. SHALL contain exactly one [1..1] Smoking Status Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.78) (CONF:81-14824).

8. MAY contain zero or more [0..*] entry (CONF:81-16816) such that ita. SHALL contain exactly one [1..1] Tobacco Use (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.85) (CONF:81-16817).

2.35Vital Signs Section - LD BD IG Specific - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.27:27Oct2014 (open)]

Table 71: Vital Signs Section - LD BD IG Specific Contexts

Contained By: Contains:Physical Exam - LD BD IG Specific (required) Mother's Weight at Delivery

Table 72: Vital Signs Section - LD BD IG Specific Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


864@root 1..1 SHALL 1137-

8652.16.840.1.113883.10.14.27


27Oct2014

entry 0..1 SHOULD

1137-866


Mother's Weight at Delivery (identifier: urn:hl7ii:2.16.840.1.113883.10.14.71:27Oct2014

1. Conforms to Vital Signs Section (entries required) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.4.1).


(CONF:1137-865).


b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1458).3. SHOULD contain zero or one [0..1] entry (CONF:1137-866) such that it

a. SHALL contain exactly one [1..1] Mother's Weight at Delivery (identifier: urn:hl7ii:2.16.840.1.113883.10.14.71:27Oct2014) (CONF:1137-867).

2.36Vital Signs Section - NB BD IG Specific Constraints (NEW) - Draft[section: identifier urn:hl7ii:2.16.840.1.113883.10.14.22:27Oct2014 (open)]

Table 73: Vital Signs Section - NB BD IG Specific Constraints (NEW) Contexts

Contained By: Contains:Physical Exam - NB BD IG Specific Constraints (NEW) (required)

Birth head circumferenceBirth heightBirth weight

Table 74: Vital Signs Section - NB BD IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


820@root 1..1 SHALL 1137-

8212.16.840.1.113883.10.14.22


27Oct2014



Birth weight (identifier: urn:oid:2.16.840.1.113883.10.20.17.3.1



Birth head circumference (identifier: urn:oid:2.16.840.1.113883.10.20.17.3.2



Birth height (identifier: urn:hl7ii:2.16.840.1.113883.10.14.44:27Oct2014

1. Conforms to Vital Signs Section (entries required) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.4.1).

2. SHALL contain exactly one [1..1] templateId (CONF:1137-820) such that it


a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.14.22" (CONF:1137-821).

b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1453).3. SHALL contain exactly one [1..1] entry (CONF:1137-822) such that it

a. SHALL contain exactly one [1..1] Birth weight (identifier: urn:oid:2.16.840.1.113883.10.20.17.3.1) (CONF:1137-823).

4. SHALL contain exactly one [1..1] entry (CONF:1137-824) such that ita. SHALL contain exactly one [1..1] Birth head circumference (identifier:

urn:oid:2.16.840.1.113883.10.20.17.3.2) (CONF:1137-826).5. SHALL contain exactly one [1..1] entry (CONF:1137-825) such that it

a. SHALL contain exactly one [1..1] Birth height (identifier: urn:hl7ii:2.16.840.1.113883.10.14.44:27Oct2014) (CONF:1137-827).

2.37Vital Signs Section (entries optional) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.4 (open)]

Table 75: Vital Signs Section (entries optional) Contexts

Contained By: Contains:Vital Signs Organizer

The Vital Signs section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, and pulse oximetry. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends.Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.


Table 76: Vital Signs Section (entries optional) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7268@root 1..1 SHALL 81-

104512.16.840.1.113883.10.20.22.2.4

code 1..1 SHALL 81-15242

@code 1..1 SHALL 81-15243

2.16.840.1.113883.6.1 (LOINC) = 8716-3


text 1..1 SHALL 81-7270

entry 0..* SHOULD

81-7271


Vital Signs Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.26



a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15243).


a. SHALL contain exactly one [1..1] Vital Signs Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.26) (CONF:81-15517).

2.38Vital Signs Section (entries required) - Published[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.4.1 (open)]

Table 77: Vital Signs Section (entries required) Contexts


Vital Signs Organizer

The Vital Signs section contains current and historically relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight,


body mass index, head circumference, and pulse oximetry. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends.Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.

Table 78: Vital Signs Section (entries required) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7273@root 1..1 SHALL 81-

104522.16.840.1.113883.10.20.22.2.4.1

code 1..1 SHALL 81-15962

@code 1..1 SHALL 81-15963

2.16.840.1.113883.6.1 (LOINC) = 8716-3


text 1..1 SHALL 81-7275



Vital Signs Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.26

1. Conforms to Vital Signs Section (entries optional) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.4).



a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-15963).


a. SHALL contain exactly one [1..1] Vital Signs Organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.26) (CONF:81-15964).


3 ENTRIES

3.1 Admission to NICU - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.37:27Oct2014 (open)]

Table 79: Admission to NICU Contexts



Table 80: Admission to NICU Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.14.37:27Oct2014)@classCode 1..1 SHALL 1137-

5582.16.840.1.113883.5.6 (HL7ActClass) = OBS

@moodCode 1..1 SHALL 1137-559

2.16.840.1.113883.5.1001 (ActMood) = EVN

@negationInd 0..1 MAY 1137-560


@root 1..1 SHALL 1137-562

2.16.840.1.113883.10.14.37


27Oct2014

id 1..* SHALL 1137-563

@root 1..1 SHALL 1137-976

code 1..1 SHALL 1137-565

@code 1..1 SHALL 1137-566

2.16.840.1.113883.6.96 (SNOMED CT) = 405269005


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96


2.16.840.1.113883.6.96 (SNOMED CT) = SNOMED CT


NICU admission

text 1..1 SHALL 1137-564


@code 1..1 SHALL 1137-571

2.16.840.1.113883.5.14 (ActStatus) = completed


value 1..1 SHALL BL 1137-572

@nullFlavor 0..1 SHOULD

1137-1360

2.16.840.1.113883.11.20.10.17 (NullValues_UNK_NI_NA)

@value 1..1 SHALL 1137-977


1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-558).

2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:1137-559).

3. MAY contain zero or one [0..1] @negationInd (CONF:1137-560).4. SHALL contain exactly one [1..1] templateId (CONF:1137-561) such that it


b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1467).5. SHALL contain at least one [1..*] id (CONF:1137-563) such that it

a. SHALL contain exactly one [1..1] @root (CONF:1137-976).6. SHALL contain exactly one [1..1] code (CONF:1137-565).

a. This code SHALL contain exactly one [1..1] @code="405269005" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-566).

b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-567).

c. This code SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-568).

d. This code SHALL contain exactly one [1..1] @displayName="NICU admission" (CONF:1137-569).

7. SHALL contain exactly one [1..1] text (CONF:1137-564).8. SHALL contain exactly one [1..1] statusCode (CONF:1137-570).

a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-571).

9. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-573).10. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1137-572) such that

ita. SHOULD contain zero or one [0..1] @nullFlavor, which SHALL be selected from

ValueSet NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17 (CONF:1137-1360).

b. SHALL contain exactly one [1..1] @value (CONF:1137-977).

3.2 Age Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.31 (open)]

Table 81: Age Observation Contexts

Contained By: Contains:Problem Observation (optional)Family History Observation (optional)

This Age Observation represents the subject's age at onset of an event or observation. The age of a relative in a Family History Observation at the time of that observation could also be inferred by comparing RelatedSubject/subject/birthTime with Observation/effectiveTime. However, a common


scenario is that a patient will know the age of a relative when the relative had a certain condition or when the relative died, but will not know the actual year (e.g., "grandpa died of a heart attack at the age of 50"). Often times, neither precise dates nor ages are known (e.g., "cousin died of congenital heart disease as an infant").

Table 82: Age Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.31)@classCode 1..1 SHALL 81-

76132.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10487

2.16.840.1.113883.10.20.22.4.31

code 1..1 SHALL 81-7615

@code 1..1 SHALL 81-16776

445518008


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96


@code 1..1 SHALL 81-15966


value 1..1 SHALL PQ 81-7617

@unit 1..1 SHALL CS 81-7618

2.16.840.1.113883.11.20.9.21 (AgePQ_UCUM)

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-7613).

2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:81-7614).



a. This code SHALL contain exactly one [1..1] @code="445518008" Age At Onset (CONF:81-16776).



5. SHALL contain exactly one [1..1] statusCode (CONF:81-15965).a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed

(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-15966).6. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:81-7617).

a. This value SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet AgePQ_UCUM 2.16.840.1.113883.11.20.9.21 DYNAMIC (CONF:81-7618).

Figure 5: Age Observation Example

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.31" />  <code code="445518008" codeSystem="2.16.840.1.113883.6.96" displayName="Age At Onset" /> <statusCode code="completed" /> <value xsi:type="PQ" value="57" unit="a" /></observation>

3.3 Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.38:27Oct2014 (open)]

Table 83: Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period Contexts

Contained By: Contains:Mothers Social History Section (NEW) (optional)


Table 84: Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


13542.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1342

2.16.840.1.113883.10.14.38


27Oct2014

code 1..1 SHALL 1137-1343

@code 1..1 SHALL 1137-1344

137952002


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96






@code 1..1 SHALL 1137-1350



value 1..1 SHALL INT 1137-1349



@value 1..1 SHALL INT 1137-1352

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-1354).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:1137-1355).




b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1468).4. SHALL contain exactly one [1..1] code (CONF:1137-1343) such that it

a. SHALL contain exactly one [1..1] @code="137952002" for Alcohol intake (CONF:1137-1344).

b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1345).

c. SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1346).

d. SHALL contain exactly one [1..1] @displayName="Alcohol Intake (glasses/week) Alcohol intake within the pregnancy period" (CONF:1137-1347).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1350).6. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1351).7. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1137-1349).

a. This value SHALL contain zero or one [0..1] @nullFlavor, which SHALL be selected from ValueSet NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17 (CONF:1137-1361).

b. This value SHALL contain exactly one [1..1] @value (CONF:1137-1352).

3.4 Antibiotic Administration Procedure - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.39:27Oct2014 (open)]

Table 85: Antibiotic Administration Procedure Contexts

Contained By: Contains:Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (optional)

Indication - BxDefects IG Specific Constraint


Table 86: Antibiotic Administration Procedure Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

procedure (identifier: urn:hl7ii:2.16.840.1.113883.10.14.39:27Oct2014)@classCode 1..1 SHALL 1137-

2782.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-281

2.16.840.1.113883.10.14.39


27Oct2014

code 1..1 SHALL 1137-284


1137-422


@code 0..1 SHOULD

1137-289

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.178 (Antibiotic Administration Procedure)


2.16.840.1.113883.6.96

originalText 0..1 SHOULD

1137-285

reference 0..1 SHOULD

1137-286

@value 0..1 SHOULD

1137-287


entryRelationship 1..1 SHALL 1137-795


2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSON


Indication - BxDefects IG Specific Constraint (identifier: urn:hl7ii:2.16.840.1.113883.10.14.11:27Oct2014

1. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:1137-278).





b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1469).4. SHALL contain exactly one [1..1] code (CONF:1137-284).

a. This code SHOULD contain zero or one [0..1] @nullFlavor (ValueSet: NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17) (CONF:1137-422).

b. This code SHOULD contain zero or one [0..1] @code (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 DYNAMIC) (ValueSet: Antibiotic Administration Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.178 DYNAMIC) (CONF:1137-289).

c. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CONF:1137-290).

d. This code SHOULD contain zero or one [0..1] originalText (CONF:1137-285).i. The originalText, if present, SHOULD contain zero or one [0..1] reference

(CONF:1137-286).1. The reference, if present, SHOULD contain zero or one [0..1] @value

(CONF:1137-287).a. This reference/@value SHALL begin with a '#' and SHALL

point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1137-288).

5. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-794).6. SHALL contain exactly one [1..1] entryRelationship (CONF:1137-795) such that it

a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-796).

b. SHALL contain exactly one [1..1] Indication - BxDefects IG Specific Constraint (identifier: urn:hl7ii:2.16.840.1.113883.10.14.11:27Oct2014) (CONF:1137-797).

3.5 Antibiotics - Draft[substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.14.40:27Oct2014 (open)]

Table 87: Antibiotics Contexts

Contained By: Contains:Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (required)



Table 88: Antibiotics Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.14.40:27Oct2014)templateId 1..1 SHALL 1137-

455@root 1..1 SHALL 1137-

4562.16.840.1.113883.10.14.40

@extension 0..1 MAY 1137-1470

27Oct2014

code 1..1 SHALL 1137-457

@code 0..1 SHOULD

1137-458

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 (Antibiotics)


2.16.840.1.113883.6.88 (RxNorm) = 2.16.840.1.113883.6.88


2.16.840.1.113883.6.88 (RxNorm) = RxNorm


1137-460

reference 1..1 SHALL 1137-461

routeCode 0..1 SHOULD

1137-462

@code 0..1 SHOULD

1137-463









1. Conforms to Medication Activity template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.16).




b. MAY contain zero or one [0..1] @extension="27Oct2014" (CONF:1137-1470).3. SHALL contain exactly one [1..1] code (CONF:1137-457).

a. This code SHOULD contain zero or one [0..1] @code (ValueSet: Antibiotics 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 DYNAMIC) (CONF:1137-458).

b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.88" (CodeSystem: RxNorm 2.16.840.1.113883.6.88 STATIC) (CONF:1137-459).

c. This code SHALL contain exactly one [1..1] @codeSystemName="RxNorm" (CodeSystem: RxNorm 2.16.840.1.113883.6.88) (CONF:1137-469).

d. This code SHOULD contain zero or one [0..1] originalText (CONF:1137-460).i. The originalText, if present, SHALL contain exactly one [1..1] reference

(CONF:1137-461).4. SHOULD contain zero or one [0..1] routeCode (CONF:1137-462).

a. The routeCode, if present, SHOULD contain zero or one [0..1] @code (CONF:1137-463).

i. A. IV Medication Administration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 orb. Intramuscular Administration Route 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 (CONF:1137-464).

b. The routeCode, if present, SHALL contain exactly one [1..1] @codeSystem (CONF:1137-465).

i. A. IV Medication Administration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 orb. Intramuscular Administration Route 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 (CONF:1137-466).

c. The routeCode, if present, SHALL contain exactly one [1..1] @displayName (CONF:1137-467).

i. A. IV Medication Administration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 or b. Intramuscular Administration Route 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 (CONF:1137-468).

5. SHALL contain exactly one [1..1] entryRelationship (CONF:1137-491) such that ita. SHALL contain exactly one [1..1] @typeCode="RSON" Reason (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-492).b. SHALL contain exactly one [1..1] Indication - BxDefects IG Specific

Constraint (identifier: urn:hl7ii:2.16.840.1.113883.10.14.11:27Oct2014) (CONF:1137-493).

i. This observation SHALL contain [0..0] @nullFlavor (CONF:1137-494).


3.6 Apgar at 10 minute - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.41:27Oct2014 (open)]

Table 89: Apgar at 10 minute Contexts

Contained By: Contains:General Status - NB BD IG Specific Constraints (NEW) (required)

Table 90: Apgar at 10 minute Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


2512.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1472

2.16.840.1.113883.10.14.41


27Oct2014

code 1..1 SHALL 1137-411


1137-413


@code 0..1 SHOULD

1137-412

bxdefects_OID (Apgar 10 minutes post birth)


@code 1..1 SHALL 1137-257





1137-1362


@value 1..1 SHALL 1137-978






4. SHALL contain exactly one [1..1] code (CONF:1137-411).a. This code SHOULD contain zero or one [0..1] @nullFlavor (ValueSet:

NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17 DYNAMIC) (CONF:1137-413).

b. This code SHOULD contain zero or one [0..1] @code (ValueSet: Apgar 10 minutes post birth bxdefects_OID DYNAMIC) (CONF:1137-412).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-257).6. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-258).7. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1137-259) such that



b. SHALL contain exactly one [1..1] @value (CONF:1137-978).

3.7 Apgar at 5 minutes - Draft[observation: identifier urn:oid:2.16.840.1.113883.10.20.17.3.5 (open)]

Table 91: Apgar at 5 minutes Contexts

Contained By: Contains:General Status - NB BD IG Specific Constraints (NEW) (required)

This observation represents the apgar score assigned to a neonate at 5 minutes after birth.


Table 92: Apgar at 5 minutes Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.17.3.5)@classCode 1..1 SHALL CD 23-

32492.16.840.1.113883.5.6 (HL7ActClass) = OBS

@moodCode 1..1 SHALL CD 23-3250

2.16.840.1.113883.5.1001 (ActMood) = EVN

code 1..1 SHALL CD 23-3251

2.16.840.1.113883.11.20.5.17 (Apgar 5 minutes post birth)

statusCode 1..1 SHALL CS 23-3252


effectiveTime 0..1 MAY 23-3254


1. Conforms to CCD Result observation template (identifier: urn:oid:2.16.840.1.113883.10.20.1.31).



4. SHALL contain exactly one [1..1] code with @xsi:type="CD", where the code SHALL be selected from ValueSet Apgar 5 minutes post birth 2.16.840.1.113883.11.20.5.17 DYNAMIC (CONF:23-3251).

5. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:23-3252).

6. MAY contain zero or one [0..1] effectiveTime (CONF:23-3254).7. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:23-3253).

3.8 Assisted Ventilation [required immediately following delivery] - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.42:27Oct2014 (open)]

Table 93: Assisted Ventilation [required immediately following delivery] Contexts

Contained By: Contains:Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (required)



Table 94: Assisted Ventilation [required immediately following delivery] Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


4292.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-432

2.16.840.1.113883.10.14.42


27Oct2014

id 1..* SHALL 1137-434

@root 1..1 SHALL 1137-801

code 1..1 SHALL 1137-435


1137-436


@code 0..1 SHOULD

1137-437

2.16.840.1.114222.4.11.7144 (Assisted Ventilation Minutes After Birth (NCHS))


2.16.840.1.114222.4.5.274 (PHIN VADS code system) = 2.16.840.1.114222.4.5.274


2.16.840.1.114222.4.5.274 (PHIN VADS code system) = PHIN VS


2.16.840.1.114222.4.11.7144 (Assisted Ventilation Minutes After Birth (NCHS))


1137-438


@code 1..1 SHALL 1137-440




1137-442


entryRelationship 1..* SHALL 1137-802






1. Conforms to Procedure Activity Procedure template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.14).

2. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-429).





6. SHALL contain exactly one [1..1] code (CONF:1137-435).a. This code SHOULD contain zero or one [0..1] @nullFlavor (ValueSet:

NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17) (CONF:1137-436).b. This code SHOULD contain zero or one [0..1] @code (ValueSet: Assisted

Ventilation Minutes After Birth (NCHS) 2.16.840.1.114222.4.11.7144) (CONF:1137-437).

c. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.114222.4.5.274" (CodeSystem: PHIN VADS code system 2.16.840.1.114222.4.5.274) (CONF:1137-531).

d. This code SHALL contain exactly one [1..1] @codeSystemName="PHIN VS" (CodeSystem: PHIN VADS code system 2.16.840.1.114222.4.5.274) (CONF:1137-532).

e. This code SHALL contain exactly one [1..1] @displayName (ValueSet: Assisted Ventilation Minutes After Birth (NCHS) 2.16.840.1.114222.4.11.7144) (CONF:1137-533).

f. This code SHOULD contain zero or one [0..1] originalText (CONF:1137-438).7. SHALL contain exactly one [1..1] statusCode (CONF:1137-439).


8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-441).a. This effectiveTime SHOULD contain zero or one [0..1] @nullFlavor (ValueSet:

NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17) (CONF:1137-442).9. SHALL contain at least one [1..*] entryRelationship (CONF:1137-802) such that it




3.9 Assisted Ventilation for 6 or more hours - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.43:27Oct2014 (open)]

Table 95: Assisted Ventilation for 6 or more hours Contexts




Table 96: Assisted Ventilation for 6 or more hours Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


4432.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-446

2.16.840.1.113883.10.14.43


27Oct2014

id 1..* SHALL 1137-448

@root 1..1 SHALL 1137-807

code 0..1 SHOULD

1137-449


1137-1363


@code 1..1 SHALL 1137-450

2.16.840.1.114222.4.11.7145 (Assisted Ventilation More Than Six Hours (NCHS))


2.16.840.1.114222.4.5.274 (PHIN VADS code system) = 2.16.840.1.114222.4.5.274


2.16.840.1.114222.4.5.274 (PHIN VADS code system) = PHIN VS


2.16.840.1.114222.4.11.7145 (Assisted Ventilation More Than Six Hours (NCHS))


1137-451


@code 1..1 SHALL 1137-808







Indication - BxDefects IG Specific Constraint (identifier:


urn:hl7ii:2.16.840.1.113883.10.14.11:27Oct2014







6. SHOULD contain zero or one [0..1] code (CONF:1137-449).a. The code, if present, SHOULD contain zero or one [0..1] @nullFlavor, which SHALL

be selected from ValueSet NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17 (CONF:1137-1363).

b. The code, if present, SHALL contain exactly one [1..1] @code (ValueSet: Assisted Ventilation More Than Six Hours (NCHS) 2.16.840.1.114222.4.11.7145) (CONF:1137-450).

c. The code, if present, SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.114222.4.5.274" (CodeSystem: PHIN VADS code system 2.16.840.1.114222.4.5.274 STATIC) (CONF:1137-534).

d. The code, if present, SHALL contain exactly one [1..1] @codeSystemName="PHIN VS" (CodeSystem: PHIN VADS code system 2.16.840.1.114222.4.5.274) (CONF:1137-535).

e. The code, if present, SHALL contain exactly one [1..1] @displayName (ValueSet: Assisted Ventilation More Than Six Hours (NCHS) 2.16.840.1.114222.4.11.7145) (CONF:1137-536).

f. The code, if present, SHOULD contain zero or one [0..1] originalText (CONF:1137-451).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-808).8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-809).9. SHALL contain at least one [1..*] entryRelationship (CONF:1137-806) such that it




3.10Birth Defect Diagnosis Observation - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.4:27Oct2014 (open)]

Table 97: Birth Defect Diagnosis Observation Contexts

Contained By: Contains:Birth Defects Diagnosis Concern Act (required)


Table 98: Birth Defect Diagnosis Observation Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


1382.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-141

2.16.840.1.113883.10.14.4


27Oct2014

id 1..* SHALL 1137-142

@root 1..1 SHALL 1137-914

code 1..1 SHALL 1137-143

@code 1..1 SHALL 1137-144

2.16.840.1.113883.6.1 (LOINC) = 29308-4


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Diagnosis

text 0..1 SHOULD

1137-146


1137-147

@value 1..1 SHALL 1137-148


@code 1..1 SHALL 1137-151




low 1..1 SHALL 1137-154


high 0..1 MAY 1137-156


value 1..1 SHALL CD 1137-157

@code 1..1 SHOULD

1137-158

2.16.840.1.113883.1.10 (Birth Defects Diagnosis / Anamolies)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96


2.16.840.1.113883.6.1 (LOINC) = LOINC


2.16.840.1.113883.1.10 (Birth Defects Diagnosis / Anamolies)

originalText 1..1 SHALL 1137-161


@value 1..1 SHALL 1137-163

qualifier 1..1 SHALL 1137-164

name 1..1 SHALL 1137-165

@code 1..1 SHALL 1137-166

2.16.840.1.113883.6.1 (LOINC) = TBD


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Dx Confirmed By

value 1..1 SHALL 1137-167

@code 0..1 SHOULD

1137-168

2.16.840.1.113883.10.14.91 (Birth Defects Diagnostic Confirmation)


2.16.840.1.113883.10.14.90 (Birth Defects Diagnostic Confirmation) = 2.16.840.1.113883.10.14.90


2.16.840.1.113883.10.14.90 (Birth Defects Diagnostic Confirmation) = Birth Defects Diagnostic Confirmation


2.16.840.1.113883.10.14.91 (Birth Defects Diagnostic Confirmation)


1137-171

reference 0..1 SHOUL 1137-


D 172@value 1..1 SHALL 1137-

173targetSiteCode 0..1 SHOUL

D1137-178

@code 1..1 SHALL 1137-179

2.16.840.1.113883.10.14.93 (Birth Defects Laterality at Diagnosis)


2.16.840.1.113883.10.14.92 (Birth Defects Laterality at Diagnosis) = 2.16.840.1.113883.10.14.92


2.16.840.1.113883.10.14.92 (Birth Defects Laterality at Diagnosis) = Birth Defects Laterality at Diagnosis


2.16.840.1.113883.10.14.93 (Birth Defects Laterality at Diagnosis)






5. SHALL contain exactly one [1..1] code (CONF:1137-143) such that ita. SHALL contain exactly one [1..1] @code="29308-4" Diagnosis (CodeSystem:

LOINC 2.16.840.1.113883.6.1) (CONF:1137-144).b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1"

(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-145).c. SHALL contain exactly one [1..1] @codeSystemName="LOINC" (CodeSystem: LOINC

2.16.840.1.113883.6.1) (CONF:1137-1530).d. SHALL contain exactly one [1..1] @displayName="Diagnosis" (CONF:1137-1531).

6. SHOULD contain zero or one [0..1] text (CONF:1137-146).a. The text, if present, SHOULD contain zero or one [0..1] reference (CONF:1137-

147).i. The reference, if present, SHALL contain exactly one [1..1] @value

(CONF:1137-148).1. This reference/@value SHALL begin with a '#' and SHALL point to its

corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1137-149).



(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:1137-151).8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-152).

a. This effectiveTime SHALL contain [0..0] @nullFlavor (CONF:1137-153).b. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1137-154).

i. This low SHALL contain [0..0] @nullFlavor (CONF:1137-155).c. This effectiveTime MAY contain zero or one [0..1] high (CONF:1137-156).

9. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1137-157) such that it

a. SHOULD contain exactly one [1..1] @code, which SHALL be selected from ValueSet Birth Defects Diagnosis / Anamolies 2.16.840.1.113883.1.10 DYNAMIC (CONF:1137-158).

b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:1137-159).


d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Birth Defects Diagnosis / Anamolies 2.16.840.1.113883.1.10 DYNAMIC (CONF:1137-160).

e. SHALL contain exactly one [1..1] originalText (CONF:1137-161).i. This originalText SHALL contain exactly one [1..1] reference (CONF:1137-

162).1. This reference SHALL contain exactly one [1..1] @value

(CONF:1137-163).Note: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1).

f. SHALL contain exactly one [1..1] qualifier, provides Diagnostic Confirmation information, indicating the best method used to confirm the presence of the BxDefect being reported (CONF:1137-164) such that it

i. SHALL contain exactly one [1..1] name (CONF:1137-165).1. This name SHALL contain exactly one [1..1] @code="TBD" Dx

confirmed by (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-166).

2. This name SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1523).

3. This name SHALL contain exactly one [1..1] @codeSystemName="LOINC" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1524).

4. This name SHALL contain exactly one [1..1] @displayName="Dx Confirmed By " (CONF:1137-1525).

ii. SHALL contain exactly one [1..1] value (CONF:1137-167).


conf:1137-163

1. This value SHOULD contain zero or one [0..1] @code, which SHALL be selected from ValueSet Birth Defects Diagnostic Confirmation 2.16.840.1.113883.10.14.91 DYNAMIC (CONF:1137-168).

a. If uncoded, SHALL be a string value describing the best method of diagnosis of the Bxdefect (CONF:1137-169).

b. If coded, SHALL be selected from Value Set Diagnostic Confirmation TBD (CONF:1137-170).

2. This value SHALL contain zero or one [0..1] @codeSystem="2.16.840.1.113883.10.14.90" (CodeSystem: Birth Defects Diagnostic Confirmation 2.16.840.1.113883.10.14.90) (CONF:1137-1526).

3. This value SHALL contain exactly one [1..1] @codeSystemName=" Birth Defects Diagnostic Confirmation" (CodeSystem: Birth Defects Diagnostic Confirmation 2.16.840.1.113883.10.14.90) (CONF:1137-1527).

4. This value SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Birth Defects Diagnostic Confirmation 2.16.840.1.113883.10.14.91 DYNAMIC (CONF:1137-1528).

5. This value SHOULD contain zero or one [0..1] originalText (CONF:1137-171).

a. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1137-172).

i. The reference, if present, SHALL contain exactly one [1..1] @value (CONF:1137-173).

1. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1137-174).

10. SHOULD contain zero or one [0..1] targetSiteCode, to indicate the anatomic location where the primary defect is present (CONF:1137-178) such that it

a. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Birth Defects Laterality at Diagnosis 2.16.840.1.113883.10.14.93 DYNAMIC (CONF:1137-179).

i. Code shall be selected from (a) Code System International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM)Volume 1 & 2 2.16.840.1.113883.6.103 DYNAMIC(b) Code System International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2.16.840.1.113883.6.90 DYNAMIC(c) Value Set Body Site (SNOMED CT) 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1137-180).


b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.10.14.92" (CodeSystem: Birth Defects Laterality at Diagnosis 2.16.840.1.113883.10.14.92) (CONF:1137-181).

i. CodeSystem shall be selected from(a) Code System International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM)Volume 1 & 2 2.16.840.1.113883.6.103 DYNAMIC (b) Code System International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2.16.840.1.113883.6.90 DYNAMIC (c) Value Set Body Site (SNOMED CT) 2.16.840.1.113883.3.88.12.3221.8.9 (CONF:1137-183).

c. SHALL contain exactly one [1..1] @codeSystemName="Birth Defects Laterality at Diagnosis" (CodeSystem: Birth Defects Laterality at Diagnosis 2.16.840.1.113883.10.14.92) (CONF:1137-1529).

d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Birth Defects Laterality at Diagnosis 2.16.840.1.113883.10.14.93 DYNAMIC (CONF:1137-182).

i. DisplayName shall be selected from(a) Code System International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM)Volume 1 & 2 2.16.840.1.113883.6.103 DYNAMIC (b) Code System International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2.16.840.1.113883.6.90 DYNAMIC (c) Value Set Body Site (SNOMED CT) 2.16.840.1.113883.3.88.12.3221.8.9 (CONF:1137-184).

3.11Birth Defects Diagnosis Concern Act - Draft[act: identifier urn:hl7ii:2.16.840.1.113883.10.14.3:27Oct2014 (open)]

Table 99: Birth Defects Diagnosis Concern Act Contexts

Contained By: Contains:Birth Defects Diagnosis Section (entries required) (NEW) (required)

Birth Defect Diagnosis Observation

Note: This template is modeled based on C-CDA R2 "Problem Concern Act (Condition) (V2)" template.This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list. In the context of "Birth Defects Diagnosis Section", the health concern is a Birth Defect.Problem Concern Act documents a provider’s concern about patient’s condition, whereas Problem Observation (contained within Problem Concern Act) documents details about the birth defect (e.g. birth defect diagnosis date.)statusCode (of Problem Concern Act) indicates a status of concern and shall be "active" for as long as birth defect is a health concern for the provider. statusCode can be "completed" if birth defect is resolved. statusCode is NOT used to indicate whether patient’s birth defect is present or absent; it is used to indicate whether patient’s birth defect is a concern to the provider.


The effectiveTime/low of the Problem Concern Act (Condition) asserts when the concern became active. The effectiveTime/high represents when the birth defect is no longer a concern / resolved. <effectiveTime> in Problem Concern Act is NOT used to indicate Birth Defects Diagnosis Date! Birth Defects Diagnosis Date is specified in <effectiveTime><low> element within "Problem Observation (V2) - Birth Defects Diagnosis Details" template (nested within entryRelationship in this "Problem Concern Act" template.A Problem Concern Act (Condition) can contain one or more entryRelationships, where each entryRelationship contains only one Problem Observation; each Problem Observation is an observation of only one birth defect. For example, if a patient has only one birth defect, then the document contains one entryRelationship with one Problem Observation. If a patient has two birth defects, then the document contains two entryRelationships, each describing one birth defect.


Table 100: Birth Defects Diagnosis Concern Act Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.14.3:27Oct2014)@classCode 1..1 SHALL 1137-

1212.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-124

2.16.840.1.113883.10.14.3


27Oct2014

id 1..* SHALL 1137-126

@root 1..1 SHALL 1137-965

code 1..1 SHALL 1137-125

@code 1..1 SHALL 1137-127

CONC


2.16.840.1.113883.5.6 (HL7ActClass) = 2.16.840.1.113883.5.6


@code 1..1 SHALL 1137-130

2.16.840.1.113883.11.20.9.19 (ProblemAct statusCode)


low 1..1 SHALL 1137-133

high 0..1 SHALL 1137-132




2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = SUBJ


Birth Defect Diagnosis Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.14.4:27Oct2014


1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:1137-121).



(CONF:1137-124).b. MAY contain zero or one [0..1] @extension="27Oct2014" (CONF:1137-403).


5. SHALL contain exactly one [1..1] code (CONF:1137-125).a. This code SHALL contain exactly one [1..1] @code="CONC" Conern (CONF:1137-

127).b. This code SHALL contain exactly one [1..1]

@codeSystem="2.16.840.1.113883.5.6" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-128).

6. SHALL contain exactly one [1..1] statusCode (CONF:1137-129).a. This statusCode SHALL contain exactly one [1..1] @code (ValueSet: ProblemAct

statusCode 2.16.840.1.113883.11.20.9.19) (CONF:1137-130).7. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-131).

a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1137-133).b. This effectiveTime SHALL contain zero or one [0..1] high (CONF:1137-132).

i. The high, if present, MAY contain zero or one [0..1] @nullFlavor (CONF:1137-134).

8. SHALL contain at least one [1..*] entryRelationship (CONF:1137-135) such that ita. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:1137-136).

b. SHALL contain exactly one [1..1] Birth Defect Diagnosis Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.14.4:27Oct2014) (CONF:1137-137).

3.12Birth head circumference - Draft[observation: identifier urn:oid:2.16.840.1.113883.10.20.17.3.2 (open)]

Table 101: Birth head circumference Contexts

Contained By: Contains:Vital Signs Section - NB BD IG Specific Constraints (NEW) (required)

This observation represents a birth head circumference result.


Table 102: Birth head circumference Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


32322.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


2.16.840.1.113883.11.20.5.19 (Birth head circumference)





2.16.840.1.113883.6.8 (UCUM) = cm




4. SHALL contain exactly one [1..1] code with @xsi:type="CD", where the code SHALL be selected from ValueSet Birth head circumference 2.16.840.1.113883.11.20.5.19 DYNAMIC (CONF:23-3234).


6. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:23-3236).a. This value SHALL contain exactly one [1..1] @unit="cm" centimeter (CodeSystem:

UCUM 2.16.840.1.113883.6.8 STATIC) (CONF:23-3237).

3.13Birth height - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.44:27Oct2014 (open)]

Table 103: Birth height Contexts


This observation represents a birth height.


Table 104: Birth height Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


2612.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1477

2.16.840.1.113883.10.14.44


27Oct2014

code 1..1 SHALL 1137-260

@code 1..1 SHALL 1137-263

2.16.840.1.113883.6.1 (LOINC) = TBD


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Birth Height


@code 1..1 SHALL 1137-267


value 1..1 SHALL IVL_PQ 1137-268


1137-1364


@value 1..1 SHALL 1137-269

@unit 1..1 SHALL 1137-270

2.16.840.1.113883.6.8 (UCUM) = cm





4. SHALL contain exactly one [1..1] code (CONF:1137-260) such that it


a. SHALL contain exactly one [1..1] @code="TBD" for Birth Height (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-263).

b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-264).


d. SHALL contain exactly one [1..1] @displayName="Birth Height" (CONF:1137-1376).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-267).6. SHALL contain exactly one [1..1] value with @xsi:type="IVL_PQ" (CONF:1137-268) such

that ita. SHOULD contain zero or one [0..1] @nullFlavor, which SHALL be selected from


b. SHALL contain exactly one [1..1] @value (CONF:1137-269).c. SHALL contain exactly one [1..1] @unit="cm" centimeter (CodeSystem: UCUM

2.16.840.1.113883.6.8) (CONF:1137-270).7. Conforms to CCD Result observation Template (templateId:

2.16.840.1.113883.10.20.1.31) (CONF:1137-265).

3.14Birth Outcome - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.45:27Oct2014 (open)]

Table 105: Birth Outcome Contexts



Table 106: Birth Outcome Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


5912.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-593

2.16.840.1.113883.10.14.45


27Oct2014

id 1..* SHALL 1137-594

@root 1..1 SHALL 1137-979

code 1..1 SHALL 1137-596

@code 1..1 SHALL 1137-597

2.16.840.1.113883.6.1 (LOINC) = 64710-7


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Pregnancy outcome

text 1..1 SHALL 1137-595


@code 1..1 SHALL 1137-604





1137-1365


@code 1..1 SHALL 1137-606

2.16.840.1.114222.4.11.3123 (Birth Outcome (VPD))



@codeSystemName 0..* SHALL 1137-608






1137-603


@value 1..1 SHALL 1137-612






5. SHALL contain exactly one [1..1] code (CONF:1137-596).a. This code SHALL contain exactly one [1..1] @code="64710-7" Pregnancy Outcome

(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-597).b. This code SHALL contain exactly one [1..1] @codeSystem="

2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-598).

c. This code SHALL contain exactly one [1..1] @codeSystemName="LOINC" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-599).

d. This code SHALL contain exactly one [1..1] @displayName="Pregnancy outcome" (CONF:1137-600).



8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-605).9. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1137-602) such that



b. SHALL contain exactly one [1..1] @code (ValueSet: Birth Outcome (VPD) 2.16.840.1.114222.4.11.3123 DYNAMIC) (CONF:1137-606).

c. SHALL contain exactly one [1..1] @codeSystem (ValueSet: Birth Outcome (VPD) 2.16.840.1.114222.4.11.3123 DYNAMIC) (CONF:1137-607).

d. SHALL contain zero or more [0..*] @codeSystemName (ValueSet: Birth Outcome (VPD) 2.16.840.1.114222.4.11.3123) (CONF:1137-608).


e. SHALL contain exactly one [1..1] @displayName (ValueSet: Birth Outcome (VPD) 2.16.840.1.114222.4.11.3123) (CONF:1137-609).

f. SHOULD contain zero or one [0..1] originalText (CONF:1137-603).i. The originalText, if present, SHALL contain exactly one [1..1] reference

(CONF:1137-611).1. This reference SHALL contain exactly one [1..1] @value

(CONF:1137-612).ii. If the Coded Value is Other, specify the value for birth outcome here

(CONF:1137-610).

3.15Birth weight - Draft[observation: identifier urn:oid:2.16.840.1.113883.10.20.17.3.1 (open)]

Table 107: Birth weight Contexts


This observation represents a birth weight.

Table 108: Birth weight Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


32262.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


2.16.840.1.113883.11.20.5.15 (Birth weight)





2.16.840.1.113883.6.8 (UCUM) = g





4. SHALL contain exactly one [1..1] code with @xsi:type="CD", where the code SHALL be selected from ValueSet Birth weight 2.16.840.1.113883.11.20.5.15 DYNAMIC (CONF:23-3228).


6. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:23-3230).a. This value SHALL contain exactly one [1..1] @unit="g" gram (CodeSystem: UCUM

2.16.840.1.113883.6.8 STATIC) (CONF:23-3231).

3.16Cause of Death - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.46:27Oct2014 (open)]

Table 109: Cause of Death Contexts



Table 110: Cause of Death Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


6462.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-648

2.16.840.1.113883.10.14.46


27Oct2014

id 1..* SHALL 1137-649

@root 1..1 SHALL 1137-980

code 1..1 SHALL 1137-645

@code 1..1 SHALL 1137-650

2.16.840.1.113883.6.96 (SNOMED CT) = 152527006


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




Cause of death

text 1..1 SHALL 1137-654



1137-1366


@code 0..1 SHOULD

1137-658

2.16.840.1.114222.4.11.3593 (Cause of Death (ICD-10))


2.16.840.1.113883.6.3 (ICD10) = 2.16.840.1.113883.6.3


2.16.840.1.113883.6.3 (ICD10) = ICD10


2.16.840.1.114222.4.11.3593 (Cause of Death (ICD-10))


1137-656


@value 1..1 SHALL 1137-


662






5. SHALL contain exactly one [1..1] code (CONF:1137-645).a. This code SHALL contain exactly one [1..1] @code="152527006" Cause of death

(observable entity) (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-650).



d. This code SHALL contain exactly one [1..1] @displayName="Cause of death" (CONF:1137-653).

6. SHALL contain exactly one [1..1] text (CONF:1137-654).7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1137-655) such that



b. SHOULD contain zero or one [0..1] @code (ValueSet: Cause of Death (ICD-10) 2.16.840.1.114222.4.11.3593) (CONF:1137-658).

c. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.3" (CodeSystem: ICD10 2.16.840.1.113883.6.3) (CONF:1137-659).

d. SHALL contain exactly one [1..1] @codeSystemName="ICD10" (CodeSystem: ICD10 2.16.840.1.113883.6.3) (CONF:1137-660).

e. SHALL contain exactly one [1..1] @displayName (ValueSet: Cause of Death (ICD-10) 2.16.840.1.114222.4.11.3593) (CONF:1137-661).

f. SHOULD contain zero or one [0..1] originalText (CONF:1137-656).i. The originalText, if present, SHALL contain exactly one [1..1] reference


(CONF:1137-662).


3.17CCD Result observation - Draft[observation: identifier urn:oid:2.16.840.1.113883.10.20.1.31 (open)]

This clinical statement represents details of a lab, radiology, or other study performed on a patient.

Table 111: CCD Result observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.1.31)

1. The value for “Observation / @moodCode” in a result observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC (CONF:14-800).

2. A result observation SHALL contain at least one Observation / id (CONF:14-801).3. A result observation SHALL contain exactly one Observation / statusCode (CONF:14-802).4. A result observation SHOULD contain exactly one Observation / effectiveTime, which

represents the biologically relevant time (e.g. time the specimen was obtained from the patient) (CONF:14-803).

5. A result observation SHALL contain exactly one Observation / code (CONF:14-804).6. The value for “Observation / code” in a result observation SHOULD be selected from

LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12) (CONF:14-805).

7. A result observation MAY contain exactly one Observation / methodCode if the method isn't inherent in Observation / code or if there is a need to further specialize the method in Observation / code (CONF:14-806).

8. Observation / methodCode SHALL NOT conflict with the method inherent in Observation / code (CONF:14-807).

9. A result observation SHALL contain exactly one Observation / value (CONF:14-808).10. Where Observation / value is a physical quantity, the unit of measure SHALL be

expressed using a valid Unified Code for Units of Measure (UCUM) expression (CONF:14-809).

11. A result observation SHOULD contain exactly one Observation / interpretationCode, which can be used to provide a rough qualitative interpretation of the observation, such as “N” (normal), “L” (low), “S” (susceptible), etc. Interpretation is generally provided for numeric results where an interpretation range has been defined, or for antimicrobial susceptibility test interpretation (CONF:14-810).

12. A result observation SHOULD contain one or more Observation / referenceRange to show the normal range of values for the observation result (CONF:14-811).


3.18Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor] - Draft[substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.14.48:27Oct2014 (open)]

Table 112: Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor] Contexts

Contained By: Contains:Medications Section - LD BD IG Specific Constraints (optional)


Table 113: Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor] Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1302@root 1..1 SHALL 1137-

13032.16.840.1.113883.10.14.48


27Oct2014

code 1..1 SHALL 1137-1304

@code 1..1 SHALL 1137-1306

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 (Epidural Anesthesia - Medication) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 (Spinal Anesthesia - Medication)


2.16.840.1.113883.6.88 (RxNorm) = 2.16.840.1.113883.6.88


2.16.840.1.113883.6.88 (RxNorm) = RxNorm


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 (Epidural Anesthesia - Medication)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 (Spinal Anesthesia - Medication)


@code 1..1 SHALL 1137-1310





2. SHALL contain exactly one [1..1] code (CONF:1137-1304) such that ita. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet

Epidural Anesthesia - Medication 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 DYNAMIC or Spinal Anesthesia - Medication 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 DYNAMIC (CONF:1137-1306).


b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.88" (CodeSystem: RxNorm 2.16.840.1.113883.6.88) (CONF:1137-1307).

c. SHALL contain exactly one [1..1] @codeSystemName="RxNorm" (CodeSystem: RxNorm 2.16.840.1.113883.6.88) (CONF:1137-1308).

d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Epidural Anesthesia - Medication 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 DYNAMIC or Spinal Anesthesia - Medication 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 DYNAMIC (CONF:1137-1309).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1310).4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1311).

3.19Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor] - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.47:27Oct2014 (open)]

Table 114: Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor] Contexts

Contained By: Contains:Procedures Section - LD BD IG Specific (optional)


Table 115: Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor] Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10332.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1035

2.16.840.1.113883.10.14.47


27Oct2014

code 1..1 SHALL 1137-1032


1137-1367


@code 1..1 SHALL 1137-1036

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 (Spinal Anesthesia - Procedure) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 (Epidural Anesthesia - Procedure)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 (Spinal Anesthesia - Procedure) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 (Epidural Anesthesia - Procedure)

1. SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-1033).




4. SHALL contain exactly one [1..1] code (CONF:1137-1032).


a. This code SHOULD contain zero or one [0..1] @nullFlavor, which SHALL be selected from ValueSet NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17 (CONF:1137-1367).

b. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Spinal Anesthesia - Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 DYNAMIC or Epidural Anesthesia - Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 DYNAMIC (CONF:1137-1036).

c. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1037).

d. This code SHALL contain exactly one [1..1] @codeSystemName=" SNOMED CT" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1038).

e. This code SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Spinal Anesthesia - Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 DYNAMIC or Epidural Anesthesia - Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 DYNAMIC (CONF:1137-1039).

3.20Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor] - Draft[substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.14.49:27Oct2014 (open)]

Table 116: Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor] Contexts



Table 117: Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor] Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1277@root 1..1 SHALL 1137-

12782.16.840.1.113883.10.14.49


27Oct2014

code 1..1 SHALL 1137-1279

@code 1..1 SHALL 1137-1280

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 (Antibiotics)


2.16.840.1.113883.6.88 (RxNorm) = 2.16.840.1.113883.6.88


2.16.840.1.113883.6.88 (RxNorm) = RxNorm


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 (Antibiotics)


@code 1..1 SHALL 1137-1285



routeCode 0..1 SHOULD

1137-1287

@code 1..1 SHALL 1137-1288

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 (IV Medication Administration)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 (Intramuscular Administration Route)


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4


Route of administration (HL7)


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 (IV Medication Administration)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 (Intramuscular Administration Route)




b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1483).2. SHALL contain exactly one [1..1] code (CONF:1137-1279).

a. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Antibiotics 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 DYNAMIC (CONF:1137-1280).

b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.88" (CodeSystem: RxNorm 2.16.840.1.113883.6.88) (CONF:1137-1281).

c. This code SHALL contain exactly one [1..1] @codeSystemName="RxNorm" (CodeSystem: RxNorm 2.16.840.1.113883.6.88) (CONF:1137-1283).

d. This code SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Antibiotics 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 (CONF:1137-1284).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1285).4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1286).5. SHOULD contain zero or one [0..1] routeCode (CONF:1137-1287).

NOTE: If Antibiotics is not null then route code shall be present.a. The routeCode, if present, SHALL contain exactly one [1..1] @code, which SHOULD

be selected from ValueSet IV Medication Administration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 DYNAMIC or Intramuscular Administration Route 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 DYNAMIC (CONF:1137-1288).

b. The routeCode, if present, SHALL contain exactly one [1..1] @codeSystem="1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4" (CONF:1137-1289).

c. The routeCode, if present, SHALL contain exactly one [1..1] @codeSystemName="Route of administration (HL7)" (CONF:1137-1290).

d. The routeCode, if present, SHALL contain exactly one [1..1] @displayName (ValueSet: IV Medication Administration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 DYNAMIC or Intramuscular Administration Route 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 DYNAMIC (CONF:1137-1291).

3.21Characteristics of Labor and Delivery: Augmentation of Labor - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.50:27Oct2014 (open)]

Table 118: Characteristics of Labor and Delivery: Augmentation of Labor Contexts



conf:1137-1287

Table 119: Characteristics of Labor and Delivery: Augmentation of Labor Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10512.16.840.1.113883.5.1002 (HL7ActRelationshipType) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1053

2.16.840.1.113883.10.14.50


27Oct2014

code 1..1 SHALL 1137-1050

@code 1..1 SHALL 1137-1054

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 (Augmentation of Labor - Procedure)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 (Augmentation of Labor - Procedure)

1. SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-1051).





Augmentation of Labor - Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 DYNAMIC (CONF:1137-1054).




d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Augmentation of Labor - Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 DYNAMIC (CONF:1137-1057).

3.22Characteristics of Labor and Delivery: Augmentation of Labor - Medication - Draft[substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.14.51:27Oct2014 (open)]

Table 120: Characteristics of Labor and Delivery: Augmentation of Labor - Medication Contexts


Table 121: Characteristics of Labor and Delivery: Augmentation of Labor - Medication Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1317@root 0..1 SHALL 1137-

13182.16.840.1.113883.10.14.51


27Oct2014

code 1..1 SHALL 1137-1319

@code 1..1 SHALL 1137-1320

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 (Augmentation of Labor - Medication)


2.16.840.1.113883.6.88 (RxNorm) = 2.16.840.1.113883.6.88


2.16.840.1.113883.6.88 (RxNorm) = RxNorm


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 (Augmentation of Labor - Medication)


@code 1..1 SHALL 1137-1325




1. SHALL contain exactly one [1..1] templateId (CONF:1137-1317) such that ita. SHALL contain zero or one [0..1] @root="2.16.840.1.113883.10.14.51"



Augmentation of Labor - Medication 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 DYNAMIC (CONF:1137-1320).



d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Augmentation of Labor - Medication 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 DYNAMIC (CONF:1137-1323).



3.23Characteristics of labor and delivery: Induction of labor - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.52:27Oct2014 (open)]

Table 122: Characteristics of labor and delivery: Induction of labor Contexts



Table 123: Characteristics of labor and delivery: Induction of labor Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10422.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1044

2.16.840.1.113883.10.14.52


27Oct2014

code 1..1 SHALL 1137-1041

@code 1..1 SHALL 1137-1045

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 (Induction of Labor)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 (Induction of Labor)





4. SHALL contain exactly one [1..1] code (CONF:1137-1041).a. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from

ValueSet Induction of Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 DYNAMIC (CONF:1137-1045).




d. This code SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Induction of Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 DYNAMIC (CONF:1137-1048).

3.24Characteristics of Labor and Delivery: Meconium Staining - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.53:27Oct2014 (open)]

Table 124: Characteristics of Labor and Delivery: Meconium Staining Contexts

Contained By: Contains:Labor and Delivery Events Section (NEW) (required)

Table 125: Characteristics of Labor and Delivery: Meconium Staining Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.14.53:27Oct2014)templateId 1..1 SHALL 1137-

1183@extension 1..1 SHALL 1137-

148727Oct2014

code 1..1 SHALL 1137-1185


1137-1368


@code 1..1 SHALL 1137-1186

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 (Meconium Staining)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 (Meconium Staining)


@code 1..1 SHALL 1137-1191



1. SHALL contain exactly one [1..1] templateId (CONF:1137-1183) such that ita. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1487).



a. SHOULD contain zero or one [0..1] @nullFlavor, which SHALL be selected from ValueSet NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17 (CONF:1137-1368).

b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Meconium Staining 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 DYNAMIC (CONF:1137-1186).

c. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1187).

d. SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1188).

e. SHALL contain exactly one [1..1] @displayName (ValueSet: Meconium Staining 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 DYNAMIC) (CONF:1137-1189).



3.25Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery] - Draft[substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.14.54:27Oct2014 (open)]

Table 126: Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery] Contexts



Table 127: Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery] Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1292@root 1..1 SHALL 1137-

12932.16.840.1.113883.10.14.54


27Oct2014

code 1..1 SHALL 1137-1294

@code 1..1 SHALL 1137-1295

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 (Glucocortico Steroids)


2.16.840.1.113883.6.88 (RxNorm) = 2.16.840.1.113883.6.88


2.16.840.1.113883.6.88 (RxNorm) = RxNorm


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 (Glucocortico Steroids)


@code 1..1 SHALL 1137-1300






Glucocortico Steroids 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 DYNAMIC (CONF:1137-1295).



d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Glucocortico Steroids 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 DYNAMIC (CONF:1137-1298).

3. SHALL contain exactly one [1..1] statusCode (CONF:1137-1299).



4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1301).

3.26Coverage Activity - Published[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.60 (open)]

Table 128: Coverage Activity Contexts

Contained By: Contains:Payers Section (optional) Policy Activity

A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources. A Coverage Activity contains one or more policy activities, each of which contains zero or more authorization activities. The Coverage Activity id is the Id from the patient's insurance card. The sequenceNumber/@value shows the policy order of preference.


Table 129: Coverage Activity Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.60)@classCode 1..1 SHALL 81-

88722.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10492

2.16.840.1.113883.10.20.22.4.60

id 1..* SHALL 81-8874

code 1..1 SHALL 81-8876

@code 1..1 SHALL 81-19160

2.16.840.1.113883.6.1 (LOINC) = 48768-6


@code 1..1 SHALL 81-19094




2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP

sequenceNumber 0..1 MAY 81-17174

@value 1..1 SHALL 81-17175

act 1..1 SHALL 81-15528

Policy Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.61




(CONF:81-10492).4. SHALL contain at least one [1..*] id (CONF:81-8874).5. SHALL contain exactly one [1..1] code (CONF:81-8876).

a. This code SHALL contain exactly one [1..1] @code="48768-6" Payment sources (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-19160).



(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19094).7. SHALL contain at least one [1..*] entryRelationship (CONF:81-8878) such that it

a. SHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8879).

b. MAY contain zero or one [0..1] sequenceNumber (CONF:81-17174).i. The sequenceNumber, if present, SHALL contain exactly one [1..1] @value

(CONF:81-17175).c. SHALL contain exactly one [1..1] Policy Activity (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.61) (CONF:81-15528).

3.27Date of Death - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.55:27Oct2014 (open)]

Table 130: Date of Death Contexts

Contained By: Contains:Newborn Delivery Information Section (NEW) (optional)


Table 131: Date of Death Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


6812.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = ENT


@root 1..1 SHALL 1137-683

2.16.840.1.113883.10.14.55


27Oct2014

id 1..* SHALL 1137-684

@root 1..1 SHALL 1137-981

code 1..1 SHALL 1137-679

@code 1..1 SHALL 1137-685

399753006


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




Date of death

text 1..1 SHALL 1137-689


@code 1..1 SHALL 1137-690



value 1..1 SHALL TS 1137-692

@value 1..1 SHALL 1137-982


2. SHALL contain exactly one [1..1] @moodCode="ENT" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:1137-682).





5. SHALL contain exactly one [1..1] code (CONF:1137-679).a. This code SHALL contain exactly one [1..1] @code="399753006" Date of death

(CONF:1137-685).b. This code SHALL contain exactly one [1..1]

@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-686).


d. This code SHALL contain exactly one [1..1] @displayName="Date of death" (CONF:1137-688).



8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-691).9. SHALL contain exactly one [1..1] value with @xsi:type="TS" (CONF:1137-692) such that

ita. SHALL contain exactly one [1..1] @value (CONF:1137-982).

3.28Date of Last Live Birth - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.56:27Oct2014 (open)]

Table 132: Date of Last Live Birth Contexts

Contained By: Contains:Prior Pregnancy History Section (NEW) (optional)


Table 133: Date of Last Live Birth Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


13872.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1389

2.16.840.1.113883.10.14.56


27Oct2014

code 1..1 SHALL 1137-1386

@code 1..1 SHALL 1137-1390

2.16.840.1.113883.6.1 (LOINC) = 68499-3


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Date last live birth


@value 1..1 SHALL TS 1137-1395





4. SHALL contain exactly one [1..1] code (CONF:1137-1386) such that ita. SHALL contain exactly one [1..1] @code="68499-3" Date last live birth

(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1390).b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1"


2.16.840.1.113883.6.1) (CONF:1137-1392).


d. SHALL contain exactly one [1..1] @displayName="Date last live birth" (CONF:1137-1393).

5. SHALL contain exactly one [1..1] value with @xsi:type="TS" (CONF:1137-1394) such that it

a. SHALL contain exactly one [1..1] @value (CONF:1137-1395).b. The date of birth of the last live born infant. Month and year should be provided

(CONF:1137-1396).

3.29Drug Vehicle - Published[participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.24 (open)]

Table 134: Drug Vehicle Contexts

Contained By: Contains:Medication Activity (optional)

This template represents the vehicle (e.g., saline, dextrose) for administering a medication.

Table 135: Drug Vehicle Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

participantRole (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.24)@classCode 1..1 SHALL 81-

74902.16.840.1.113883.5.110 (RoleClass) = MANU


@root 1..1 SHALL 81-10493

2.16.840.1.113883.10.20.22.4.24

code 1..1 SHALL 81-19137

@code 1..1 SHALL 81-19138

412307009


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96

playingEntity 1..1 SHALL 81-7492

code 1..1 SHALL 81-7493

name 0..1 MAY 81-7494

1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:81-7490).



a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.24" (CONF:81-10493).

3. SHALL contain exactly one [1..1] code (CONF:81-19137).a. This code SHALL contain exactly one [1..1] @code="412307009" Drug Vehicle

(CONF:81-19138).b. This code SHALL contain exactly one [1..1]


4. SHALL contain exactly one [1..1] playingEntity (CONF:81-7492).This playingEntity/code is used to supply a coded term for the drug vehicle.

a. This playingEntity SHALL contain exactly one [1..1] code (CONF:81-7493).b. This playingEntity MAY contain zero or one [0..1] name (CONF:81-7494).

i. This playingEntity/name MAY be used for the vehicle name in text, such as Normal Saline (CONF:81-10087).

Figure 6: Drug Vehicle Example

<participantRole classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.24"/> <code code="412307009" displayName="drug vehicle"codeSystem="2.16.840.1.113883.6.96"/> <playingEntity classCode="MMAT"> <code code="324049" displayName="Aerosol"codeSystem="2.16.840.1.113883.6.88"codeSystemName="RxNorm"/>

<name>Aerosol</name> </playingEntity></participantRole>

3.30Estimate of Gestation - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.57:27Oct2014 (open)]

Table 136: Estimate of Gestation Contexts


The delivery attendant's final estimate of gestation based on all perinatal factors and assessments.


Table 137: Estimate of Gestation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


13992.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1401

2.16.840.1.113883.10.14.57


27Oct2014

code 1..1 SHALL 1137-1398

@code 1..1 SHALL 1137-1402

2.16.840.1.113883.6.1 (LOINC) = 11884-4


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Gestational age Estimated

text 1..* SHALL 1137-1406






4. SHALL contain exactly one [1..1] code (CONF:1137-1398) such that ita. SHALL contain exactly one [1..1] @code="11884-4" to specify Gestational age

Estimated (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1402).b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1"


2.16.840.1.113883.6.1) (CONF:1137-1404).


d. SHALL contain exactly one [1..1] @displayName="Gestational age Estimated" (CONF:1137-1405).

5. SHALL contain at least one [1..*] text (CONF:1137-1406).6. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:1137-1407).

a. The value is to be provided as a number of completed weeks (CONF:1137-1408).

3.31Estimated Date of Delivery - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.15.3.1 (closed)]

Table 138: Estimated Date of Delivery Contexts

Contained By: Contains:Pregnancy Observation (optional)

This clinical statement represents the anticipated date when a woman will give birth.

Table 139: Estimated Date of Delivery Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.1)@classCode 1..1 SHALL 81-444 2.16.840.1.113883.5.6

(HL7ActClass) = OBS@moodCode 1..1 SHALL 81-445 2.16.840.1.113883.5.1001

(ActMood) = EVNtemplateId 1..1 SHALL 81-

16762@root 1..1 SHALL 81-

167632.16.840.1.113883.10.20.15.3.1

code 1..1 SHALL 81-19139

@code 1..1 SHALL 81-19140

11778-8


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1

statusCode 1..1 SHALL 81-448@code 1..1 SHALL 81-








4. SHALL contain exactly one [1..1] code (CONF:81-19139).a. This code SHALL contain exactly one [1..1] @code="11778-8" Estimated date of

delivery (CONF:81-19140).b. This code SHALL contain exactly one [1..1]

@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:81-26503).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19096).6. SHALL contain exactly one [1..1] value with @xsi:type="TS" (CONF:81-450).

Figure 7: Estimated Date of Delivery Example

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.15.3.1"/> <id extension="123456789" root="2.16.840.1.113883.19"/> <code code="11778-8" codeSystem="2.16.840.1.113883.6.1" displayName="Estimated date of delivery"/> <statusCode code="completed"/> <value xsi:type="TS" value="20110919" /></observation>

3.32Family History Death Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.47 (open)]

Table 140: Family History Death Observation Contexts

Contained By: Contains:Family History Observation (optional)

This clinical statement records whether the family member is deceased.


Table 141: Family History Death Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


86212.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10495

2.16.840.1.113883.10.20.22.4.47

code 1..1 SHALL 81-19141

@code 1..1 SHALL 81-19142

ASSERTION


2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4


@code 1..1 SHALL 81-19097



@code 1..1 SHALL 81-26470

2.16.840.1.113883.6.96 (SNOMED CT) = 419099009





a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:81-19142).

b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:81-26504).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19097).6. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:81-8626).


a. This value SHALL contain exactly one [1..1] @code="419099009" Dead (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:81-26470).

Figure 8: Family History Death Observation Example

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.47"/> <id root="6898fae0-5c8a-11db-b0de-0800200c9a66"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <value xsi:type="CD" code="419099009" codeSystem="2.16.840.1.113883.6.96" displayName="Dead"/></observation>

3.33Family History Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.46 (open)]

Table 142: Family History Observation Contexts

Contained By: Contains:Family History Organizer (required) Age Observation

Family History Death Observation

Family History Observations related to a particular family member are contained within a Family History Organizer. The effectiveTime in the Family History Observation is the biologically or clinically relevant time of the observation. The biologically or clinically relevant time is the time at which the observation holds (is effective) for the family member (the subject of the observation).


Table 143: Family History Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


85862.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10496

2.16.840.1.113883.10.20.22.4.46

id 1..* SHALL 81-8592

code 1..1 SHALL 81-8589

2.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)


@code 1..1 SHALL 81-19098


effectiveTime 0..1 SHOULD

81-8593


2.16.840.1.113883.3.88.12.3221.7.4 (Problem)

entryRelationship 0..1 MAY 81-8675


2.16.840.1.113883.5.90 (HL7ParticipationType) = SUBJ

@inversionInd 1..1 SHALL 81-8677

true


Age Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.31



2.16.840.1.113883.5.90 (HL7ParticipationType) = CAUS


Family History Death Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.47





(CONF:81-10496).4. SHALL contain at least one [1..*] id (CONF:81-8592).5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem

Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:81-8589).6. SHALL contain exactly one [1..1] statusCode (CONF:81-8590).

a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19098).

7. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-8593).8. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be

selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:81-8591).

9. MAY contain zero or one [0..1] entryRelationship (CONF:81-8675) such that ita. SHALL contain exactly one [1..1] @typeCode="SUBJ" Subject (CodeSystem:

HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-8676).b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:81-8677).c. SHALL contain exactly one [1..1] Age Observation (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.31) (CONF:81-15526).10. MAY contain zero or one [0..1] entryRelationship (CONF:81-8678) such that it

a. SHALL contain exactly one [1..1] @typeCode="CAUS" Causal or Contributory (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-8679).

b. SHALL contain exactly one [1..1] Family History Death Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.47) (CONF:81-15527).


Figure 9: Family History Observation Example

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.46"/>  <id root="d42ebf70-5c89-11db-b0de-0800200c9a66"/> <code code="64572001" displayName="Condition" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/> <statusCode code="completed"/> <effectiveTime value="1967"/> <value xsi:type="CD" code="22298006" codeSystem="2.16.840.1.113883.6.96" displayName="Myocardial infarction"/> <entryRelationship typeCode="CAUS"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.47"/>

...

</observation> </entryRelationship> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.31"/> <code code="445518008" codeSystem="2.16.840.1.113883.6.96"/>

.... </entryRelationship></observation>

3.34Family History Organizer - Published[organizer: identifier urn:oid:2.16.840.1.113883.10.20.22.4.45 (open)]

Table 144: Family History Organizer Contexts

Contained By: Contains:Family History Section (optional) Family History Observation

The Family History Organizer associates a set of observations with a family member. For example, the Family History Organizer can group a set of observations about the patient’s father.


Table 145: Family History Organizer Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

organizer (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.45)@classCode 1..1 SHALL 81-

86002.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10497

2.16.840.1.113883.10.20.22.4.45


@code 1..1 SHALL 81-19099


subject 1..1 SHALL 81-8609

relatedSubject 1..1 SHALL 81-15244


2.16.840.1.113883.5.41 (EntityClass) = PRS

code 1..1 SHALL 81-15246

@code 1..1 SHALL 81-15247

2.16.840.1.113883.1.11.19579 (Family Member Value Set)

subject 0..1 SHOULD

81-15248


@code 1..1 SHALL 81-15975


birthTime 0..1 SHOULD

81-15976

component 1..* SHALL 81-8607


Family History Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.46

1. SHALL contain exactly one [1..1] @classCode="CLUSTER" Cluster (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-8600).




(CONF:81-10497).4. SHALL contain exactly one [1..1] statusCode (CONF:81-8602).


5. SHALL contain exactly one [1..1] subject (CONF:81-8609).a. This subject SHALL contain exactly one [1..1] relatedSubject (CONF:81-15244).

i. This relatedSubject SHALL contain exactly one [1..1] @classCode="PRS" Person (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) (CONF:81-15245).

ii. This relatedSubject SHALL contain exactly one [1..1] code (CONF:81-15246).

1. This code SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Family Member Value Set 2.16.840.1.113883.1.11.19579 DYNAMIC (CONF:81-15247).

iii. This relatedSubject SHOULD contain zero or one [0..1] subject (CONF:81-15248).

1. The subject, if present, SHALL contain exactly one [1..1] administrativeGenderCode (CONF:81-15974).

a. This administrativeGenderCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 STATIC (CONF:81-15975).

2. The subject, if present, SHOULD contain zero or one [0..1] birthTime (CONF:81-15976).

3. The subject SHOULD contain zero or more 0..] sdtc:id. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the id element (CONF:81-15249).

4. The subject MAY contain zero or one sdtc:deceasedInd. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedInd element (CONF:81-15981).

5. The subject MAY contain zero or one sdtc:deceasedTime. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the deceasedTime element (CONF:81-15982).

6. The age of a relative at the time of a family history observation SHOULD be inferred by comparing RelatedSubject/subject/birthTime with Observation/effectiveTime (CONF:81-15983).

6. SHALL contain at least one [1..*] component (CONF:81-8607).a. Such components SHALL contain exactly one [1..1] Family History Observation

(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.46) (CONF:81-16888).


Figure 10: Family History Organizer Example

<organizer moodCode="EVN" classCode="CLUSTER"> <templateId root="2.16.840.1.113883.10.20.22.4.45"/> <statusCode code="completed"/> <subject> <relatedSubject classCode="PRS"> <code code="FTH" displayName="Father" codeSystemName="HL7 FamilyMember"codeSystem="2.16.840.1.113883.5.111">

<translation code="9947008" displayName="Natural father"codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96"/>

</code> <subject> <sdtc:id root="2.16.840.1.113883.19.5.99999.2" extension="99999999"/> <id xmlns="urn:hl7-org:sdtc" root="2.16.840.1.113883.19.5.99999.2" extension="1234"/> <administrativeGenderCode code="M"/> <birthTime value="1910"/>   </subject> </relatedSubject> </subject> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.46"/>

. . .

</observation> </component> </organizer>

3.35Gestational age - Draft[observation: identifier urn:oid:2.16.840.1.113883.10.20.17.3.3 (open)]

Table 146: Gestational age Contexts


This observation represents the gestational age of an infant at birth; it is not the gestation of a pregnancy. Although gestational age of an infant is typically recorded in weeks plus days (e.g., 27 weeks and 3 days), the xsi:type PQ does not allow for mixed units. The gestational age must be represented in days. For example, 27 weeks and 3 days would be represented with 192 days.


Table 147: Gestational age Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


32382.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


2.16.840.1.113883.6.96 (SNOMED CT) = 412726003





2.16.840.1.113883.6.8 (UCUM) = d




4. SHALL contain exactly one [1..1] code="412726003" Gestational age at birth with @xsi:type="CD" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:23-3240).


6. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:23-3242).a. This value SHALL contain exactly one [1..1] @unit="d" day (CodeSystem: UCUM

2.16.840.1.113883.6.8 STATIC) (CONF:23-3243).

3.36Health Status Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.5 (closed)]

Table 148: Health Status Observation Contexts

Contained By: Contains:Problem Observation (optional)

The Health Status Observation records information about the current health status of the patient.


Table 149: Health Status Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


90572.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-16757

2.16.840.1.113883.10.20.22.4.5

code 1..1 SHALL 81-19143

@code 1..1 SHALL 81-19144

2.16.840.1.113883.6.1 (LOINC) = 11323-3

text 0..1 SHOULD

81-9270


81-15529

@value 0..1 SHOULD

81-15530


@code 1..1 SHALL 81-19103



2.16.840.1.113883.1.11.20.12 (HealthStatus)





a. This code SHALL contain exactly one [1..1] @code="11323-3" Health status (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-19144).


15529).i. The reference, if present, SHOULD contain zero or one [0..1] @value

(CONF:81-15530).


1. SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15531).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19103).7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be

selected from ValueSet HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC (CONF:81-9075).

Figure 11: Health Status Observation Example

<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.5"/><code code="11323-3" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Health status"/>

<text><reference value="#healthstatus"/>

</text><statusCode code="completed"/><value xsi:type="CD" code="81323004" codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED CT" displayName="Alive and well"/>

</observation>

3.37Highest Pressure Ulcer Stage - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.77 (open)]

Table 150: Highest Pressure Ulcer Stage Contexts

Contained By: Contains:Physical Exam Section (optional)

This observation contains a description of the wound tissue of the most severe or highest staged pressure ulcer observed on a patient.


Table 151: Highest Pressure Ulcer Stage Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


147262.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-14729

2.16.840.1.113883.10.20.22.4.77

id 1..* SHALL 81-14730

code 1..1 SHALL 81-14731

@code 1..1 SHALL 81-14732

2.16.840.1.113883.6.96 (SNOMED CT) = 420905001


1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-14726).

2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:81-14727).



a. This code SHALL contain exactly one [1..1] @code="420905001" Highest Pressure Ulcer Stage (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:81-14732).

6. SHALL contain exactly one [1..1] value (CONF:81-14733).


Figure 12: Highest Pressure Ulcer Stage Example

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.77"/> <id root="08edb7c0-2111-43f2-a784-9a5fdfaa67f0"/> <code code="420905001" codeSystem="2.16.840.1.113883.6.96" displayName=" Highest Pressure Ulcer Stage"/> <statusCode code="completed"/> <value xsi:type="CD" code="421306004" codeSystem="2.16.840.1.113883.6.96" displayName="necrotic eschar"/></observation>

3.38Immunization Medication Information - Published[manufacturedProduct: identifier urn:oid:2.16.840.1.113883.10.20.22.4.54 (open)]

Table 152: Immunization Medication Information Contexts

Contained By: Contains:Medication Supply Order (optional)Medication Dispense (optional)

The Immunization Medication Information represents product information about the immunization substance. The vaccine manufacturer and vaccine lot number are typically recorded in the medical record and should be included if known.


Table 153: Immunization Medication Information Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

manufacturedProduct (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.54)@classCode 1..1 SHALL 81-

90022.16.840.1.113883.5.110 (RoleClass) = MANU


@root 1..1 SHALL 81-10499

2.16.840.1.113883.10.20.22.4.54

id 0..* MAY 81-9005

manufacturedMaterial 1..1 SHALL 81-9006

code 1..1 SHALL 81-9007

2.16.840.1.113883.3.88.12.80.22 (Vaccine Administered Value Set)


81-9008


81-15555

@value 0..1 SHOULD

81-15556

translation 0..* MAY SET<PQR>

81-9011

lotNumberText 0..1 SHOULD

81-9014

manufacturerOrganization 0..1 SHOULD

81-9012



(CONF:81-10499).3. MAY contain zero or more [0..*] id (CONF:81-9005).4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:81-9006).

a. This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Vaccine Administered Value Set 2.16.840.1.113883.3.88.12.80.22 DYNAMIC (CONF:81-9007).

i. This code SHOULD contain zero or one [0..1] originalText (CONF:81-9008).

1. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:81-15555).


a. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:81-15556).

i. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15557).

ii. This code MAY contain zero or more [0..*] translation (CONF:81-9011).1. Translations can be used to represent generic product name,

packaged product code, etc (CONF:81-16887).b. This manufacturedMaterial SHOULD contain zero or one [0..1] lotNumberText

(CONF:81-9014).5. SHOULD contain zero or one [0..1] manufacturerOrganization (CONF:81-9012).

Figure 13: Immunization Medication Information Example

<manufacturedProduct> <templateId root="2.16.840.1.113883.10.20.22.4.54"/>  <manufacturedMaterial> <code code="103" codeSystem="2.16.840.1.113883.12.292" codeSystemName="CVX" displayName="Tetanus and diphtheria toxoids – preservative free" codeSystemName="CVX"> <originalText>Tetanus and diphtheria toxoids - preservative free</originalText> <translation code="09" displayName="Tetanus and diphtheria toxoids – preservative free" codeSystemName="CVX" codeSystem="2.16.840.1.113883.12.292"/> </code> </manufacturedMaterial></manufacturedProduct>

3.39Indication - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.19 (open)]

Table 154: Indication Contexts

Contained By: Contains:Medication Activity (optional)Procedure Activity Procedure (optional)Procedure Activity Act (optional)Procedure Activity Observation (optional)

The Indication Observation documents the rationale for an activity. It can do this with the id element to reference a problem recorded elsewhere in the document or with a code and value to


record the problem type and problem within the Indication. For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section.

Table 155: Indication Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


74802.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10502

2.16.840.1.113883.10.20.22.4.19

id 1..1 SHALL 81-7483

code 1..1 SHALL 81-16886

2.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)


@code 1..1 SHALL 81-19105



81-7488

value 0..1 SHOULD

CD 81-7489


@code 0..1 SHOULD

81-15985

2.16.840.1.113883.3.88.12.3221.7.4 (Problem)




(CONF:81-10502).4. SHALL contain exactly one [1..1] id (CONF:81-7483).

a. Set the observation/id equal to an ID on the problem list to signify that problem as an indication (CONF:81-16885).

5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:81-16886).




7. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-7488).8. SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:81-7489).

a. The value, if present, MAY contain zero or one [0..1] @nullFlavor (CONF:81-15990).

i. If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element (CONF:81-15991).

b. The value, if present, SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:81-15985).

3.40Indication - BxDefects IG Specific Constraint - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.11:27Oct2014 (open)]

Table 156: Indication - BxDefects IG Specific Constraint Contexts

Contained By: Contains:Antibiotic Administration Procedure (required)Karyotype Determination (required)Newborn given Surfactant replacement therapy? (required)Assisted Ventilation [required immediately following delivery] (required)Assisted Ventilation for 6 or more hours (required)Antibiotics (required)Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) (required)Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) (required)

This template explains birth defects-specific constraints to the C-CDA R2.0 Indication (V2) template.


Table 157: Indication - BxDefects IG Specific Constraint Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


4952.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-498

2.16.840.1.113883.10.14.11

id 1..* SHALL 1137-499


@root 1..1 SHALL 1137-964

1. Conforms to Indication template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.19).




(CONF:1137-498).5. SHALL contain at least one [1..*] id (CONF:1137-499) such that it

Note: id SHALL reference a problem recorded in the Problem Observation.a. SHALL contain [0..0] @nullFlavor (CONF:1137-500).b. SHALL contain exactly one [1..1] @root (CONF:1137-964).

3.41Infant Living at Time of Report? - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.58:27Oct2014 (open)]

Table 158: Infant Living at Time of Report? Contexts



Table 159: Infant Living at Time of Report? Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


6332.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-635

2.16.840.1.113883.10.14.58


27Oct2014

id 1..* SHALL 1137-636

@root 1..1 SHALL 1137-983

code 1..1 SHALL 1137-638

@code 1..1 SHALL 1137-639

73757-7


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Infant living at time of report

text 1..1 SHALL 1137-637

value 1..1 SHALL BL 1137-643

@value 1..1 SHALL BL 1137-984







5. SHALL contain exactly one [1..1] code (CONF:1137-638).a. This code SHALL contain exactly one [1..1] @code="73757-7" to specify if Infant

living is at time of report (CONF:1137-639).b. This code SHALL contain exactly one [1..1]



d. This code SHALL contain exactly one [1..1] @displayName="Infant living at time of report" (CONF:1137-642).

6. SHALL contain exactly one [1..1] text (CONF:1137-637).7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1137-643) such that

ita. SHALL contain exactly one [1..1] @value (CONF:1137-984).

3.42Instructions - Published[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.20 (open)]

Table 160: Instructions Contexts

Contained By: Contains:Medication Activity (optional)Medication Supply Order (optional)Procedure Activity Procedure (optional)Plan of Care Section (optional)Procedure Activity Act (optional)Procedure Activity Observation (optional)

The Instructions template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The act/code defines the type of instruction. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through act/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode.


Table 161: Instructions Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


73912.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.5.1001 (ActMood) = INT


@root 1..1 SHALL 81-10503

2.16.840.1.113883.10.20.22.4.20

code 1..1 SHALL 81-16884

2.16.840.1.113883.11.20.9.34 (Patient Education)

text 0..1 SHOULD

81-7395


81-15577

@value 0..1 SHOULD

81-15578


@code 1..1 SHALL 81-19106


1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-7391).

2. SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:81-7392).


(CONF:81-10503).4. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Patient

Education 2.16.840.1.113883.11.20.9.34 DYNAMIC (CONF:81-16884).5. SHOULD contain zero or one [0..1] text (CONF:81-7395).

a. The text, if present, SHOULD contain zero or one [0..1] reference (CONF:81-15577).

i. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:81-15578).

1. This @value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15579).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19106).


3.43Karyotype Determination - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.59:27Oct2014 (open)]

Table 162: Karyotype Determination Contexts




Table 163: Karyotype Determination Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


2932.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-297

2.16.840.1.113883.10.14.59


27Oct2014

code 1..1 SHALL 1137-296

@code 1..1 SHALL 1137-300

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 (Karyotype Determination)


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 (Karyotype Determination)


1137-302


1137-303

@value 0..1 SHOULD

1137-304


@code 1..1 SHALL 1137-813

2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = completed











b. MAY contain zero or one [0..1] @extension="27Oct2014" (CONF:1137-1493).4. SHALL contain exactly one [1..1] code (CONF:1137-296).

a. This code SHALL contain exactly one [1..1] @code (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 DYNAMIC) (ValueSet: Karyotype Determination 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 DYNAMIC) (CONF:1137-300).

b. This code SHALL contain exactly one [1..1] @codeSystem (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 DYNAMIC) (ValueSet: Karyotype Determination 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 DYNAMIC) (CONF:1137-301).

c. This code SHOULD contain zero or one [0..1] originalText (CONF:1137-302).i. The originalText, if present, SHOULD contain zero or one [0..1] reference





(CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-813).

6. SHALL contain exactly one [1..1] entryRelationship (CONF:1137-798) such that ita. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:



3.44Location of Death - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.60:27Oct2014 (open)]

Table 164: Location of Death Contexts



Table 165: Location of Death Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


6662.16.840.1.113883.5.6 (HL7ActClass)


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-668

2.16.840.1.113883.10.14.60


27Oct2014

id 1..* SHALL 1137-669

@root 1..1 SHALL 1137-985

code 1..1 SHALL 1137-664

@code 1..1 SHALL 1137-670

58332-8


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Location of death

text 1..1 SHALL 1137-674


@code 1..1 SHALL 1137-675

2.16.840.1.113883.5.14 (ActStatus) = complete


value 1..1 SHALL ST 1137-677

1. SHALL contain exactly one [1..1] @classCode (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-666).



(CONF:1137-668).




a. This code SHALL contain exactly one [1..1] @code="58332-8" to specify Location of death (CONF:1137-670).

b. This code SHALL contain exactly one [1..1] @codeSystem=" 2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-671).


d. This code SHALL contain exactly one [1..1] @displayName="Location of death" (CONF:1137-673).


a. This statusCode SHALL contain exactly one [1..1] @code="complete" Complete (CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-675).

8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-676).9. SHALL contain exactly one [1..1] value with @xsi:type="ST" (CONF:1137-677).

3.45Maternal Morbidity - Admission to Intensive Care [unit] - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.61:27Oct2014 (open)]

Table 166: Maternal Morbidity - Admission to Intensive Care [unit] Contexts



Table 167: Maternal Morbidity - Admission to Intensive Care [unit] Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1158@root 1..1 SHALL 1137-

11602.16.840.1.113883.10.14.61


27Oct2014

code 1..1 SHALL 1137-1159


1137-1369


@code 1..1 SHALL 1137-1161

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 (ICU Care (NCHS))


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96



@displayName 1..1 SHOULD

1137-1164

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 (ICU Care (NCHS))


@code 1..1 SHALL 1137-1166

completed




2. SHALL contain exactly one [1..1] code (CONF:1137-1159) such that ita. SHOULD contain zero or one [0..1] @nullFlavor, which SHALL be selected from


b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ICU Care (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 DYNAMIC (CONF:1137-1161).

c. SHALL contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1162).



e. SHOULD contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet ICU Care (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 (CONF:1137-1164).


(CONF:1137-1166).4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1167).

3.46Maternal Morbidity: [Third or fourth degree] perineal laceration - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.62:27Oct2014 (open)]

Table 168: Maternal Morbidity: [Third or fourth degree] perineal laceration Contexts



Table 169: Maternal Morbidity: [Third or fourth degree] perineal laceration Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1193@root 1..1 SHALL 1137-

11952.16.840.1.113883.10.14.62


27Oct2014

code 1..1 SHALL 1137-1194


1137-1370


@code 1..1 SHALL 1137-1196

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 (Fourth Degree Perineal Laceration) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 (Third Degree Perineal Laceration)


2.16.840.1.113883.6.96 (SNOMED CT)




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 (Fourth Degree Perineal Laceration) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 (Third Degree Perineal Laceration)





b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Fourth Degree Perineal Laceration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 DYNAMIC OR Third Degree Perineal Laceration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 DYNAMIC (CONF:1137-1196).

c. SHALL contain exactly one [1..1] @codeSystem (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1197).



e. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Fourth Degree Perineal Laceration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 DYNAMIC OR Third Degree Perineal Laceration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 DYNAMIC (CONF:1137-1199).

3.47Maternal Morbidity: Maternal Transfusion - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.63:27Oct2014 (open)]

Table 170: Maternal Morbidity: Maternal Transfusion Contexts



Table 171: Maternal Morbidity: Maternal Transfusion Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10192.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1497

2.16.840.1.113883.10.14.63


27Oct2014

code 1..1 SHALL 1137-1023

@code 1..1 SHALL 1137-1024

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 (Transfusion Whole Blood or Packed Red Blood)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 (Transfusion Whole Blood or Packed Red Blood)


@code 1..1 SHALL 1137-1029







4. SHALL contain exactly one [1..1] code (CONF:1137-1023).a. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from

ValueSet Transfusion Whole Blood or Packed Red Blood 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 (CONF:1137-1024).




d. This code SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Transfusion Whole Blood or Packed Red Blood 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 (CONF:1137-1027).

5. SHALL contain exactly one [1..1] statusCode (CONF:1137-1028) such that ita. SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem:

ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1029).6. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1030).

3.48Maternal Morbidity: Ruptured Uterus - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.64:27Oct2014 (open)]

Table 172: Maternal Morbidity: Ruptured Uterus Contexts



Table 173: Maternal Morbidity: Ruptured Uterus Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1200@root 1..1 SHALL 1137-

12022.16.840.1.113883.10.14.64


27Oct2014

code 1..1 SHALL 1137-1201

@code 1..1 SHALL 1137-1203

2.16.840.1.113883.6.96 (SNOMED CT) = 156231001


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




Ruptured uterus


@code 1..1 SHALL 1137-1208




@code 1..1 SHALL 1137-1211

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.102 (Ruptured Uterus)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.102 (Ruptured Uterus)



2. SHALL contain exactly one [1..1] code (CONF:1137-1201) such that ita. SHALL contain exactly one [1..1] @code="156231001" for Ruptured uterus

(CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1203).




d. SHALL contain exactly one [1..1] @displayName="Ruptured uterus" (CONF:1137-1206).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1208).4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1210).5. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1137-1209) such

that ita. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet

Ruptured Uterus 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.102 DYNAMIC (CONF:1137-1211).

b. SHALL contain exactly one [1..1] @codeSystem=" 2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1212).


d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Ruptured Uterus 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.102 DYNAMIC (CONF:1137-1214).

3.49Maternal Morbidity: Unplanned Hysterectomy - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.65:27Oct2014 (open)]

Table 174: Maternal Morbidity: Unplanned Hysterectomy Contexts



Table 175: Maternal Morbidity: Unplanned Hysterectomy Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10042.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-998

2.16.840.1.113883.10.14.65


27Oct2014

code 1..1 SHALL 1137-999

@code 1..1 SHALL 1137-1000

236987005


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




Emergency cesarean hysterectomy


@code 1..1 SHALL 1137-1007






4. SHALL contain exactly one [1..1] code (CONF:1137-999) such that ita. SHALL contain exactly one [1..1] @code="236987005" (CONF:1137-1000).b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96"

(CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:1137-1001).c. SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CodeSystem:

SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1002).


d. SHALL contain exactly one [1..1] @displayName="Emergency cesarean hysterectomy" (CONF:1137-1003).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1007).

3.50Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery] - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.66:27Oct2014 (open)]

Table 176: Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery] Contexts


Table 177: Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery] Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10092.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 0..1 MAY 1137-1011

2.16.840.1.113883.10.14.66


27Oct2014

code 1..1 SHALL 1137-1012

@code 1..1 SHALL 1137-1013

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105 (Unplanned Operation)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105 (Unplanned Operation)


@code 1..1 SHALL 1137-1018





3. SHALL contain exactly one [1..1] templateId (CONF:1137-1008) such that ita. MAY contain zero or one [0..1] @root="2.16.840.1.113883.10.14.66"


4. SHALL contain exactly one [1..1] code (CONF:1137-1012) such that ita. SHALL contain exactly one [1..1] @code (ValueSet: Unplanned Operation

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105) (CONF:1137-1013).b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96"

(CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1014).c. SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CodeSystem:

SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1015).d. SHALL contain exactly one [1..1] @displayName (ValueSet: Unplanned Operation

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105) (CONF:1137-1016).5. SHALL contain exactly one [1..1] statusCode (CONF:1137-1017).


3.51Maternal Risk Factors - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.67:27Oct2014 (open)]

Table 178: Maternal Risk Factors Contexts

Contained By: Contains:Prior Pregnancy History Section (NEW) (required)

Information on one or more risk factors of the mother during pregnancy.


Table 179: Maternal Risk Factors Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


14122.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1414

2.16.840.1.113883.10.14.67


27Oct2014

code 1..1 SHALL 1137-1410

@code 1..1 SHALL 1137-1415

2.16.840.1.113883.6.1 (LOINC) = 73775-9


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Risk factors in this pregnancy

text 1..1 SHALL 1137-1419



1137-1421


@code 1..1 SHALL 1137-1420

2.16.840.1.114222.4.11.7126 (Pregnancy Risk Factors (NCHS) )


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




2.16.840.1.114222.4.11.7126 (Pregnancy Risk Factors (NCHS) )






4. SHALL contain exactly one [1..1] code (CONF:1137-1410) such that ita. SHALL contain exactly one [1..1] @code="73775-9" to specify Risk factors in this

pregnancy (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1415).b. SHALL contain exactly one [1..1] @codeSystem=" 2.16.840.1.113883.6.1"


2.16.840.1.113883.6.1) (CONF:1137-1417).d. SHALL contain zero or one [0..1] @displayName="Risk factors in this

pregnancy" (CONF:1137-1418).5. SHALL contain exactly one [1..1] text (CONF:1137-1419).6. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1137-1411) such



b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Pregnancy Risk Factors (NCHS) 2.16.840.1.114222.4.11.7126 (CONF:1137-1420).



e. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Pregnancy Risk Factors (NCHS) 2.16.840.1.114222.4.11.7126 DYNAMIC (CONF:1137-1424).

3.52Medication Activity - Published[substanceAdministration: identifier urn:oid:2.16.840.1.113883.10.20.22.4.16 (open)]

Table 180: Medication Activity Contexts

Contained By: Contains:Reaction Observation (optional)Procedure Activity Procedure (optional)Medications Section (entries required) (required)Medications Section (entries optional) (optional)Procedure Activity Act (optional)Procedure Activity Observation (optional)Medications Administered Section (optional)

Drug VehicleIndicationInstructionsMedication DispenseMedication InformationMedication Supply OrderPrecondition for Substance AdministrationReaction Observation


A medication activity describes substance administrations that have actually occurred (e.g., pills ingested or injections given) or are intended to occur (e.g., "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. Medication activities in "EVN" mood reflect actual use.Medication timing is complex. This template requires that there be a substanceAdministration/effectiveTime valued with a time interval, representing the start and stop dates. Additional effectiveTime elements are optional, and can be used to represent frequency and other aspects of more detailed dosing regimens.


Table 181: Medication Activity Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value

substanceAdministration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.16)@classCode 1..1 SHALL 81-

74962.16.840.1.113883.5.6 (HL7ActClass) = SBADM


2.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)


@root 1..1 SHALL 81-10504

2.16.840.1.113883.10.20.22.4.16

id 1..* SHALL 81-7500

code 0..1 MAY 81-7506

text 0..1 SHOULD

81-7501


81-15977

@value 0..1 SHOULD

81-15978



low 1..1 SHALL 81-7511

high 1..1 SHALL 81-7512


81-7513

@operator 1..1 SHALL 81-9106

A

repeatNumber 0..1 MAY 81-7555

routeCode 0..1 MAY 81-7514

2.16.840.1.113883.3.88.12.3221.8.7 (Medication Route FDA)

approachSiteCode 0..1 MAY SET<CD>

81-7515

2.16.840.1.113883.3.88.12.3221.8.9 (Body Site)

doseQuantity 0..1 SHOULD

81-7516

@unit 0..1 SHOULD

81-7526

2.16.840.1.113883.1.11.12839 (UnitsOfMeasureCaseSensitive)

rateQuantity 0..1 MAY 81-7517

@unit 1..1 SHALL 81-7525

2.16.840.1.113883.1.11.12839 (UnitsOfMeasureCaseSensitive)


maxDoseQuantity 0..1 MAY RTO<PQ, PQ>

81-7518

administrationUnitCode 0..1 MAY 81-7519

2.16.840.1.113883.3.88.12.3221.8.11 (Medication Product Form Value Set)

consumable 1..1 SHALL 81-7520

manufacturedProduct 1..1 SHALL 81-16085

Medication Information (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.23

performer 0..1 MAY 81-7522



2.16.840.1.113883.5.90 (HL7ParticipationType) = CSM

participantRole 1..1 SHALL 81-16086

Drug Vehicle (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.24

entryRelationship 0..* MAY 81-7536




Indication (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.19





true

act 1..1 SHALL 81-16088




2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR

supply 1..1 SHALL 81-16089

Medication Supply Order (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.17






Medication Dispense (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.18



2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = CAUS


Reaction Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.9

precondition 0..* MAY 81-7546


2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = PRCN

criterion 1..1 SHALL 81-16092

Precondition for Substance Administration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.25

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-7496).

2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:81-7497).


(CONF:81-10504).4. SHALL contain at least one [1..*] id (CONF:81-7500).5. MAY contain zero or one [0..1] code (CONF:81-7506).6. SHOULD contain zero or one [0..1] text (CONF:81-7501).




7. SHALL contain exactly one [1..1] statusCode (CONF:81-7507).8. SHALL contain exactly one [1..1] effectiveTime (CONF:81-7508) such that it

a. SHALL contain exactly one [1..1] low (CONF:81-7511).b. SHALL contain exactly one [1..1] high (CONF:81-7512).

9. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-7513) such that it


a. SHALL contain exactly one [1..1] @operator="A" (CONF:81-9106).b. SHALL contain exactly one 1..1] @xsi:type=”PIVLTS” or “EIVLTS” (CONF:81-9105).

10. MAY contain zero or one [0..1] repeatNumber (CONF:81-7555).a. In "INT" (intent) mood, the repeatNumber defines the number of allowed

administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series (CONF:81-16877).

11. MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:81-7514).

12. MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:81-7515).

13. SHOULD contain zero or one [0..1] doseQuantity (CONF:81-7516).a. The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which

SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:81-7526).

b. Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet") (CONF:81-16878).

c. Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:81-16879).

14. MAY contain zero or one [0..1] rateQuantity (CONF:81-7517).a. The rateQuantity, if present, SHALL contain exactly one [1..1] @unit, which SHALL

be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:81-7525).

15. MAY contain zero or one [0..1] maxDoseQuantity (CONF:81-7518).16. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from

ValueSet Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC (CONF:81-7519).

17. SHALL contain exactly one [1..1] consumable (CONF:81-7520).a. This consumable SHALL contain exactly one [1..1] Medication Information

(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.23) (CONF:81-16085).18. MAY contain zero or one [0..1] performer (CONF:81-7522).19. MAY contain zero or more [0..*] participant (CONF:81-7523) such that it

a. SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-7524).

b. SHALL contain exactly one [1..1] Drug Vehicle (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.24) (CONF:81-16086).


20. MAY contain zero or more [0..*] entryRelationship (CONF:81-7536) such that ita. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7537).b. SHALL contain exactly one [1..1] Indication (identifier:


a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7540).

b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:81-7542).c. SHALL contain exactly one [1..1] Instructions (identifier:


a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7547).

b. SHALL contain exactly one [1..1] Medication Supply Order (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.17) (CONF:81-16089).

23. MAY contain zero or more [0..*] entryRelationship (CONF:81-7549) such that ita. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7553).b. SHALL contain exactly one [1..1] Medication Dispense (identifier:


a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7544).

b. SHALL contain exactly one [1..1] Reaction Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.9) (CONF:81-16091).

25. MAY contain zero or more [0..*] precondition (CONF:81-7546) such that ita. SHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7550).b. SHALL contain exactly one [1..1] Precondition for Substance Administration

(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.25) (CONF:81-16092).26. Medication Activity SHOULD include doseQuantity OR rateQuantity (CONF:81-7529).


3.53Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) - Draft[substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.14.15:27Oct2014 (open)]

Table 182: Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) Contexts

Contained By: Contains:Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW) (required)Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (required)


Table 183: Medication Activity (V2) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


919@root 1..1 SHALL 1137-

9202.16.840.1.113883.10.14.15


27Oct2014









3. SHALL contain at least one [1..*] entryRelationship (CONF:1137-921) such that ita. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:




3.54Medication Dispense - Published[supply: identifier urn:oid:2.16.840.1.113883.10.20.22.4.18 (open)]

Table 184: Medication Dispense Contexts

Contained By: Contains:Medication Activity (optional) Immunization Medication Information

Medication InformationMedication Supply Order

This template records the act of supplying medications (i.e., dispensing).


Table 185: Medication Dispense Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value

supply (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.18)@classCode 1..1 SHALL 81-

74512.16.840.1.113883.5.6 (HL7ActClass) = SPLY


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10505

2.16.840.1.113883.10.20.22.4.18

id 1..* SHALL 81-7454


2.16.840.1.113883.3.88.12.80.64 (Medication Fill Status)


81-7456

repeatNumber 0..1 SHOULD

81-7457

quantity 0..1 SHOULD

81-7458

product 0..1 MAY 81-7459





Immunization Medication Information (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.54

performer 0..1 MAY 81-7461


addr 0..1 SHOULD

81-7468





Medication Supply Order (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.17


1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-7451).



(CONF:81-10505).4. SHALL contain at least one [1..*] id (CONF:81-7454).5. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet

Medication Fill Status 2.16.840.1.113883.3.88.12.80.64 DYNAMIC (CONF:81-7455).

6. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-7456).7. SHOULD contain zero or one [0..1] repeatNumber (CONF:81-7457).

a. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a dispense act means that the current dispensation is the 3rd (CONF:81-16876).

8. SHOULD contain zero or one [0..1] quantity (CONF:81-7458).9. MAY contain zero or one [0..1] product (CONF:81-7459) such that it

a. SHALL contain exactly one [1..1] Medication Information (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.23) (CONF:81-15607).

10. MAY contain zero or one [0..1] product (CONF:81-9331) such that ita. SHALL contain exactly one [1..1] Immunization Medication Information

(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.54) (CONF:81-15608).11. MAY contain zero or one [0..1] performer (CONF:81-7461).

a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:81-7467).

i. This assignedEntity SHOULD contain zero or one [0..1] addr (CONF:81-7468).


12. MAY contain zero or one [0..1] entryRelationship (CONF:81-7473) such that ita. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7474).b. SHALL contain exactly one [1..1] Medication Supply Order (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.17) (CONF:81-15606).13. A supply act SHALL contain one product/Medication Information or one

product/Immunization Medication Information template (CONF:81-9333).


3.55Medication Information - Published[manufacturedProduct: identifier urn:oid:2.16.840.1.113883.10.20.22.4.23 (open)]

Table 186: Medication Information Contexts

Contained By: Contains:Medication Activity (required)Medication Supply Order (optional)Medication Dispense (optional)

The medication can be recorded as a pre-coordinated product strength, product form, or product concentration (e.g., “metoprolol 25mg tablet”, “amoxicillin 400mg/5mL suspension”) or not pre-coordinated (e.g., “metoprolol product”).To report immunizations administered, the vaccinations are represented using CVX codes instead of RxNorm codes. This should be reported by setting the manufacturedMaterial/code/@nullFlavor="OTH", and the code from the CVX code system should be sent using the manufacturedMaterial/code/translation/code.

Table 187: Medication Information Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

manufacturedProduct (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.23)@classCode 1..1 SHALL 81-

74082.16.840.1.113883.5.110 (RoleClass) = MANU


@root 1..1 SHALL 81-10506

2.16.840.1.113883.10.20.22.4.23

id 0..* MAY 81-7410

manufacturedMaterial 1..1 SHALL 81-7411

code 1..1 SHALL 81-7412

2.16.840.1.113883.3.88.12.80.17 (Medication Clinical Drug Name Value Set)


81-7413


81-15986

@value 0..1 SHOULD

81-15987

translation 0..* MAY SET<PQR>

81-7414

manufacturerOrganization 0..1 MAY 81-7416




(CONF:81-10506).3. MAY contain zero or more [0..*] id (CONF:81-7410).4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:81-7411).

a. This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Medication Clinical Drug Name Value Set 2.16.840.1.113883.3.88.12.80.17 DYNAMIC (CONF:81-7412).

i. This code SHOULD contain zero or one [0..1] originalText (CONF:81-7413).

1. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:81-15986).

a. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:81-15987).

i. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15988).

ii. This code MAY contain zero or more [0..*] translation (CONF:81-7414).1. Translations can be used to represent generic product name,

packaged product code, etc (CONF:81-16875).5. MAY contain zero or one [0..1] manufacturerOrganization (CONF:81-7416).

3.56Medication Supply Order - Published[supply: identifier urn:oid:2.16.840.1.113883.10.20.22.4.17 (open)]

Table 188: Medication Supply Order Contexts

Contained By: Contains:Medication Activity (optional)Medication Dispense (optional)

Immunization Medication InformationInstructionsMedication Information

This template records the intent to supply a patient with medications.


Table 189: Medication Supply Order Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


74272.16.840.1.113883.5.6 (HL7ActClass) = SPLY


2.16.840.1.113883.5.1001 (ActMood) = INT


@root 1..1 SHALL 81-10507

2.16.840.1.113883.10.20.22.4.17

id 1..* SHALL 81-7430



IVL_TS 81-15143

high 1..1 SHALL 81-15144

repeatNumber 0..1 SHOULD

81-7434

quantity 0..1 SHOULD

81-7436






Immunization Medication Information (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.54

author 0..1 MAY 81-7438





true

act 1..1 SHALL 81-16095




2. SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:81-7428).


(CONF:81-10507).4. SHALL contain at least one [1..*] id (CONF:81-7430).5. SHALL contain exactly one [1..1] statusCode (CONF:81-7432).6. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-15143) such that it

a. SHALL contain exactly one [1..1] high (CONF:81-15144).7. SHOULD contain zero or one [0..1] repeatNumber (CONF:81-7434).

a. In "INT" (intent) mood, the repeatNumber defines the number of allowed fills. For example, a repeatNumber of "3" means that the substance can be supplied up to 3 times (or, can be dispensed, with 2 refills) (CONF:81-16869).

8. SHOULD contain zero or one [0..1] quantity (CONF:81-7436).9. MAY contain zero or one [0..1] product (CONF:81-7439) such that it

a. SHALL contain exactly one [1..1] Medication Information (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.23) (CONF:81-16093).

10. MAY contain zero or one [0..1] product (CONF:81-9334) such that ita. SHALL contain exactly one [1..1] Immunization Medication Information

(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.54) (CONF:81-16094).i. A supply act SHALL contain one product/Medication Information or one

product/Immunization Medication Information template (CONF:81-16870).11. MAY contain zero or one [0..1] author (CONF:81-7438).12. MAY contain zero or one [0..1] entryRelationship (CONF:81-7442).

a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7444).

b. The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:81-7445).

c. The entryRelationship, if present, SHALL contain exactly one [1..1] Instructions (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.20) (CONF:81-16095).

3.57Method of Delivery: [Final] Route and Method of Delivery - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.68:27Oct2014 (open)]

Table 190: Method of Delivery: [Final] Route and Method of Delivery Contexts



Table 191: Method of Delivery: [Final] Route and Method of Delivery Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


10782.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1080

2.16.840.1.113883.10.14.68


27Oct2014

code 1..1 SHOULD

1137-1077

@code 1..1 SHALL 1137-1081

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 (Route and Method of Delivery - Cesarean) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 (Route and Method of Delivery - Spontaneous)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 (Route and Method of Delivery - Forceps) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 (Route and Method of Delivery – Vacuum)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 (Route and Method of Delivery - Cesarean) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 (Route and Method of Delivery - Spontaneous)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 (Route and Method of Delivery - Forceps) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 (Route and Method of Delivery – Vacuum)


@code 1..1 SHALL 1137-1086








4. SHOULD contain exactly one [1..1] code (CONF:1137-1077) such that ita. SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet

Route and Method of Delivery - Cesarean 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 DYNAMIC OR Route and Method of Delivery - Spontaneous 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 DYNAMIC or Route and Method of Delivery - Forceps 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 DYNAMIC or Route and Method of Delivery – Vacuum 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 DYNAMIC (CONF:1137-1081).



d. SHALL contain exactly one [1..1] @displayName, which SHOULD be selected from ValueSet Route and Method of Delivery - Cesarean 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 DYNAMIC OR Route and Method of Delivery - Spontaneous 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 DYNAMIC or Route and Method of Delivery - Forceps 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 DYNAMIC or Route and Method of Delivery – Vacuum 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 DYNAMIC (CONF:1137-1084).



3.58Method of Delivery: Fetal Presentation [at birth] - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.69:27Oct2014 (open)]

Table 192: Method of Delivery: Fetal Presentation [at birth] Contexts



Table 193: Method of Delivery: Fetal Presentation [at birth] Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


1168@root 1..1 SHALL 1137-

11692.16.840.1.113883.10.14.69


27Oct2014

code 1..1 SHALL 1137-1170

@code 1..1 SHALL 1137-1171

2.16.840.1.113883.6.1 (LOINC) = 73761-9


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Fetal presentation at birth [US Standard Certificate of Live Birth]


@code 1..1 SHALL 1137-1176





1137-1371


@code 1..1 SHALL 1137-1179

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 (Fetal Presentation at Birth- Breech)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 (Fetal Presentation at Birth- Cephalic) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 (Fetal Presentation at Birth- Other)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 (Fetal Presentation at Birth- Breech) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 (Fetal Presentation at Birth-


Cephalic) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 (Fetal Presentation at Birth- Other)



2. SHALL contain exactly one [1..1] code (CONF:1137-1170) such that ita. SHALL contain exactly one [1..1] @code="73761-9" to specify Fetal presentation

at birth (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1171).b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1"


2.16.840.1.113883.6.1) (CONF:1137-1173).d. SHALL contain exactly one [1..1] @displayName="Fetal presentation at birth

[US Standard Certificate of Live Birth]" (CONF:1137-1174).3. SHALL contain exactly one [1..1] statusCode (CONF:1137-1175).


4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1178).5. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1137-1177) such



b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Fetal Presentation at Birth- Breech 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 DYNAMIC OR Fetal Presentation at Birth- Cephalic 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 DYNAMIC OR Fetal Presentation at Birth- Other 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 DYNAMIC (CONF:1137-1179).



e. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Fetal Presentation at Birth- Breech 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 DYNAMIC OR Fetal Presentation at Birth- Cephalic 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 DYNAMIC OR Fetal Presentation at Birth- Other 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 DYNAMIC (CONF:1137-1182).


3.59Method of Delivery: Trial of Labor Attempted - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.70:27Oct2014 (open)]

Table 194: Method of Delivery: Trial of Labor Attempted Contexts



Table 195: Method of Delivery: Trial of Labor Attempted Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10892.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1091

2.16.840.1.113883.10.14.70


27Oct2014

code 1..1 SHALL 1137-1092

@code 1..1 SHALL 1137-1093

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 (Route Method of Delivery - Trial of Labor)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 (Route and Method of Delivery - Scheduled C)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 (Route and Method of Delivery – Cesarean)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 (Route Method of Delivery - Trial of Labor) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 (Route and Method of Delivery - Scheduled C)1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 (Route and Method of Delivery – Cesarean)


@code 1..1 SHALL 1137-1098








4. SHALL contain exactly one [1..1] code (CONF:1137-1092).a. This code SHALL contain exactly one [1..1] @code, which SHOULD be selected from

ValueSet Route Method of Delivery - Trial of Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 DYNAMIC OR Route and Method of Delivery - Scheduled C 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 DYNAMIC or Route and Method of Delivery – Cesarean 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 DYNAMIC (CONF:1137-1093).



d. This code SHALL contain exactly one [1..1] @displayName, which SHOULD be selected from ValueSet Route Method of Delivery - Trial of Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 DYNAMIC OR Route and Method of Delivery - Scheduled C 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 DYNAMIC or Route and Method of Delivery – Cesarean 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 DYNAMIC (CONF:1137-1096).



3.60Mother's Weight at Delivery - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.71:27Oct2014 (open)]

Table 196: Mother's Weight at Delivery Contexts

Contained By: Contains:Vital Signs Section - LD BD IG Specific (optional)


Table 197: Mother's Weight at Delivery Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


3112.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-314

2.16.840.1.113883.10.14.71


27Oct2014

id 1..1 SHALL 1137-316

@root 1..1 SHALL 1137-986

code 1..1 SHALL 1137-317

@code 1..1 SHALL 1137-318

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 (Mother’s Delivery Weight)


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 (Mother’s Delivery Weight)

statusCode 0..1 MAY 1137-324

@code 0..1 MAY 1137-327

completed

effectiveTime 0..1 MAY 1137-325

@value 1..1 SHALL 1137-328


@value 1..1 SHALL 1137-329

@unit 1..1 SHALL 1137-330




(CONF:1137-314).


b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-315).4. SHALL contain exactly one [1..1] id (CONF:1137-316) such that it


a. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Mother’s Delivery Weight 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 (CONF:1137-318).

b. This code SHALL contain exactly one [1..1] @codeSystem, which SHALL be selected from ValueSet Mother’s Delivery Weight 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 (CONF:1137-323).

6. MAY contain zero or one [0..1] statusCode (CONF:1137-324).a. The statusCode, if present, MAY contain zero or one [0..1] @code="completed"

Completed (CONF:1137-327).7. MAY contain zero or one [0..1] effectiveTime (CONF:1137-325).

a. The effectiveTime, if present, SHALL contain exactly one [1..1] @value (CONF:1137-328).

8. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:1137-326) such that it

a. SHALL contain exactly one [1..1] @value (CONF:1137-329).b. SHALL contain exactly one [1..1] @unit (CONF:1137-330).

3.61Newborn given Surfactant replacement therapy? - Draft[substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.14.72:27Oct2014 (open)]

Table 198: Newborn given Surfactant replacement therapy? Contexts

Contained By: Contains:Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (required)



Table 199: Newborn given Surfactant replacement therapy? Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value

substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.14.72:27Oct2014)@classCode 1..1 SHALL 1137-



2.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt) = INT


@root 1..1 SHALL 1137-843

2.16.840.1.113883.10.14.72


27Oct2014

code 1..1 SHALL 1137-844


1137-1359


@code 1..1 SHALL 1137-845

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 (Newborn Receiving Surfactant Replacement Therapy)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 (Newborn Receiving Surfactant Replacement Therapy)


@code 1..1 SHALL 1137-851

2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = completed


@value 0..1 SHOULD

1137-855








2. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-307).

3. SHALL contain exactly one [1..1] @moodCode="INT" (ValueSet: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC) (CONF:1137-308).



5. SHALL contain exactly one [1..1] code (CONF:1137-844).a. This code SHOULD contain zero or one [0..1] @nullFlavor, which SHALL be

selected from ValueSet NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17 (CONF:1137-1359).

b. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Newborn Receiving Surfactant Replacement Therapy 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 (CONF:1137-845).

c. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-846).

d. This code SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-847).

e. This code SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Newborn Receiving Surfactant Replacement Therapy 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 (CONF:1137-848).


(CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-851).

7. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-852) such that ita. SHOULD contain zero or one [0..1] @value (CONF:1137-855).





3.62Number of Fetal Deaths - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.73:27Oct2014 (open)]

Table 200: Number of Fetal Deaths Contexts

Contained By: Contains:Labor and Delivery Events Section (NEW) (optional)

Table 201: Number of Fetal Deaths Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1147@root 1..1 SHALL 1137-

11482.16.840.1.113883.10.14.73


27Oct2014

code 1..1 SHALL 1137-1149

@code 1..1 SHALL 1137-1150

2.16.840.1.113883.6.1 (LOINC) = 57062-2


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Births.stillborn


@code 1..1 SHALL 1137-1155








a. SHALL contain exactly one [1..1] @code="57062-2" to specify the number of infants in this delivery born alive. (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1150).

b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1151).


d. SHALL contain exactly one [1..1] @displayName="Births.stillborn" (CONF:1137-1153).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1155).4. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1137-1156) such

that ita. SHALL contain exactly one [1..1] @value (CONF:1137-1157).

3.63Number of Pressure Ulcers Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.76 (open)]

Table 202: Number of Pressure Ulcers Observation Contexts


This clinical statement enumerates the number of pressure ulcers observed in a particular stage.


Table 203: Number of Pressure Ulcers Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


147052.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-14708

2.16.840.1.113883.10.20.22.4.76

id 1..* SHALL 81-14709

code 1..1 SHALL 81-14767

@code 1..1 SHALL 81-14768

2264892003


@code 1..1 SHALL 81-19108




author 0..1 MAY 81-14717






2.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


2.16.840.1.113883.11.20.9.35 (Pressure Ulcer Stage)






a. This code SHALL contain exactly one [1..1] @code="2264892003" number of pressure ulcers (CONF:81-14768).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19108).7. SHALL contain exactly one [1..1] effectiveTime (CONF:81-14715).8. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:81-14771).9. MAY contain zero or one [0..1] author (CONF:81-14717).10. SHALL contain exactly one [1..1] entryRelationship (CONF:81-14718).

a. This entryRelationship SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-14719).

b. This entryRelationship SHALL contain exactly one [1..1] observation (CONF:81-14720).

i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-14721).

ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:81-14722).

iii. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 STATIC (CONF:81-14725).


Figure 14: Number of Pressure Ulcers Example

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.76"/> <id root="08edb7c0-2111-43f2-a784-9a5fdfaa67f0"/> <code code="2264892003" codeSystem="2.16.840.1.113883.6.96" displayName="number of pressure ulcers"/> <statusCode code="completed"/> <value xsi:type="INT" value="3"/> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <value xsi:type="CD" code="421927004" codeSystem="2.16.840.1.113883.6.96" displayName="Pressure ulcer stage 3"/> </observation> </entryRelationship></observation>

3.64Obstetric Procedures: Cervical Cerclage - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.74:27Oct2014 (open)]

Table 204: Obstetric Procedures: Cervical Cerclage Contexts



Table 205: Obstetric Procedures: Cervical Cerclage Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10592.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1061

2.16.840.1.113883.10.14.74


27Oct2014

code 1..1 SHALL 1137-1062

@code 1..1 SHALL 1137-1063

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125 (Cervical Cerclage)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125 (Cervical Cerclage)





4. SHALL contain exactly one [1..1] code (CONF:1137-1062).a. This code SHALL contain exactly one [1..1] @code (ValueSet: Cervical Cerclage

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125) (CONF:1137-1063).b. This code SHALL contain exactly one [1..1]



d. This code SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Cervical Cerclage 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125 DYNAMIC (CONF:1137-1066).


3.65Obstetric Procedures: Tocolysis - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.75:27Oct2014 (open)]

Table 206: Obstetric Procedures: Tocolysis Contexts


Table 207: Obstetric Procedures: Tocolysis Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


10682.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1070

2.16.840.1.113883.10.14.75


27Oct2014

code 1..1 SHALL 1137-1071

@code 1..1 SHALL 1137-1072

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 (Tocolysis)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 (Tocolysis)







a. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Tocolysis 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 DYNAMIC (CONF:1137-1072).



d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Tocolysis 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 DYNAMIC (CONF:1137-1075).

3.66Onset of Labor: Precipitous Labor - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.76:27Oct2014 (open)]

Table 208: Onset of Labor: Precipitous Labor Contexts



Table 209: Onset of Labor: Precipitous Labor Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1215@root 1..1 SHALL 1137-

12172.16.840.1.113883.10.14.76


27Oct2014

code 1..1 SHALL 1137-1216


1137-1372


@code 1..1 SHALL 1137-1218

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130 (Precipitous Labor)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130 (Precipitous Labor)


@code 1..1 SHALL 1137-1223







b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Precipitous Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130 DYNAMIC (CONF:1137-1218).




e. SHALL contain zero or one [0..1] @displayName (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (ValueSet: Precipitous Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130) (CONF:1137-1222).



3.67Onset of Labor: Premature Rupture - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.77:27Oct2014 (open)]

Table 210: Onset of Labor: Premature Rupture Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1267@root 1..1 SHALL 1137-

12692.16.840.1.113883.10.14.77


27Oct2014

code 1..1 SHALL 1137-1268


1137-1373


@code 1..1 SHALL 1137-1270

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129 (Premature Rupture)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129 (Premature Rupture)


@code 1..1 SHALL 1137-1275








b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Premature Rupture 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129 DYNAMIC (CONF:1137-1270).



e. SHALL contain exactly one [1..1] @displayName (ValueSet: Premature Rupture 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129) (CONF:1137-1274).



3.68Onset of Labor: Prolonged Labor - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.78:27Oct2014 (open)]

Table 211: Onset of Labor: Prolonged Labor Contexts



Table 212: Onset of Labor: Prolonged Labor Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1225@root 1..1 SHALL 1137-

12262.16.840.1.113883.10.14.78


27Oct2014

code 1..1 SHALL 1137-1227


1137-1374


@code 1..1 SHALL 1137-1228

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 (Prolonged Labor)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 (Prolonged Labor)


@code 1..1 SHALL 1137-1233







b. SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Prolonged Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 DYNAMIC (CONF:1137-1228).


d. SHALL contain exactly one [1..1] @codeSystemName=" SNOMED CT" (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-1230).


e. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Prolonged Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 DYNAMIC (CONF:1137-1231).



3.69Other Pregnancy Outcome - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.79:27Oct2014 (open)]

Table 213: Other Pregnancy Outcome Contexts


Total number of other pregnancy outcomes that did not result in a live birth. Includes pregnancy losses of any gestation age. For multiple deliveries include all previous pregnancy losses before this infant in this pregnancy and in previous pregnancies.


Table 214: Other Pregnancy Outcome Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


14342.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-1436

2.16.840.1.113883.10.14.79


27Oct2014

code 1..1 SHALL 1137-1432

@code 1..1 SHALL 1137-1437

2.16.840.1.113883.6.1 (LOINC) = 69043-8


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Other pregnancy outcomes

text 1..1 SHALL 1137-1441


1137-1433






4. SHALL contain exactly one [1..1] code (CONF:1137-1432) such that ita. SHALL contain exactly one [1..1] @code="69043-8" to specify Other pregnancy

outcomes (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1437).b. SHALL contain exactly one [1..1] @codeSystem=" 2.16.840.1.113883.6.1"

(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-1438).



d. SHALL contain exactly one [1..1] @displayName="Other pregnancy outcomes" (CONF:1137-1440).

5. SHALL contain exactly one [1..1] text (CONF:1137-1441).6. SHOULD contain zero or one [0..1] effectiveTime (CONF:1137-1433).

a. The date that the last pregnancy that did not result in a live birth ended. The effective time for the other pregnancy outcomes is the interval between the first such outcome and the latest. Value the high property of the interval data type (CONF:1137-1442).

7. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1137-1443).

3.70Place of Birth (type or birthing place) - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.80:27Oct2014 (open)]

Table 215: Place of Birth (type or birthing place) Contexts


Specify the type of place or situation in which the birth or delivery occurred.


Table 216: Place of Birth (type or birthing place) Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


6142.16.840.1.113883.5.6 (HL7ActClass) = BIRTHPL


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-616

2.16.840.1.113883.10.14.80


27Oct2014

id 1..* SHALL 1137-617

@root 1..1 SHALL 1137-987

code 1..1 SHALL 1137-619

@code 1..1 SHALL 1137-620

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.184 (Birthplace Setting (NCHS))


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.184 (Birthplace Setting (NCHS))

text 1..1 SHALL 1137-618


@code 1..1 SHALL 1137-627

2.16.840.1.114222.4.11.7124 (Birth or Delivery Occurred (NCHS))


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




2.16.840.1.114222.4.11.7124 (Birth or Delivery Occurred (NCHS))


1137-625



@value 1..1 SHALL 1137-631

1. SHALL contain exactly one [1..1] @classCode="BIRTHPL" Birth Place (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-614).





5. SHALL contain exactly one [1..1] code (CONF:1137-619).NOTE: A code that indicates the type of facility or place at which the delivery took place.

a. This code SHALL contain exactly one [1..1] @code (ValueSet: Birthplace Setting (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.184 DYNAMIC) (CONF:1137-620).



d. This code SHALL contain exactly one [1..1] @displayName (ValueSet: Birthplace Setting (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.184) (CONF:1137-623).

6. SHALL contain exactly one [1..1] text (CONF:1137-618).7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1137-624) such that

ita. SHALL contain exactly one [1..1] @code (ValueSet: Birth or Delivery Occurred

(NCHS) 2.16.840.1.114222.4.11.7124 STATIC) (CONF:1137-627).b. SHALL contain exactly one [1..1] @codeSystem=" 2.16.840.1.113883.6.96"

(CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-628).c. SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CodeSystem:

SNOMED CT 2.16.840.1.113883.6.96) (CONF:1137-629).d. SHALL contain exactly one [1..1] @displayName (ValueSet: Birth or Delivery

Occurred (NCHS) 2.16.840.1.114222.4.11.7124) (CONF:1137-630).e. SHOULD contain zero or one [0..1] originalText (CONF:1137-625).

NOTE: If the coded value is other, specify the place of birth here.i. The originalText, if present, SHALL contain exactly one [1..1] reference


(CONF:1137-631).


conf:1137-625

conf:1137-619

3.71Plan of Care Activity Act - Published[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.39 (open)]

Table 217: Plan of Care Activity Act Contexts

Contained By: Contains:Plan of Care Section (optional)

This is the generic template for the Plan of Care Activity.

Table 218: Plan of Care Activity Act Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


85382.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.11.20.9.23 (Planned moodCode (Act/Encounter/Procedure))


@root 1..1 SHALL 81-10510

2.16.840.1.113883.10.20.22.4.39

id 1..* SHALL 81-8546

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-8538).

2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:81-8539).


(CONF:81-10510).4. SHALL contain at least one [1..*] id (CONF:81-8546).

3.72Plan of Care Activity Encounter - Published[encounter: identifier urn:oid:2.16.840.1.113883.10.20.22.4.40 (open)]

Table 219: Plan of Care Activity Encounter Contexts


This is the template for the Plan of Care Activity Encounter.


Table 220: Plan of Care Activity Encounter Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

encounter (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.40)@classCode 1..1 SHALL 81-

85642.16.840.1.113883.5.6 (HL7ActClass) = ENC




@root 1..1 SHALL 81-10511

2.16.840.1.113883.10.20.22.4.40

id 1..* SHALL 81-8567

1. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-8564).




3.73Plan of Care Activity Encounter - Birth Defects IG Specific Constraints - Draft[encounter: identifier urn:hl7ii:2.16.840.1.113883.10.14.13:27Oct2014 (open)]

Table 221: Plan of Care Activity Encounter - Birth Defects IG Specific Constraints Contexts

Contained By: Contains:Plan of Care Section - Birth Defects IG Specific Constraints (NEW) (required)

This template describes further Birth Defects IG specific constraints to C-CDA R2.0 Plan of Care Activity Encounter template.


Table 222: Plan of Care Activity Encounter - Birth Defects IG Specific Constraints Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.14.13:27Oct2014)@classCode 1..1 SHALL 1137-

9712.16.840.1.113883.5.6 (HL7ActClass) = ENC



@root 1..1 SHALL 1137-973

2.16.840.1.113883.10.14.13

performer 1..1 SHALL 1137-974


participant 1..1 SHALL 1137-975


1. Conforms to Plan of Care Activity Encounter template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.40).

2. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-971).

3. SHALL contain exactly one [1..1] @moodCode (CONF:1137-972).4. SHALL contain exactly one [1..1] templateId (CONF:1137-970) such that it


5. SHALL contain exactly one [1..1] performer (CONF:1137-974) such that ita. SHALL contain exactly one [1..1] assignedEntity (CONF:1137-1357).

6. SHALL contain exactly one [1..1] participant (CONF:1137-975) such that ita. SHALL contain exactly one [1..1] participantRole (CONF:1137-1358).

3.74Plan of Care Activity Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.44 (open)]

Table 223: Plan of Care Activity Observation Contexts


This is the template for the Plan of Care Activity Observation.


Table 224: Plan of Care Activity Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


85812.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.11.20.9.25 (Planned moodCode (Observation))


@root 1..1 SHALL 81-10512

2.16.840.1.113883.10.20.22.4.44

id 1..* SHALL 81-8584


2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Observation) 2.16.840.1.113883.11.20.9.25 STATIC 2011-09-30 (CONF:81-8582).



3.75Plan of Care Activity Procedure - Published[procedure: identifier urn:oid:2.16.840.1.113883.10.20.22.4.41 (open)]

Table 225: Plan of Care Activity Procedure Contexts


This is the template for the Plan of Care Activity Procedure.


Table 226: Plan of Care Activity Procedure Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

procedure (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.41)@classCode 1..1 SHALL 81-

85682.16.840.1.113883.5.6 (HL7ActClass) = PROC




@root 1..1 SHALL 81-10513

2.16.840.1.113883.10.20.22.4.41

id 1..* SHALL 81-8571

1. SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-8568).




3.76Plan of Care Activity Substance Administration - Published[substanceAdministration: identifier urn:oid:2.16.840.1.113883.10.20.22.4.42 (open)]

Table 227: Plan of Care Activity Substance Administration Contexts


This is the template for the Plan of Care Activity Substance Administration


Table 228: Plan of Care Activity Substance Administration Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

substanceAdministration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.42)@classCode 1..1 SHALL 81-



2.16.840.1.113883.11.20.9.24 (Planned moodCode (SubstanceAdministration/Supply))


@root 1..1 SHALL 81-10514

2.16.840.1.113883.10.20.22.4.42

id 1..* SHALL 81-8575

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-8572).

2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (SubstanceAdministration/Supply) 2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:81-8573).



3.77Plan of Care Activity Supply - Published[supply: identifier urn:oid:2.16.840.1.113883.10.20.22.4.43 (open)]

Table 229: Plan of Care Activity Supply Contexts


This is the template for the Plan of Care Activity Supply.


Table 230: Plan of Care Activity Supply Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


85772.16.840.1.113883.5.6 (HL7ActClass) = SPLY


2.16.840.1.113883.11.20.9.24 (Planned moodCode (SubstanceAdministration/Supply))


@root 1..1 SHALL 81-10515

2.16.840.1.113883.10.20.22.4.43

id 1..* SHALL 81-8580


2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (SubstanceAdministration/Supply) 2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:81-8578).



3.78Plurality (The number of babies resulting from a single pregnancy) - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.81:27Oct2014 (open)]

Table 231: Plurality (The number of babies resulting from a single pregnancy) Contexts



Table 232: Plurality (The number of babies resulting from a single pregnancy) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1124@root 1..1 SHALL 1137-

11252.16.840.1.113883.10.14.81


27Oct2014

code 1..1 SHALL 1137-1126

@code 1..1 SHALL 1137-1127

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132 (Birth Plurality of Delivery)


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132 (Birth Plurality of Delivery)


@code 1..1 SHALL 1137-1133

2.16.840.1.113883.5.8 (ActReason) = completed





2. SHALL contain exactly one [1..1] code (CONF:1137-1126) such that ita. SHALL contain exactly one [1..1] @code (ValueSet: Birth Plurality of Delivery

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132) (CONF:1137-1127).b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1"


2.16.840.1.113883.6.1) (CONF:1137-1129).d. SHALL contain exactly one [1..1] @displayName (ValueSet: Birth Plurality of

Delivery 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132) (CONF:1137-1130).3. SHALL contain exactly one [1..1] statusCode (CONF:1137-1132).


a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActReason 2.16.840.1.113883.5.8) (CONF:1137-1133).

4. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1137-1131) such that it

a. SHALL contain exactly one [1..1] @value (CONF:1137-1134).

3.79Policy Activity - Published[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.61 (closed)]

Table 233: Policy Activity Contexts

Contained By: Contains:Coverage Activity (required)

A policy activity represents the policy or program providing the coverage. The person for whom payment is being provided (i.e., the patient) is the covered party. The subscriber of the policy or program is represented as a participant that is the holder the coverage. The payer is represented as the performer of the policy activity.


Table 234: Policy Activity Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


88982.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10516

2.16.840.1.113883.10.20.22.4.61

id 1..* SHALL 81-8901

code 1..1 SHALL 81-8903

@code 0..1 SHOULD

81-19185

2.16.840.1.113883.3.88.12.3221.5.2 (Health Insurance Type)


@code 1..1 SHALL 81-19109


performer 1..1 SHALL 81-8906


2.16.840.1.113883.5.90 (HL7ParticipationType) = PRF


@root 1..1 SHALL 81-16809

2.16.840.1.113883.10.20.22.4.87


id 1..* SHALL 81-8909

code 0..1 SHOULD

81-8914

@code 1..1 SHALL 81-15992

2.16.840.1.113883.1.11.10416 (HL7FinanciallyResponsiblePartyType)

addr 0..1 MAY 81-8910

telecom 0..1 MAY 81-8911

representedOrganization 0..1 SHOULD

81-8912

name 0..1 SHOULD

81-8913

performer 0..1 SHOUL 81- 2.16.840.1.113883.5.90


D 8961 (HL7ParticipationType) = PRF



@root 1..1 SHALL 81-16811

2.16.840.1.113883.10.20.22.4.88

time 0..1 SHOULD

81-8963


code 1..1 SHALL 81-8968

@code 1..1 SHALL 81-16096

2.16.840.1.113883.5.110 (RoleClass) = GUAR

addr 0..1 SHOULD

81-8964

telecom 0..1 SHOULD

81-8965

participant 1..1 SHALL 81-8916


2.16.840.1.113883.5.90 (HL7ParticipationType) = COV


@root 1..1 SHALL 81-16814

2.16.840.1.113883.10.20.22.4.89

time 0..1 SHOULD

81-8918

low 0..1 SHOULD

81-8919

high 0..1 SHOULD

81-8920


id 1..* SHALL 81-8922

code 1..1 SHALL 81-8923

@code 0..1 SHOULD

81-16078

2.16.840.1.113883.1.11.18877 (Coverage Role Type)

addr 0..1 SHOULD

81-8956

playingEntity 0..1 SHOULD

81-8932

name 1..1 SHALL 81-8930


81-8934

@typeCode 1..1 SHALL 81- 2.16.840.1.113883.5.90


8935 (HL7ParticipationType) = HLDtemplateId 1..1 SHALL 81-

16813@root 1..1 SHALL 81-

168152.16.840.1.113883.10.20.22.4.90

time 0..1 MAY 81-8938


id 1..* SHALL 81-8937

addr 0..1 SHOULD

81-8925







(CONF:81-10516).This id is a unique identifier for the policy or program providing the coverage

4. SHALL contain at least one [1..*] id (CONF:81-8901).5. SHALL contain exactly one [1..1] code (CONF:81-8903).

a. This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Health Insurance Type 2.16.840.1.113883.3.88.12.3221.5.2 DYNAMIC (CONF:81-19185).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19109).This performer represents the Payer.

7. SHALL contain exactly one [1..1] performer (CONF:81-8906) such that ita. SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem:

HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-8907).b. SHALL contain exactly one [1..1] templateId (CONF:81-16808).

i. This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.87" Payer Performer (CONF:81-16809).

c. SHALL contain exactly one [1..1] assignedEntity (CONF:81-8908).


i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-8909).ii. This assignedEntity SHOULD contain zero or one [0..1] code (CONF:81-

8914).1. The code, if present, SHALL contain exactly one [1..1] @code, which

SHOULD be selected from ValueSet HL7FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416 DYNAMIC (CONF:81-15992).

iii. This assignedEntity MAY contain zero or one [0..1] addr (CONF:81-8910).1. The content of addr SHALL be a conformant US Realm Address


iv. This assignedEntity MAY contain zero or one [0..1] telecom (CONF:81-8911).

v. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:81-8912).

1. The representedOrganization, if present, SHOULD contain zero or one [0..1] name (CONF:81-8913).

This performer represents the Guarantor.8. SHOULD contain zero or one [0..1] performer="PRF" Performer (CodeSystem:

HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-8961) such that ita. SHALL contain exactly one [1..1] templateId (CONF:81-16810).

i. This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.88" Guarantor Performer (CONF:81-16811).

b. SHOULD contain zero or one [0..1] time (CONF:81-8963).c. SHALL contain exactly one [1..1] assignedEntity (CONF:81-8962).

i. This assignedEntity SHALL contain exactly one [1..1] code (CONF:81-8968).1. This code SHALL contain exactly one [1..1] @code="GUAR"

Guarantor (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:81-16096).

ii. This assignedEntity SHOULD contain zero or one [0..1] addr (CONF:81-8964).


iii. This assignedEntity SHOULD contain zero or one [0..1] telecom (CONF:81-8965).

iv. SHOULD include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:81-8967).

9. SHALL contain exactly one [1..1] participant (CONF:81-8916) such that ita. SHALL contain exactly one [1..1] @typeCode="COV" Coverage target

(CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-8917).


b. SHALL contain exactly one [1..1] templateId (CONF:81-16812).i. This templateId SHALL contain exactly one [1..1]

@root="2.16.840.1.113883.10.20.22.4.89" Covered Party Participant (CONF:81-16814).

c. SHOULD contain zero or one [0..1] time (CONF:81-8918).i. The time, if present, SHOULD contain zero or one [0..1] low (CONF:81-

8919).ii. The time, if present, SHOULD contain zero or one [0..1] high (CONF:81-

8920).d. SHALL contain exactly one [1..1] participantRole (CONF:81-8921).

i. This participantRole SHALL contain at least one [1..*] id (CONF:81-8922).1. This id is a unique identifier for the covered party member.

Implementers SHOULD use the same GUID for each instance of a member identifier from the same health plan (CONF:81-8984).

ii. This participantRole SHALL contain exactly one [1..1] code (CONF:81-8923).

1. This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Coverage Role Type 2.16.840.1.113883.1.11.18877 DYNAMIC (CONF:81-16078).

iii. This participantRole SHOULD contain zero or one [0..1] addr (CONF:81-8956).


iv. This participantRole SHOULD contain zero or one [0..1] playingEntity (CONF:81-8932).

If the covered party’s name is recorded differently in the health plan and in the registration/medication summary (due to marriage or for other reasons), use the name as it is recorded in the health plan.

1. The playingEntity, if present, SHALL contain exactly one [1..1] name (CONF:81-8930).

2. If the member date of birth as recorded by the health plan differs from the patient date of birth as recorded in the registration/medication summary, then the member date of birth SHALL be recorded in sdtc:birthTime. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the birthTime element (CONF:81-8933).

10. SHOULD contain zero or one [0..1] participant (CONF:81-8934) such that itNOTE: When the Subscriber is the patient, the participant element describing the subscriber SHALL NOT be present. This information will be recorded instead in the data elements used to record member information.

a. SHALL contain exactly one [1..1] @typeCode="HLD" Holder (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-8935).


b. SHALL contain exactly one [1..1] templateId (CONF:81-16813).i. This templateId SHALL contain exactly one [1..1]

@root="2.16.840.1.113883.10.20.22.4.90" Policy Holder Participant (CONF:81-16815).

c. MAY contain zero or one [0..1] time (CONF:81-8938).d. SHALL contain exactly one [1..1] participantRole (CONF:81-8936).

i. This participantRole SHALL contain at least one [1..*] id (CONF:81-8937).1. This id is a unique identifier for the subscriber of the coverage

(CONF:81-10120).ii. This participantRole SHOULD contain zero or one [0..1] addr (CONF:81-

8925).1. The content of addr SHALL be a conformant US Realm Address


e. When the Subscriber is the patient, the participant element describing the subscriber SHALL NOT be present. This information will be recorded instead in the data elements used to record member information (CONF:81-17139).

11. SHALL contain at least one [1..*] entryRelationship (CONF:81-8939) such that ita. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8940).b. The target of a policy activity with act/entryRelationship/@typeCode="REFR"

SHALL be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) OR an act, with act@classCode="ACT"] and act@moodCode="DEF"], representing a description of the coverage plan (CONF:81-8942).

c. A description of the coverage plan SHALL contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:81-8943).

3.80Precondition for Substance Administration - Published[criterion: identifier urn:oid:2.16.840.1.113883.10.20.22.4.25 (open)]

Table 235: Precondition for Substance Administration Contexts

Contained By: Contains:Medication Activity (optional)

A criterion for administration can be used to record that the medication is to be administered only when the associated criteria are met.


Table 236: Precondition for Substance Administration Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

criterion (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.25)templateId 1..1 SHALL 81-

7372@root 1..1 SHALL 81-

105172.16.840.1.113883.10.20.22.4.25

code 0..1 SHOULD

81-16854

text 0..1 MAY 81-7373

value 0..1 SHOULD

CD 81-7369


(CONF:81-10517).2. SHOULD contain zero or one [0..1] code (CONF:81-16854).3. MAY contain zero or one [0..1] text (CONF:81-7373).4. SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:81-7369).

Figure 15: Precondition for Substance Administration Example

<precondition typeCode="PRCN"> <templateId root="2.16.840.1.113883.10.20.22.4.25" /> <criterion> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" /> <value xsi:type="CE" code="56018004" codeSystem="2.16.840.1.113883.6.96"

displayName="Wheezing" /> </criterion></precondition>

3.81Pregnancy Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.15.3.8 (open)]

Table 237: Pregnancy Observation Contexts

Contained By: Contains:Social History Section (optional) Estimated Date of Delivery

This clinical statement represents current and/or prior pregnancy dates enabling investigators to determine if the subject of the case report was pregnant during the course of a condition.


Table 238: Pregnancy Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.8)@classCode 1..1 SHALL 81-451 2.16.840.1.113883.5.6

(HL7ActClass) = OBS@moodCode 1..1 SHALL 81-452 2.16.840.1.113883.5.1001

(ActMood) = EVNtemplateId 1..1 SHALL 81-

16768@root 1..1 SHALL 81-

168682.16.840.1.113883.10.20.15.3.8

code 1..1 SHALL 81-19153

@code 1..1 SHALL 81-19154

ASSERTION


2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4

statusCode 1..1 SHALL 81-455@code 1..1 SHALL 81-



81-2018

value 1..1 SHALL CD 81-457@code 1..1 SHALL 81-

264602.16.840.1.113883.6.96 (SNOMED CT) = 77386006

entryRelationship 0..1 MAY 81-458@typeCode 1..1 SHALL 81-459 2.16.840.1.113883.5.1002

(HL7ActRelationshipType) = REFR


Estimated Date of Delivery (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.1





a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:81-19154).


b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode 2.16.840.1.113883.5.4) (CONF:81-26505).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19110).6. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-2018).7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:81-457).

a. This value SHALL contain exactly one [1..1] @code="77386006" Pregnant (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) (CONF:81-26460).

8. MAY contain zero or one [0..1] entryRelationship (CONF:81-458) such that ita. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-459).b. SHALL contain exactly one [1..1] Estimated Date of Delivery (identifier:

urn:oid:2.16.840.1.113883.10.20.15.3.1) (CONF:81-15584).

Figure 16: Pregnancy Observation Example

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.15.3.8"/> <id extension="123456789" root="2.16.840.1.113883.19"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <effectiveTime> <low value="20110410"/> </effectiveTime> <value xsi:type="CD" code="77386006" displayName="pregnant" codeSystem="2.16.840.1.113883.6.96"/> <entryRelationship typeCode="REFR"> <templateId root="2.16.840.1.113883.10.20.15.3.1"/> . . . </entryRelationship></observation>

3.82Pregnancy Outcome - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.82:27Oct2014 (open)]

Table 239: Pregnancy Outcome Contexts



Table 240: Pregnancy Outcome Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1235@root 1..1 SHALL 1137-

12362.16.840.1.113883.10.14.82


27Oct2014

code 1..1 SHALL 1137-1237

@code 0..1 SHALL 1137-1238



2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96






@code 1..1 SHALL 1137-1243





2. SHALL contain exactly one [1..1] code (CONF:1137-1237) such that ita. SHALL contain zero or one [0..1] @code, which SHALL be selected from ValueSet

Birth Outcome (VPD) 2.16.840.1.114222.4.11.3123 DYNAMIC (CONF:1137-1238).



d. SHALL contain exactly one [1..1] @displayName, which SHALL be selected from ValueSet Birth Outcome (VPD) 2.16.840.1.114222.4.11.3123 DYNAMIC (CONF:1137-1241).




4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1244).

3.83Pressure Ulcer Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.70 (open)]

Table 241: Pressure Ulcer Observation Contexts


The pressure ulcer observation contains details about the pressure ulcer such as the stage of the ulcer, location, and dimensions. If the pressure ulcer is a diagnosis, you may find this on the problem list. An example of how this would appear is in the Problem Section.


Table 242: Pressure Ulcer Observation Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


143832.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN



@root 1..1 SHALL 81-14388

2.16.840.1.113883.10.20.22.4.70

id 1..* SHALL 81-14389

code 1..1 SHALL 81-14759

@code 1..1 SHALL 81-14760

2.16.840.1.113883.5.4 (ActCode) = ASSERTION

text 0..1 SHOULD

81-14391


81-14392

@value 1..1 SHALL 81-15585


@code 1..1 SHALL 81-19111




2.16.840.1.113883.11.20.9.35 (Pressure Ulcer Stage)


targetSiteCode 0..* SHOULD

81-14797

@code 1..1 SHALL 81-14798

2.16.840.1.113883.11.20.9.36 (Pressure Point )

qualifier 0..1 SHOULD

81-14799

name 1..1 SHALL 81-14800

@code 0..1 SHOULD

81-14801

2.16.840.1.113883.6.96 (SNOMED CT) = 272741003



@code 0..1 SHOULD

81-14803

2.16.840.1.113883.11.20.9.37 (TargetSite Qualifiers )

entryRelationship 0..1 SHOULD

81-14410





2.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN

code 1..1 SHALL 81-14620

@code 1..1 SHALL 81-14621

2.16.840.1.113883.6.96 (SNOMED CT) = 401238003



81-14601


COMP



2.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN

code 1..1 SHALL 81-14624

@code 1..1 SHALL 81-14625

2.16.840.1.113883.6.96 (SNOMED CT) = 401239006



81-14605


COMP



2.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN

code 1..1 SHALL 81-14628


@code 1..1 SHALL 81-14629

2.16.840.1.113883.6.96 (SNOMED CT) = 425094009




Use negationInd="true" to indicate that the problem was not observed.3. MAY contain zero or one [0..1] @negationInd (CONF:81-14385).4. SHALL contain exactly one [1..1] templateId (CONF:81-14387) such that it


5. SHALL contain at least one [1..*] id (CONF:81-14389).6. SHALL contain exactly one [1..1] code (CONF:81-14759).

a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:81-14760).






(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19111).9. SHALL contain exactly one [1..1] effectiveTime (CONF:81-14395).10. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be

selected from ValueSet Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 STATIC (CONF:81-14396).

a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:81-14397).i. If the stage unknown or the SNOMED code is unknown, @nullFlavor

SHOULD be “UNK”. If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element (CONF:81-14398).

11. SHOULD contain zero or more [0..*] targetSiteCode (CONF:81-14797).a. The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which

SHOULD be selected from ValueSet Pressure Point 2.16.840.1.113883.11.20.9.36 STATIC (CONF:81-14798).


b. The targetSiteCode, if present, SHOULD contain zero or one [0..1] qualifier (CONF:81-14799).

i. The qualifier, if present, SHALL contain exactly one [1..1] name (CONF:81-14800).

1. This name SHOULD contain zero or one [0..1] @code="272741003" laterality (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:81-14801).

ii. The qualifier, if present, SHALL contain exactly one [1..1] value (CONF:81-14802).

1. This value SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet TargetSite Qualifiers 2.16.840.1.113883.11.20.9.37 STATIC (CONF:81-14803).

12. SHOULD contain zero or one [0..1] entryRelationship (CONF:81-14410) such that ita. SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-14411).

b. SHALL contain exactly one [1..1] observation (CONF:81-14619).i. This observation SHALL contain exactly one [1..1] @classCode="OBS"

(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-14685).


iii. This observation SHALL contain exactly one [1..1] code (CONF:81-14620).1. This code SHALL contain exactly one [1..1] @code="401238003"

Length of Wound (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:81-14621).

iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:81-14622).

13. SHOULD contain zero or one [0..1] entryRelationship (CONF:81-14601) such that ita. SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:81-14602).b. SHALL contain exactly one [1..1] observation (CONF:81-14623).




Width of Wound (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:81-14625).


14. SHOULD contain zero or one [0..1] entryRelationship (CONF:81-14605) such that it


a. SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:81-14606).b. SHALL contain exactly one [1..1] observation (CONF:81-14627).




Depth of Wound (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:81-14629).


3.84Problem Concern Act (Condition) - Published[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.3 (open)]

Table 243: Problem Concern Act (Condition) Contexts

Contained By: Contains:Problem Section (entries required) (required)Problem Section (entries optional) (optional)

Problem Observation

Observations of problems or other clinical statements captured at a point in time are wrapped in a ""Concern"" act, which represents the ongoing process tracked over time. This allows for binding related observations of problems. For example, the observation of ""Acute MI"" in 2004 can be related to the observation of ""History of MI"" in 2006 because they are the same concern. The conformance statements in this section define an outer ""problem act"" (representing the ""Concern"") that can contain a nested ""problem observation"" or other nested clinical statements.


Table 244: Problem Concern Act (Condition) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


90242.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-16773

2.16.840.1.113883.10.20.22.4.3

id 1..* SHALL 81-9026

code 1..1 SHALL 81-9027

@code 1..1 SHALL 81-19184

2.16.840.1.113883.5.6 (HL7ActClass) = CONC


2.16.840.1.113883.11.20.9.19 (ProblemAct statusCode)


low 1..1 SHALL 81-9032

high 0..1 SHOULD

81-9033





Problem Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.4





a. This code SHALL contain exactly one [1..1] @code="CONC" Concern (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-19184).


6. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ProblemAct statusCode 2.16.840.1.113883.11.20.9.19 STATIC 2011-09-09 (CONF:81-9029).

The effectiveTime element records the starting and ending times during which the concern was active on the Problem List.

7. SHALL contain exactly one [1..1] effectiveTime (CONF:81-9030).a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:81-9032).b. This effectiveTime SHOULD contain zero or one [0..1] high (CONF:81-9033).

8. SHALL contain at least one [1..*] entryRelationship (CONF:81-9034) such that ita. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-9035).b. SHALL contain exactly one [1..1] Problem Observation (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.4) (CONF:81-15980).

3.85Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) - Draft[act: identifier urn:hl7ii:2.16.840.1.113883.10.14.7:27Oct2014 (open)]

Table 245: Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) Contexts

Contained By: Contains:Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (required)

Problem Observation (V2) - Birth Defect IG Specific

This template defines Birth Defects Report-specific constraints to C-CDA R2.0 Problem Concern Act (V2).


Table 246: Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


9322.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-935

2.16.840.1.113883.10.14.7





Problem Observation (V2) - Birth Defect IG Specific (identifier: urn:hl7ii:2.16.840.1.113883.10.14.8:27Oct2014

1. Conforms to Problem Concern Act (Condition) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.3).

2. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-932).



(CONF:1137-935).5. SHALL contain at least one [1..*] entryRelationship (CONF:1137-936) such that it

a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-937).

b. SHALL contain exactly one [1..1] Problem Observation (V2) - Birth Defect IG Specific (identifier: urn:hl7ii:2.16.840.1.113883.10.14.8:27Oct2014) (CONF:1137-938).


3.86Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) - Draft[act: identifier urn:hl7ii:2.16.840.1.113883.10.14.20:27Oct2014 (open)]

Table 247: Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) Contexts

Contained By: Contains:Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW) (required)

Seizure or Serious Neurologic DysfunctionSuspected Neonatal Sepsis

This template defines NewBorn Delivery Information Birth Defects Report-specific constraints to C-CDA R2.0 Problem Concern Act (V2).

Table 248: Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


7642.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-766

2.16.840.1.113883.10.14.20


27Oct2014





1137-768

Seizure or Serious Neurologic Dysfunction (identifier: urn:hl7ii:2.16.840.1.113883.10.14.84:27Oct2014





Suspected Neonatal Sepsis (identifier: urn:hl7ii:2.16.840.1.113883.10.14.87:27Oct2014


1. Conforms to Problem Concern Act (Condition) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.3).

2. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-764).




5. SHALL contain exactly one [1..1] entryRelationship (CONF:1137-763) such that ita. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-767).b. SHOULD contain zero or one [0..1] Seizure or Serious Neurologic

Dysfunction (identifier: urn:hl7ii:2.16.840.1.113883.10.14.84:27Oct2014) (CONF:1137-768).

6. SHALL contain exactly one [1..1] entryRelationship (CONF:1137-769) such that ita. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:1137-770).b. SHALL contain exactly one [1..1] Suspected Neonatal Sepsis (identifier:

urn:hl7ii:2.16.840.1.113883.10.14.87:27Oct2014) (CONF:1137-771).

3.87Problem Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.4 (open)]

Table 249: Problem Observation Contexts

Contained By: Contains:Problem Concern Act (Condition) (required) Age Observation

Health Status ObservationProblem Status

A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need.A Problem Observation is required to be wrapped in an act wrapper in locations such as the Problem Section, Allergies Section, and Hospital Discharge Diagnosis Section, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid “standalone” template instance in cases where a simple problem observation is to be sent.The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). NegationInd='true' is an acceptable way to make a clinical assertion that something did not occur, for example, “no diabetes”.


Table 250: Problem Observation Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


90412.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN



@root 1..1 SHALL 81-14927

2.16.840.1.113883.10.20.22.4.4

id 1..* SHALL 81-9043

code 1..1 SHALL 81-9045

2.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)

text 0..1 SHOULD

81-9185


81-15587

@value 1..1 SHALL 81-15588


@code 1..1 SHALL 81-19112



81-9050

low 1..1 SHALL 81-15603

high 0..1 MAY 81-15604


2.16.840.1.113883.3.88.12.3221.7.4 (Problem)

translation 0..* MAY 81-16749

@code 0..1 MAY 81-16750

2.16.840.1.113883.6.90 (ICD10CM)





@inversionInd 1..1 SHALL 81- true


9069observation 1..1 SHALL 81-

15590Age Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.31





Problem Status (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.6





Health Status Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.5



3. MAY contain zero or one [0..1] @negationInd (CONF:81-10139).a. Use negationInd="true" to indicate that the problem was not observed (CONF:81-

16880).4. SHALL contain exactly one [1..1] templateId (CONF:81-14926) such that it


5. SHALL contain at least one [1..*] id (CONF:81-9043).6. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem

Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:81-9045).7. SHOULD contain zero or one [0..1] text (CONF:81-9185).


i. The reference, if present, SHALL contain exactly one [1..1] @value (CONF:81-15588).





9. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-9050).The value of effectiveTime/low represents onset date.

a. The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:81-15603).

If the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.

b. The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:81-15604).

10. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:81-9058).

a. This value MAY contain zero or more [0..*] translation (CONF:81-16749).i. The translation, if present, MAY contain zero or one [0..1] @code

(CodeSystem: ICD10CM 2.16.840.1.113883.6.90 STATIC) (CONF:81-16750).

b. This value MAY contain zero or one [0..1] @nullFlavor (CONF:81-10141).i. If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor

SHOULD be “UNK”. If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element (CONF:81-10142).

11. MAY contain zero or one [0..1] entryRelationship (CONF:81-9059) such that ita. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-9060).b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:81-9069).c. SHALL contain exactly one [1..1] Age Observation (identifier:


a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-9068).

b. SHALL contain exactly one [1..1] Problem Status (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.6) (CONF:81-15591).

13. MAY contain zero or one [0..1] entryRelationship (CONF:81-9067) such that ita. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-9064).b. SHALL contain exactly one [1..1] Health Status Observation (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.5) (CONF:81-15592).


3.88Problem Observation (V2) - Birth Defect IG Specific - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.8:27Oct2014 (open)]

Table 251: Problem Observation (V2) - Birth Defect IG Specific Contexts

Contained By: Contains:Problem Concern Act (V2) - Birth Defects IG Specific Constraints (NEW) (required)

This template defines Birth Defect Report-specific constraints to C-CDA R2.0 Problem Observation (V2).

Table 252: Problem Observation (V2) - Birth Defect IG Specific Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


9402.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-942

2.16.840.1.113883.10.14.8


27Oct2014


@code 1..1 SHALL 1137-944



1. Conforms to Problem Observation template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.4).







a. SHALL contain exactly one [1..1] @code (CONF:1137-944).i. @code in a problem observation SHALL be selected from Problem Value Set

(Value Set OID: 2.16.840.1.113883.3.88.12.3221.7.4; NOTE: Problem Value Set is a subset of SNOMED CT CodeSystem: 2.16.840.1.113883.6.96), ICD-10-CM (CodeSystem: 2.16.840.1.113883.6.90) or ICD-9-CM (CodeSystem: 2.16.840.1.113883.6.103) (CONF:1137-945).

b. SHALL contain exactly one [1..1] @codeSystem (CONF:1137-946).i. @codeSystem in a problem observation SHALL be selected from SNOMED

CT (CodeSystem: 2.16.840.1.113883.6.96), ICD-10-CM (CodeSystem: 2.16.840.1.113883.6.90) or ICD-9-CM (CodeSystem: 2.16.840.1.113883.6.103) (CONF:1137-948).

c. SHALL contain exactly one [1..1] @displayName (CONF:1137-947).i. @displayName in a problem observation SHALL be selected from Problem

Value Set (Value Set OID: 2.16.840.1.113883.3.88.12.3221.7.4; NOTE: Problem Value Set is a subset of SNOMED CT CodeSystem: 2.16.840.1.113883.6.96), ICD-10-CM (CodeSystem: 2.16.840.1.113883.6.90) or ICD-9-CM (CodeSystem: 2.16.840.1.113883.6.103) (CONF:1137-949).

3.89Problem Status - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.6 (open)]

Table 253: Problem Status Contexts

Contained By: Contains:Problem Observation (optional)

The Problem Status records whether the indicated problem is active, inactive, or resolved.


Table 254: Problem Status Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


73572.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10518

2.16.840.1.113883.10.20.22.4.6

code 1..1 SHALL 81-19162

@code 1..1 SHALL 81-19163

2.16.840.1.113883.6.1 (LOINC) = 33999-4

text 0..1 SHOULD

81-7362


81-15593

@value 1..1 SHALL 81-15594


@code 1..1 SHALL 81-19113



2.16.840.1.113883.3.88.12.80.68 (Problem Status)





a. This code SHALL contain exactly one [1..1] @code="33999-4" Status (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:81-19163).



(CONF:81-15594).





selected from ValueSet Problem Status 2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:81-7365).

3.90Procedure Activity Act - Published[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.12 (open)]

Table 255: Procedure Activity Act Contexts

Contained By: Contains:Procedures Section (entries required) (optional)Procedures Section (entries optional) (optional)

IndicationInstructionsMedication ActivityService Delivery Location

The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). This clinical statement represents any procedure that cannot be classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures.


Table 256: Procedure Activity Act Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


82892.16.840.1.113883.5.6 (HL7ActClass) = ACT


2.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)


@root 1..1 SHALL 81-10519

2.16.840.1.113883.10.20.22.4.12

id 1..* SHALL 81-8292

code 1..1 SHALL 81-8293


81-19186

reference 0..1 MAY 81-19187

@value 0..1 MAY 81-19188


2.16.840.1.113883.11.20.9.22 (ProcedureAct statusCode)


81-8299

priorityCode 0..1 MAY 81-8300

2.16.840.1.113883.1.11.16866 (Act Priority)


81-8301


id 1..* SHALL 81-8303

addr 1..1 SHALL 81-8304



81-8306

id 0..* SHOULD

81-8307

name 0..* MAY 81-8308


addr 1..1 SHALL 81-8309




2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOC


Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32





true



2.16.840.1.113883.5.6 (HL7ActClass) = ENC


2.16.840.1.113883.5.1001 (ActMood) = EVN

id 1..1 SHALL 81-8320





true

act 1..1 SHALL 81-15600

















a. This code SHOULD contain zero or one [0..1] originalText (CONF:81-19186).i. The originalText, if present, MAY contain zero or one [0..1] reference

(CONF:81-19187).1. The reference, if present, MAY contain zero or one [0..1] @value



b. This code in a procedure activity act SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:81-19190).

6. SHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:81-8298).

7. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-8299).8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act

Priority 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:81-8300).9. SHOULD contain zero or more [0..*] performer (CONF:81-8301).

a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:81-8302).

i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-8303).ii. This assignedEntity SHALL contain exactly one [1..1] addr (CONF:81-8304).iii. This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:81-

8305).iv. This assignedEntity SHOULD contain zero or one [0..1]

representedOrganization (CONF:81-8306).1. The representedOrganization, if present, SHOULD contain zero or

more [0..*] id (CONF:81-8307).2. The representedOrganization, if present, MAY contain zero or more

[0..*] name (CONF:81-8308).3. The representedOrganization, if present, SHALL contain exactly one

[1..1] telecom (CONF:81-8310).4. The representedOrganization, if present, SHALL contain exactly one

[1..1] addr (CONF:81-8309).


10. MAY contain zero or more [0..*] participant (CONF:81-8311).a. The participant, if present, SHALL contain exactly one [1..1] @typeCode="LOC"

Location (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8312).

b. The participant, if present, SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:81-15599).

11. MAY contain zero or more [0..*] entryRelationship (CONF:81-8314) such that ita. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component

(CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8315).

b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:81-8316).c. SHALL contain exactly one [1..1] encounter (CONF:81-8317).

i. This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-8318).

ii. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:81-8319).

iii. This encounter SHALL contain exactly one [1..1] id (CONF:81-8320).1. Set the encounter ID to the ID of an encounter in another section

to signify they are the same encounter (CONF:81-16849).12. MAY contain zero or one [0..1] entryRelationship (CONF:81-8322) such that it

a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8323).

b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:81-8324).c. SHALL contain exactly one [1..1] Instructions (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.20) (CONF:81-15600).13. MAY contain zero or more [0..*] entryRelationship (CONF:81-8326) such that it

a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8327).

b. SHALL contain exactly one [1..1] Indication (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.19) (CONF:81-15601).



b. SHALL contain exactly one [1..1] Medication Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.16) (CONF:81-15602).


3.91Procedure Activity Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.13 (open)]

Table 257: Procedure Activity Observation Contexts

Contained By: Contains:Procedures Section (entries required) (optional)Procedures Section (entries optional) (optional)

IndicationInstructionsMedication ActivityService Delivery Location

The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs.


Table 258: Procedure Activity Observation Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


82822.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)


@root 1..1 SHALL 81-10520

2.16.840.1.113883.10.20.22.4.13

id 1..* SHALL 81-8239

code 1..1 SHALL 81-19197


81-19198


81-19199

@value 0..1 SHOULD

81-19200




81-8246


2.16.840.1.113883.1.11.16866 (Act Priority)



methodCode 0..1 MAY SET<CE>

81-8248


81-8250

@code 1..1 SHALL 81-16071

2.16.840.1.113883.3.88.12.3221.8.9 (Body Site)


81-8251


id 1..* SHALL 81-8253

addr 1..1 SHALL 81-8254




81-8256

id 0..* SHOULD

81-8257

name 0..* MAY 81-8258


addr 1..1 SHALL 81-8259



2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOC







true



2.16.840.1.113883.5.6 (HL7ActClass) = ENC


2.16.840.1.113883.5.1001 (ActMood) = EVN

id 1..1 SHALL 81-8270





true

act 1..1 SHALL 81-15905

















a. This code SHOULD contain zero or one [0..1] originalText (CONF:81-19198).i. The originalText, if present, SHOULD contain zero or one [0..1] reference




b. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12), ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:81-19202).


7. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-8246).8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act

Priority 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:81-8247).9. SHALL contain exactly one [1..1] value (CONF:81-16846).

If nothing is appropriate for value, use an appropriate nullFlavor.a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:81-26512).

10. MAY contain zero or one [0..1] methodCode (CONF:81-8248).a. MethodCode SHALL NOT conflict with the method inherent in Observation / code

(CONF:81-8249).


11. SHOULD contain zero or more [0..*] targetSiteCode (CONF:81-8250).a. The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which

SHALL be selected from ValueSet Body Site 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:81-16071).

12. SHOULD contain zero or more [0..*] performer (CONF:81-8251).a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity

(CONF:81-8252).i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-8253).ii. This assignedEntity SHALL contain exactly one [1..1] addr (CONF:81-8254).iii. This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:81-






[1..1] addr (CONF:81-8259).13. MAY contain zero or more [0..*] participant (CONF:81-8261).

a. The participant, if present, SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8262).

b. The participant, if present, SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:81-15904).

14. MAY contain zero or more [0..*] entryRelationship (CONF:81-8264) such that ita. SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-8265).b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:81-8266).c. SHALL contain exactly one [1..1] encounter (CONF:81-8267).



iii. This encounter SHALL contain exactly one [1..1] id (CONF:81-8270).1. Set encounter/id to the id of an encounter in another section to

signify they are the same encounter (CONF:81-16847).15. MAY contain zero or one [0..1] entryRelationship (CONF:81-8272) such that it










3.92Procedure Activity Procedure - Published[procedure: identifier urn:oid:2.16.840.1.113883.10.20.22.4.14 (open)]

Table 259: Procedure Activity Procedure Contexts

Contained By: Contains:Procedures Section (entries required) (optional)Procedures Section (entries optional) (optional)Reaction Observation (optional)

IndicationInstructionsMedication ActivityProduct InstanceService Delivery Location

The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). This clinical statement represents procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement and a creation of a gastrostomy.


Table 260: Procedure Activity Procedure Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value

procedure (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.14)@classCode 1..1 SHALL 81-

76522.16.840.1.113883.5.6 (HL7ActClass) = PROC


2.16.840.1.113883.11.20.9.18 (MoodCodeEvnInt)


@root 1..1 SHALL 81-10521

2.16.840.1.113883.10.20.22.4.14

id 1..* SHALL 81-7655

code 1..1 SHALL 81-7656


81-19203


81-19204

@value 0..1 SHOULD

81-19205




81-7662


2.16.840.1.113883.1.11.16866 (Act Priority)


81-7670


81-7683

@code 1..1 SHALL 81-16082

2.16.840.1.113883.3.88.12.3221.8.9 (Body Site)

specimen 0..* MAY 81-7697

specimenRole 1..1 SHALL 81-7704

id 0..* SHOULD

81-7716


81-7718


id 1..* SHALL 81-7722

addr 1..1 SHALL 81-7731




81-7733

id 0..* SHOULD

81-7734

name 0..* MAY 81-7735


addr 1..1 SHALL 81-7736



2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = DEV


Product Instance (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.37



2.16.840.1.113883.5.90 (HL7ParticipationType) = LOC







true



2.16.840.1.113883.5.6 (HL7ActClass) = ENC


2.16.840.1.113883.5.1001 (ActMood) = EVN

id 1..1 SHALL 81-7773




@inversionInd 1..1 SHALL 81- true


7777act 1..1 SHALL 81-

15913Instructions (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.20











1. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-7652).




a. This code SHOULD contain zero or one [0..1] originalText (CONF:81-19203).i. The originalText, if present, SHOULD contain zero or one [0..1] reference




b. This code in a procedure activity SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:81-19207).


7. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-7662).


8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:81-7668).

9. MAY contain zero or one [0..1] methodCode (CONF:81-7670).a. MethodCode SHALL NOT conflict with the method inherent in Procedure / code

(CONF:81-7890).10. SHOULD contain zero or more [0..*] targetSiteCode (CONF:81-7683).

a. The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Body Site 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:81-16082).

11. MAY contain zero or more [0..*] specimen (CONF:81-7697).a. The specimen, if present, SHALL contain exactly one [1..1] specimenRole

(CONF:81-7704).i. This specimenRole SHOULD contain zero or more [0..*] id (CONF:81-7716).

1. If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id (CONF:81-7717).

b. This specimen is for representing specimens obtained from a procedure (CONF:81-16842).

12. SHOULD contain zero or more [0..*] performer (CONF:81-7718) such that ita. SHALL contain exactly one [1..1] assignedEntity (CONF:81-7720).

i. This assignedEntity SHALL contain at least one [1..*] id (CONF:81-7722).ii. This assignedEntity SHALL contain exactly one [1..1] addr (CONF:81-7731).iii. This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:81-






[1..1] addr (CONF:81-7736).13. MAY contain zero or more [0..*] participant (CONF:81-7751) such that it

a. SHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7752).

b. SHALL contain exactly one [1..1] Product Instance (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.37) (CONF:81-15911).

14. MAY contain zero or more [0..*] participant (CONF:81-7765) such that ita. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:

HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:81-7766).


b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:81-15912).



b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:81-8009).c. SHALL contain exactly one [1..1] encounter (CONF:81-7770).



iii. This encounter SHALL contain exactly one [1..1] id (CONF:81-7773).1. Set the encounter ID to the ID of an encounter in another section

to signify they are the same encounter (CONF:81-16843).16. MAY contain zero or one [0..1] entryRelationship (CONF:81-7775) such that it










3.93Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) - Draft[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.14.10:27Oct2014 (open)]

Table 261: Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) Contexts

Contained By: Contains:Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW) (required)

Indication - BxDefects IG Specific ConstraintService Delivery Location

This template provides Birth Defects-specific information in addition to the C-CDA R2 template "Procedure Activity Procedure (V2)". Conformance has been changed to “SHALL” for Participant/Service Delivery Location and Indication Observation.

Table 262: Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

procedure (identifier: urn:hl7ii:2.16.840.1.113883.10.14.10:27Oct2014)templateId 1..1 SHALL 1137-

954@root 1..1 SHALL 1137-

9552.16.840.1.113883.10.14.10


low 1..1 SHALL 1137-958

participant 1..* SHALL 1137-957


2.16.840.1.113883.5.90 (HL7ParticipationType) = LOC











(CONF:1137-955).3. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-956) such that it

a. SHALL contain exactly one [1..1] low (CONF:1137-958).4. SHALL contain at least one [1..*] participant (CONF:1137-957) such that it

a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:1137-959).

b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1137-960).




3.94Product Instance - Published[participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.37 (open)]

Table 263: Product Instance Contexts

Contained By: Contains:Procedure Activity Procedure (optional)

This clinical statement represents a particular device that was placed in a patient or used as part of a procedure or other act. This provides a record of the identifier and other details about the given product that was used. For example, it is important to have a record that indicates not just that a hip prostheses was placed in a patient but that it was a particular hip prostheses number with a unique identifier.The FDA Amendments Act specifies the creation of a Unique Device Identification (UDI) System that requires the label of devices to bear a unique identifier that will standardize device identification and identify the device through distribution and use. The FDA permits an issuing agency to designate that their Device Identifier (DI) + Production Identifier (PI) format qualifies as a UDI through a process of accreditation. Currently, there are three FDA-accredited issuing agencies that are allowed to call their format a UDI. These organizations are GS1, HIBCC, and ICCBBA. For additional information on technical formats that qualify as UDI from each of the issuing agencies see the UDI Appendix.When communicating only the issuing agency device identifier (i.e., subcomponent of the UDI), the use of the issuing agency OID is appropriate. However, when communicating the unique device identifier (DI + PI), the FDA OID (2.16.840.1.113883.3.3719) must be used.


When sending a UDI, populate the participantRole/id/@root with the FDA OID (2.16.840.1.113883.3.3719) and participantRole/id/@extension with the UDI.When sending a DI, populate the participantRole/id/@root with the appropriate assigning agency OID and participantRole/id/@extension with the DI.The scopingEntity/id should correspond to FDA or the appropriate issuing agency.

Table 264: Product Instance Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


79002.16.840.1.113883.5.110 (RoleClass) = MANU


@root 1..1 SHALL 81-10522

2.16.840.1.113883.10.20.22.4.37

id 1..* SHALL 81-7902

playingDevice 1..1 SHALL 81-7903

code 0..1 SHOULD

81-16837

scopingEntity 1..1 SHALL 81-7905

id 1..* SHALL 81-7908

1. SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass 2.16.840.1.113883.5.110 STATIC) (CONF:81-7900).


(CONF:81-10522).3. SHALL contain at least one [1..*] id (CONF:81-7902).4. SHALL contain exactly one [1..1] playingDevice (CONF:81-7903).

a. This playingDevice SHOULD contain zero or one [0..1] code (CONF:81-16837).5. SHALL contain exactly one [1..1] scopingEntity (CONF:81-7905).

a. This scopingEntity SHALL contain at least one [1..*] id (CONF:81-7908).


Figure 17: Product Instance Example

<participantRole classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.37"/> <id root="2.16.840.1.113883.3.3719" extension="(01)51022222233336(11)141231(17)150707(10)A213B1(21)1234" assigningAuthorityName="FDA"/> <playingDevice> <code code="90412006" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscope"/> </playingDevice> <scopingEntity> <id root="2.16.840.1.113883.3.3719"/> </scopingEntity></participantRole>

3.95Rank of Birth (Birth Order / Set Order) - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.83:27Oct2014 (open)]

Table 265: Rank of Birth (Birth Order / Set Order) Contexts


The order in which the newborn or fetus was delivered in the pregnancy. All live births and fetal losses resulting from the pregnancy should be included.


Table 266: Rank of Birth (Birth Order / Set Order) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


5752.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-577

2.16.840.1.113883.10.14.83


27Oct2014

id 1..* SHALL 1137-578

@root 1..1 SHALL 1137-988

code 1..1 SHALL 1137-579

@code 1..1 SHALL 1137-580

2.16.840.1.113883.6.1 (LOINC) = 73771-8


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Birth order

text 1..1 SHALL 1137-584


2.16.840.1.113883.5.14 (ActStatus)

@code 1..1 SHALL 1137-586




@value 1..1 SHALL 1137-989








a. This code SHALL contain exactly one [1..1] @code="73771-8" to specify the order in which the newborn is delivered (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-580).

b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-581).


d. This code SHALL contain exactly one [1..1] @displayName="Birth order" (CONF:1137-583).

6. SHALL contain exactly one [1..1] text (CONF:1137-584).7. SHALL contain exactly one [1..1] statusCode (CodeSystem: ActStatus

2.16.840.1.113883.5.14) (CONF:1137-585).a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed

(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-586).8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-587).9. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1137-588) such that

ita. SHALL contain exactly one [1..1] @value (CONF:1137-989).b. Indicate the order the baby or fetus delivered in this pregnancy, aka "Set

Number". Leave the field empty for singleton births (CONF:1137-589).

3.96Reaction Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.9 (open)]

Table 267: Reaction Observation Contexts

Contained By: Contains:Medication Activity (optional) Medication Activity

Procedure Activity ProcedureSeverity Observation

This clinical statement represents an undesired symptom, finding, etc., due to an administered or exposed substance. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions.


Table 268: Reaction Observation Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


73252.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10523

2.16.840.1.113883.10.20.22.4.9

id 1..1 SHALL 81-7329

code 1..1 SHALL 81-16851

text 0..1 SHOULD

81-7330


81-15917

@value 0..1 SHOULD

81-15918


@code 1..1 SHALL 81-19114



81-7332

low 0..1 SHOULD

81-7333

high 0..1 SHOULD

81-7334


2.16.840.1.113883.3.88.12.3221.7.4 (Problem)





true





2.16.840.1.113883.5.1002 (HL7ActRelationshipType) =


RSON@inversionInd 1..1 SHALL 81-

7344true







true


Severity Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.8




(CONF:81-10523).4. SHALL contain exactly one [1..1] id (CONF:81-7329).5. SHALL contain exactly one [1..1] code (CONF:81-16851).

a. The value set for this code element has not been specified. Implementers are allowed to use any code system, such as SNOMED CT, a locally determined code, or a nullFlavor (CONF:81-16852).






(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19114).8. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-7332).

a. The effectiveTime, if present, SHOULD contain zero or one [0..1] low (CONF:81-7333).

b. The effectiveTime, if present, SHOULD contain zero or one [0..1] high (CONF:81-7334).


9. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:81-7335).

10. MAY contain zero or more [0..*] entryRelationship (CONF:81-7337) such that ita. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7338).b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:81-7343).c. SHALL contain exactly one [1..1] Procedure Activity Procedure (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.14) (CONF:81-15920).i. This procedure activity is intended to contain information about

procedures that were performed in response to an allergy reaction (CONF:81-16853).

11. MAY contain zero or more [0..*] entryRelationship (CONF:81-7340) such that ita. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7341).b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:81-7344).c. SHALL contain exactly one [1..1] Medication Activity (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.16) (CONF:81-15921).i. This medication activity is intended to contain information about

medications that were administered in response to an allergy reaction (CONF:81-16840).

12. MAY contain zero or one [0..1] entryRelationship (CONF:81-7580) such that ita. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:

HL7ActRelationshipType 2.16.840.1.113883.5.1002 STATIC) (CONF:81-7581).b. SHALL contain exactly one [1..1] @inversionInd="true" TRUE (CONF:81-10375).c. SHALL contain exactly one [1..1] Severity Observation (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.8) (CONF:81-15922).

3.97Result Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.2 (open)]

Table 269: Result Observation Contexts

Contained By: Contains:Result Organizer (required)

This clinical statement represents details of a lab, radiology, or other study performed on a patient.The result observation includes a statusCode to allow recording the status of an observation. If a Result Observation is not completed, the Result Organizer must include corresponding statusCode. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus.


Table 270: Result Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


71302.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-9138

2.16.840.1.113883.10.20.22.4.2

id 1..* SHALL 81-7137

code 1..1 SHALL 81-7133

text 0..1 SHOULD

81-7138


81-15924

@value 0..1 SHOULD

81-15925


@code 1..1 SHALL 81-14849

2.16.840.1.113883.11.20.9.39 (Result Status)



interpretationCode 0..* SHOULD

81-7147


81-7148

targetSiteCode 0..1 MAY SET<CD>

81-7153

author 0..1 MAY 81-7149

referenceRange 0..* SHOULD

81-7150

observationRange 1..1 SHALL 81-7151

code 0..0 SHALL NOT

81-7152






a. SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:81-19211).

b. Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency. Local and/or regional codes for laboratory results are allowed. The Local and/or regional codes SHOULD be sent in the translation element. See the Local code example figure (CONF:81-19212).





7. SHALL contain exactly one [1..1] statusCode (CONF:81-7134).a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected

from ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC (CONF:81-14849).

8. SHALL contain exactly one [1..1] effectiveTime (CONF:81-7140).a. Represents clinically effective time of the measurement, which may be when the

measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) (CONF:81-16838).

9. SHALL contain exactly one [1..1] value (CONF:81-7143).10. SHOULD contain zero or more [0..*] interpretationCode (CONF:81-7147).11. MAY contain zero or one [0..1] methodCode (CONF:81-7148).12. MAY contain zero or one [0..1] targetSiteCode (CONF:81-7153).13. MAY contain zero or one [0..1] author (CONF:81-7149).14. SHOULD contain zero or more [0..*] referenceRange (CONF:81-7150).

a. The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:81-7151).

i. This observationRange SHALL NOT contain [0..0] code (CONF:81-7152).


3.98Result Organizer - Published[organizer: identifier urn:oid:2.16.840.1.113883.10.20.22.4.1 (open)]

Table 271: Result Organizer Contexts

Contained By: Contains:Results Section (entries required) (required)Results Section (entries optional) (optional)

Result Observation

This clinical statement identifies set of result observations. It contains information applicable to all of the contained result observations. Result type codes categorize a result into one of several commonly accepted values (e.g., “Hematology”, “Chemistry”, “Nuclear Medicine”). These values are often implicit in the Organizer/code (e.g., an Organizer/code of “complete blood count” implies a ResultTypeCode of “Hematology”). This template requires Organizer/code to include a ResultTypeCode either directly or as a translation of a code from some other code system.An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown.If any Result Observation within the organizer has a statusCode of ‘active’, the Result Organizer must also have as statusCode of ‘active.

Table 272: Result Organizer Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


71212.16.840.1.113883.5.6 (HL7ActClass)


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-9134

2.16.840.1.113883.10.20.22.4.1

id 1..* SHALL 81-7127

code 1..1 SHALL 81-7128


@code 1..1 SHALL 81-14848

2.16.840.1.113883.11.20.9.39 (Result Status)



Result Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.2


1. SHALL contain exactly one [1..1] @classCode (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-7121).

a. SHOULD contain zero or one 0..1] @classCode="CLUSTER" Cluster (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) OR SHOULD contain zero or one 0..1] @classCode="BATTERY" Battery (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:81-7165).




a. SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12) (CONF:81-19218).

b. Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency. Local and/or regional codes for laboratory results SHOULD also be allowed (CONF:81-19219).

6. SHALL contain exactly one [1..1] statusCode (CONF:81-7123).a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected

from ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC (CONF:81-14848).

7. SHALL contain at least one [1..*] component (CONF:81-7124) such that ita. SHALL contain exactly one [1..1] Result Observation (identifier:

urn:oid:2.16.840.1.113883.10.20.22.4.2) (CONF:81-14850).

3.99Seizure or Serious Neurologic Dysfunction - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.84:27Oct2014 (open)]

Table 273: Seizure or Serious Neurologic Dysfunction Contexts

Contained By: Contains:Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) (optional)


Table 274: Seizure or Serious Neurologic Dysfunction Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


471OBS


EVN


@root 1..1 SHALL 1137-474

2.16.840.1.113883.10.14.84


27Oct2014

id 1..1 SHALL 1137-475

@root 1..1 SHALL 1137-990

code 1..1 SHALL 1137-477

@code 1..1 SHALL 1137-478

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 (Seizure or Serious Neurologic Dysfunction )


2.16.840.1.113883.6.96


SNOMED CT


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 (Seizure or Serious Neurologic Dysfunction )

text 1..1 SHALL 1137-476


1. Conforms to Problem Observation template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.4).

2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CONF:1137-471).3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CONF:1137-472).4. SHALL contain exactly one [1..1] templateId (CONF:1137-473) such that it


b. SHALL contain exactly one [1..1] @extension="27Oct2014" (CONF:1137-1518).5. SHALL contain exactly one [1..1] id (CONF:1137-475) such that it

a. SHALL contain exactly one [1..1] @root (CONF:1137-990).


6. SHALL contain exactly one [1..1] code (CONF:1137-477).a. This code SHALL contain exactly one [1..1] @code (ValueSet: Seizure or Serious

Neurologic Dysfunction 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 DYNAMIC) (CONF:1137-478).

b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" SNOMED CT (CONF:1137-479).

c. This code SHALL contain exactly one [1..1] @codeSystemName="SNOMED CT" (CONF:1137-480).

d. This code SHALL contain exactly one [1..1] @displayName (ValueSet: Seizure or Serious Neurologic Dysfunction 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10) (CONF:1137-481).

7. SHALL contain exactly one [1..1] text (CONF:1137-476).8. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-482).

3.100 Service Delivery Location - Published[participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.32 (open)]

Table 275: Service Delivery Location Contexts

Contained By: Contains:Procedure Activity Procedure (optional)Procedure Activity Act (optional)Procedure Activity Observation (optional)Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW) (required)

This clinical statement represents the location of a service event where an act, observation or procedure took place.


Table 276: Service Delivery Location Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


77582.16.840.1.113883.5.111 (RoleCode) = SDLOC


@root 1..1 SHALL 81-10524

2.16.840.1.113883.10.20.22.4.32

code 1..1 SHALL 81-16850

2.16.840.1.113883.1.11.20275 (HealthcareServiceLocation)

addr 0..* SHOULD

81-7760

telecom 0..* SHOULD

81-7761

playingEntity 0..1 MAY 81-7762


2.16.840.1.113883.5.41 (EntityClass) = PLC

name 0..1 MAY 81-16037

1. SHALL contain exactly one [1..1] @classCode="SDLOC" (CodeSystem: RoleCode 2.16.840.1.113883.5.111 STATIC) (CONF:81-7758).


(CONF:81-10524).3. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet

HealthcareServiceLocation 2.16.840.1.113883.1.11.20275 STATIC (CONF:81-16850).

4. SHOULD contain zero or more [0..*] addr (CONF:81-7760).5. SHOULD contain zero or more [0..*] telecom (CONF:81-7761).6. MAY contain zero or one [0..1] playingEntity (CONF:81-7762).

a. The playingEntity, if present, SHALL contain exactly one [1..1] @classCode="PLC" (CodeSystem: EntityClass 2.16.840.1.113883.5.41 STATIC) (CONF:81-7763).

b. The playingEntity, if present, MAY contain zero or one [0..1] name (CONF:81-16037).


Figure 18: Service Delivery Location Example

<participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32"/> <code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HealthcareServiceLocation" displayName="Urgent Care Center"/> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)555-5000"/> <playingEntity classCode="PLC"> <name>Community Health and Hospitals</name> </playingEntity></participantRole>

3.101 Severity Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.8 (open)]

Table 277: Severity Observation Contexts

Contained By: Contains:Reaction Observation (optional)

This clinical statement represents the gravity of the problem, such as allergy or reaction, in terms of its actual or potential impact on the patient. The Severity Observation can be associated with an Allergy - Intolerance Observation, Substance or Device Allergy - Intolerance Observation, Reaction Observation or all. When the Severity Observation is associated directly with an allergy it characterizes the allergy. When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. A person may manifest many symptoms in a reaction to a single substance, and each reaction to the substance can be represented. However, each reaction observation can have only one severity observation associated with it. For example, someone may have a rash reaction observation as well as an itching reaction observation, but each can have only one level of severity.


Table 278: Severity Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


73452.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10525

2.16.840.1.113883.10.20.22.4.8

code 1..1 SHALL 81-19168

@code 1..1 SHALL 81-19169

2.16.840.1.113883.5.4 (ActCode) = SEV

text 0..1 SHOULD

81-7350


81-15928

@value 0..1 SHOULD

81-15929


@code 1..1 SHALL 81-19115



2.16.840.1.113883.3.88.12.3221.6.8 (Problem Severity)





a. This code SHALL contain exactly one [1..1] @code="SEV" (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:81-19169).



(CONF:81-15929).





selected from ValueSet Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC (CONF:81-7356).

3.102 Significant Birth Injury - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.85:27Oct2014 (open)]

Table 279: Significant Birth Injury Contexts


Abnormal Conditions of the Newborn: Significant Birth Injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention).


Table 280: Significant Birth Injury Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


5372.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-540

2.16.840.1.113883.10.14.85


27Oct2014

id 1..* SHALL 1137-541

@root 1..1 SHALL 1137-991

code 1..1 SHALL 1137-542

@code 1..1 SHALL 1137-543

2.16.840.1.113883.6.1 (LOINC) = 32386-5


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Significant Birth Injury

text 1..1 SHALL 1137-547


@code 1..1 SHALL 1137-549



@code 0..1 SHOULD

1137-551

1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 (Significant Birth Injury)


2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96




1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 (Significant Birth Injury)


1137-553

reference 1..1 SHALL 1137-


554@value 1..1 SHALL 1137-

557






5. SHALL contain exactly one [1..1] code (CONF:1137-542).a. This code SHALL contain exactly one [1..1] @code="32386-5" Birth Injury

(CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:1137-543).b. This code SHALL contain exactly one [1..1]

@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:1137-544).


d. This code SHALL contain exactly one [1..1] @displayName="Significant Birth Injury" (CONF:1137-546).




a. SHOULD contain zero or one [0..1] @code (ValueSet: Significant Birth Injury 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 DYNAMIC) (CONF:1137-551).



d. SHALL contain exactly one [1..1] @displayName (ValueSet: Significant Birth Injury 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9) (CONF:1137-556).

e. SHOULD contain zero or one [0..1] originalText (CONF:1137-553).i. The originalText, if present, SHALL contain exactly one [1..1] reference


(CONF:1137-557).


3.103 Smoking Status Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.78 (open)]

Table 281: Smoking Status Observation Contexts

Contained By: Contains:Social History Section (optional)

This clinical statement represents a patient’s current smoking status. The vocabulary selected for this clinical statement is the best approximation of the statuses in Meaningful Use (MU) Stage 1. If the patient is a smoker (77176002), the effectiveTime/low element must be present. If the patient is an ex-smoker (8517006), both the effectiveTime/low and effectiveTime/high element must be present.The smoking status value set includes a special code to communicate if the smoking status is unknown which is different from how Consolidated CDA generally communicates unknown information.

Table 282: Smoking Status Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


148062.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-14816

2.16.840.1.113883.10.20.22.4.78

code 1..1 SHALL 81-19170

@code 1..1 SHALL 81-19171



@code 1..1 SHALL 81-19116



low 1..1 SHALL 81-14818


@code 1..1 SHALL 81-14817

2.16.840.1.113883.11.20.9.38 (Current Smoking Status)


1. Conforms to Tobacco Use template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.85).








a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:81-14818).8. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:81-14810).

a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Current Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2012-07-01 (CONF:81-14817).

3.104 Social History Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.38 (open)]

Table 283: Social History Observation Contexts


This Social History Observation defines the patient’s occupational, personal (e.g., lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity, and religious affiliation.


Table 284: Social History Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


85482.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10526

2.16.840.1.113883.10.20.22.4.38

id 1..* SHALL 81-8551

code 1..1 SHALL 81-8558

@code 0..1 SHOULD

81-19220

2.16.840.1.113883.3.88.12.80.60 (Social History Type )


81-19221


81-19222

@value 0..1 SHOULD

81-19223


@code 1..1 SHALL 81-19117


value 0..1 SHOULD

81-8559





a. This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Social History Type 2.16.840.1.113883.3.88.12.80.60 STATIC (CONF:81-19220).

b. This code SHOULD contain zero or one [0..1] originalText (CONF:81-19221).


i. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:81-19222).

1. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:81-19223).

a. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-19224).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19117).7. SHOULD contain zero or one [0..1] value (CONF:81-8559).

a. Observation/value can be any data type. Where Observation/value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression (CONF:81-8555).

3.105 Specify number of infants in this delivery born alive when not single birth - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.86:27Oct2014 (open)]

Table 285: Specify number of infants in this delivery born alive when not single birth Contexts



Table 286: Specify number of infants in this delivery born alive when not single birth Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


1135@root 1..1 SHALL 1137-

11362.16.840.1.113883.10.14.86


27Oct2014

code 1..1 SHALL 1137-1137

@code 1..1 SHALL 1137-1138

2.16.840.1.113883.6.1 (LOINC) = 11636-8


2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1


2.16.840.1.113883.6.1 (LOINC) = LOINC


Births.live


@code 1..1 SHALL 1137-1145







2. SHALL contain exactly one [1..1] code (CONF:1137-1137).a. This code SHALL contain exactly one [1..1] @code="11636-8" (CodeSystem: LOINC

2.16.840.1.113883.6.1) (CONF:1137-1138).b. This code SHALL contain exactly one [1..1]




d. This code SHALL contain exactly one [1..1] @displayName="Births.live" (CONF:1137-1141).


(CodeSystem: ActStatus 2.16.840.1.113883.5.14) (CONF:1137-1145).4. SHALL contain exactly one [1..1] effectiveTime (CONF:1137-1146).5. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1137-1142).

a. This value SHALL contain exactly one [1..1] @value (CONF:1137-1143).

3.106 Suspected Neonatal Sepsis - Draft[observation: identifier urn:hl7ii:2.16.840.1.113883.10.14.87:27Oct2014 (open)]

Table 287: Suspected Neonatal Sepsis Contexts

Contained By: Contains:Problem Concern Act (V2) - NB BD IG Specific Constraints (NEW) (required)


Table 288: Suspected Neonatal Sepsis Constraints Overview


XPath Card.

Verb Data Type

CONF#

Value


5102.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 1137-513

2.16.840.1.113883.10.14.87


27Oct2014

id 1..* SHALL 1137-514

@root 1..1 SHALL 1137-992

code 1..1 SHALL 1137-515

2.16.840.1.113883.3.88.12.3221.7.2 (Problem Type)

text 0..1 SHOULD

1137-516


1137-517

@value 1..1 SHALL 1137-518


@code 1..1 SHALL 1137-521




1137-523


low 0..1 SHOULD

1137-524

high 0..1 MAY 1137-525


1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6 (Neonatal Sepsis)

@code 0..1 MAY 1137-529

qualifier 0..* MAY 1137-527

translation 0..* MAY 1137-528

@code 0..1 MAY 1137-530

2.16.840.1.113883.6.90 (ICD10CM)







5. SHALL contain exactly one [1..1] code (ValueSet: Problem Type 2.16.840.1.113883.3.88.12.3221.7.2) (CONF:1137-515).







a. This effectiveTime SHOULD contain zero or one [0..1] @nullFlavor (ValueSet: NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17) (CONF:1137-523).

b. This effectiveTime SHOULD contain zero or one [0..1] low (CONF:1137-524).c. This effectiveTime MAY contain zero or one [0..1] high (CONF:1137-525).

9. SHALL contain exactly one [1..1] value with @xsi:type="CD" (ValueSet: Neonatal Sepsis 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6) (CONF:1137-526).

a. This value MAY contain zero or one [0..1] @code (CONF:1137-529).Note: A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.

b. This value MAY contain zero or more [0..*] qualifier (CONF:1137-527).c. This value MAY contain zero or more [0..*] translation (CONF:1137-528).

i. The translation, if present, MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM 2.16.840.1.113883.6.90 STATIC) (CONF:1137-530).


conf:1137-529

3.107 Tobacco Use - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.85 (open)]

Table 289: Tobacco Use Contexts


This clinical statement represents a patient’s tobacco use. All types of tobacco use are represented using the codes from the tobacco use and exposure - finding hierarchy in SNOMED CT.

Table 290: Tobacco Use Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


165582.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-16567

2.16.840.1.113883.10.20.22.4.85

code 1..1 SHALL 81-19174

@code 1..1 SHALL 81-19175



@code 1..1 SHALL 81-19118



low 1..1 SHALL 81-16565

high 0..1 MAY 81-26507


@code 1..1 SHALL 81-16563

2.16.840.1.113883.11.20.9.41 (Tobacco Use)









a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:81-16565).b. This effectiveTime MAY contain zero or one [0..1] high (CONF:81-26507).

7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:81-16562).a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from

ValueSet Tobacco Use 2.16.840.1.113883.11.20.9.41 DYNAMIC (CONF:81-16563).

3.108 Vital Sign Observation - Published[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.27 (open)]

Table 291: Vital Sign Observation Contexts

Contained By: Contains:Vital Signs Organizer (required)

Vital signs are represented as are other results, with additional vocabulary constraints.


Table 292: Vital Sign Observation Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


72972.16.840.1.113883.5.6 (HL7ActClass) = OBS


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10527

2.16.840.1.113883.10.20.22.4.27

id 1..* SHALL 81-7300

code 1..1 SHALL 81-7301

2.16.840.1.113883.3.88.12.80.62 (Vital Sign Result)

text 0..1 SHOULD

81-7302


81-15943

@value 0..1 SHOULD

81-15944


@code 1..1 SHALL 81-19119




interpretationCode 0..1 MAY 81-7307


81-7308

targetSiteCode 0..1 MAY SET<CD>

81-7309

author 0..1 MAY 81-7310




(CONF:81-10527).


4. SHALL contain at least one [1..*] id (CONF:81-7300).5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Vital

Sign Result 2.16.840.1.113883.3.88.12.80.62 DYNAMIC (CONF:81-7301).6. SHOULD contain zero or one [0..1] text (CONF:81-7302).





(CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:81-19119).8. SHALL contain exactly one [1..1] effectiveTime (CONF:81-7304).9. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:81-7305).10. MAY contain zero or one [0..1] interpretationCode (CONF:81-7307).11. MAY contain zero or one [0..1] methodCode (CONF:81-7308).12. MAY contain zero or one [0..1] targetSiteCode (CONF:81-7309).13. MAY contain zero or one [0..1] author (CONF:81-7310).

3.109 Vital Signs Organizer - Published[organizer: identifier urn:oid:2.16.840.1.113883.10.20.22.4.26 (open)]

Table 293: Vital Signs Organizer Contexts

Contained By: Contains:Vital Signs Section (entries required) (required)Vital Signs Section (entries optional) (optional)

Vital Sign Observation

The Vital Signs Organizer groups vital signs, which is similar to the Result Organizer, but with further constraints. An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown.


Table 294: Vital Signs Organizer Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value


72792.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER


2.16.840.1.113883.5.1001 (ActMood) = EVN


@root 1..1 SHALL 81-10528

2.16.840.1.113883.10.20.22.4.26

id 1..* SHALL 81-7282

code 1..1 SHALL 81-19176

@code 1..1 SHALL 81-19177

2.16.840.1.113883.6.96 (SNOMED CT) = 46680005


@code 1..1 SHALL 81-19120





Vital Sign Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.27

1. SHALL contain exactly one [1..1] @classCode="CLUSTER" CLUSTER (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:81-7279).




a. This code SHALL contain exactly one [1..1] @code="46680005" Vital signs (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96 STATIC) (CONF:81-19177).




The effectiveTime represents clinically effective time of the measurement, which is most likely when the measurement was performed (e.g., a BP measurement).

7. SHALL contain exactly one [1..1] effectiveTime (CONF:81-7288).8. SHALL contain at least one [1..*] component (CONF:81-7285) such that it

a. SHALL contain exactly one [1..1] Vital Sign Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.27) (CONF:81-15946).


4 UNSPECIFIED

4.1 Participant - Father - Draft[participant: identifier urn:hl7ii:2.16.840.1.113883.10.14.34:27Oct2014 (open)]

Table 295: Participant - Father Contexts

Contained By: Contains:Birth Defects Event Report Document (NEW) (optional)

US Realm Address (AD.US.FIELDED)

Birth Father Details.


Table 296: Participant - Father Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

participant (identifier: urn:hl7ii:2.16.840.1.113883.10.14.34:27Oct2014)@typeCode 1..1 SHALL 1137-

8912.16.840.1.113883.5.90 (HL7ParticipationType) = FTH

templateId 1..1 SHOULD

1137-892

@root 1..1 SHALL 1137-893

2.16.840.1.113883.10.14.34


27Oct2014

associatedEntity 1..1 SHALL 1137-894

id 1..1 SHALL 1137-895

@root 1..1 SHALL 1137-1356

addr 0..* MAY 1137-896

US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2

telecom 0..* MAY 1137-897

associatedPerson 1..1 SHALL 1137-898

name 1..* SHALL 1137-899

family 1..1 SHALL 1137-900

given 1..1 SHALL 1137-901

scopingOrganization 0..0 SHALL 1137-902

1. SHALL contain exactly one [1..1] @typeCode="FTH" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:1137-891).

2. SHOULD contain exactly one [1..1] templateId (CONF:1137-892) such that ita. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.14.34"


3. SHALL contain exactly one [1..1] associatedEntity (CONF:1137-894).a. This associatedEntity SHALL contain exactly one [1..1] id (CONF:1137-895) such

that itNote: This ID will act as an Identifier for the father if specified anywhere else in the CDA, like for example <subject>.


i. SHALL contain exactly one [1..1] @root (CONF:1137-1356).b. This associatedEntity MAY contain zero or more [0..*] US Realm Address

(AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1137-896).

c. This associatedEntity MAY contain zero or more [0..*] telecom (CONF:1137-897).d. This associatedEntity SHALL contain exactly one [1..1] associatedPerson

(CONF:1137-898).i. This associatedPerson SHALL contain at least one [1..*] name (CONF:1137-

899) such that it1. SHALL contain exactly one [1..1] family (CONF:1137-900).2. SHALL contain exactly one [1..1] given (CONF:1137-901).

e. This associatedEntity SHALL contain [0..0] scopingOrganization (CONF:1137-902).

4.2 Participant - Mother - Draft[participant: identifier urn:hl7ii:2.16.840.1.113883.10.14.33:27Oct2014 (open)]

Table 297: Participant - Mother Contexts

Contained By: Contains:Birth Defects Event Report Document (NEW) (optional)

Birth Mothers Details.


Table 298: Participant - Mother Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

participant (identifier: urn:hl7ii:2.16.840.1.113883.10.14.33:27Oct2014)@typeCode 1..1 SHALL 1137-

8712.16.840.1.113883.5.90 (HL7ParticipationType) = MTH


@root 1..1 SHALL 1137-872

2.16.840.1.113883.10.14.33


27Oct2014

associatedEntity 1..1 SHALL 1137-873


2.16.840.1.113883.5.6 (HL7ActClass) = PRS

id 1..1 SHALL 1137-875

@root 1..1 SHALL 1137-877

addr 0..* SHOULD

1137-878

country 0..1 SHOULD

1137-886


city 1..1 SHALL 1137-888

streetAddressLine 0..1 SHOULD

1137-889

telecom 0..* SHOULD

1137-879

@value 1..1 SHALL 1137-885

associatedPerson 1..1 SHALL 1137-876

name 1..* SHALL 1137-880

family 1..1 SHALL 1137-882



scopingOrganization 0..0 SHALL 1137-881


1. SHALL contain exactly one [1..1] @typeCode="MTH" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:1137-871).



3. SHALL contain exactly one [1..1] associatedEntity (CONF:1137-873).a. This associatedEntity SHALL contain exactly one [1..1] @classCode="PRS"

(CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:1137-874).b. This associatedEntity SHALL contain exactly one [1..1] id (CONF:1137-875) such

that itNote: This ID is to represent mother. When <subject> is used for mother in sections, its ID should be the same as Participant ID.

i. SHALL contain exactly one [1..1] @root (CONF:1137-877).c. This associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1137-878)

such that iti. SHOULD contain zero or one [0..1] country (CONF:1137-886).ii. SHALL contain exactly one [1..1] state (CONF:1137-887).iii. SHALL contain exactly one [1..1] city (CONF:1137-888).iv. SHOULD contain zero or one [0..1] streetAddressLine (CONF:1137-889).

d. This associatedEntity SHOULD contain zero or more [0..*] telecom (CONF:1137-879) such that it

i. SHALL contain exactly one [1..1] @value (CONF:1137-885).e. This associatedEntity SHALL contain exactly one [1..1] associatedPerson

(CONF:1137-876).i. This associatedPerson SHALL contain at least one [1..*] name (CONF:1137-

880) such that it1. SHALL contain exactly one [1..1] family (CONF:1137-882).2. SHALL contain exactly one [1..1] given (CONF:1137-883).3. SHALL contain zero or one [0..1] given (CONF:1137-884).

NOTE: 2ND GIVEN NAME IS USED AS MIDDLE NAME.f. This associatedEntity SHALL contain [0..0] scopingOrganization (CONF:1137-

881).

4.3 US Realm Address (AD.US.FIELDED) - Published[addr: identifier urn:oid:2.16.840.1.113883.10.20.22.5.2 (open)]

Table 299: US Realm Address (AD.US.FIELDED) Contexts

Contained By: Contains:Birth Defects Event Report Document (NEW) (required)Participant - Father (optional)


conf:1137-884

Reusable address template, for use in US Realm CDA Header.

Table 300: US Realm Address (AD.US.FIELDED) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

addr (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2)@use 0..1 SHOUL

D81-7290

2.16.840.1.113883.1.11.10637 (PostalAddressUse)

country 0..1 SHOULD

81-7295

2.16.840.1.113883.3.88.12.80.63 (Country)

state 0..1 SHOULD

ST 81-7293

2.16.840.1.113883.3.88.12.80.1 (StateValueSet)

city 1..1 SHALL ST 81-7292

postalCode 0..1 SHOULD

81-7294

2.16.840.1.113883.3.88.12.80.2 (PostalCode)

streetAddressLine 1..4 SHALL ST 81-7291

1. SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 (CONF:81-7290).

2. SHOULD contain zero or one [0..1] country, which SHALL be selected from ValueSet Country 2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:81-7295).

3. SHOULD contain zero or one [0..1] state (ValueSet: StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC) (CONF:81-7293).

a. State is required if the country is US. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024).

4. SHALL contain exactly one [1..1] city (CONF:81-7292).5. SHOULD contain zero or one [0..1] postalCode, which SHOULD be selected from ValueSet

PostalCode 2.16.840.1.113883.3.88.12.80.2 DYNAMIC (CONF:81-7294).a. PostalCode is required if the country is US. If country is not specified, it's assumed

to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025).

6. SHALL contain at least one and not more than 4 streetAddressLine (CONF:81-7291).7. SHALL NOT have mixed content except for white space (CONF:81-7296).


Figure 19: US Realm Address Example

<addr use="HP"> <streetAddressLine>22 Sample Street</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97867</postalCode> <country>US</country></addr>

4.4 US Realm Address (AD.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) - Draft[addr: identifier urn:hl7ii:2.16.840.1.113883.10.14.35:27Oct2014 (open)]

This section describes further constraints to "US Realm Address (AD.US.FIELDED)" that are specific for Birth Defects Implementation Guide. There are additional constrains for the following two elements:(1) city(2) usablePeriodIn order to provide an address history for a birth defects patient, we expect ambulatory health care providers to maintain each of the addresses the patient provides over time. Addresses should not be overwritten by newer addresses.When an address is first collected for a patient, the date the patient began living at the address, if known, should be recorded and maintained as the start date for the address. If not known, the date of the encounter should be recorded and maintained as the start date for the address. When a new address is provided, the end date of the old address should be set to the day before the start date of the new address.


Table 301: US Realm Address (AD.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

addr (identifier: urn:hl7ii:2.16.840.1.113883.10.14.35:27Oct2014)@use 1..1 SHALL 1137-

7322.16.840.1.113883.1.11.10637 (PostalAddressUse)


2.16.840.1.113883.3.88.12.80.63 (Country)


2.16.840.1.113883.3.88.12.80.1 (StateValueSet)

city 1..1 SHALL 1137-724

2.16.840.1.114222.4.11.973 (City)

postalCode 1..1 SHALL 1137-728

2.16.840.1.113883.3.88.12.80.2 (PostalCode)

useablePeriod 1..* SHALL IVL_TS 1137-730

low 1..1 SHALL 1137-733

high 0..1 SHALL 1137-731


1. Conforms to US Realm Address (AD.US.FIELDED) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2).

2. SHALL contain exactly one [1..1] @use (ValueSet: PostalAddressUse 2.16.840.1.113883.1.11.10637 DYNAMIC) (CONF:1137-732).

3. SHALL contain exactly one [1..1] country (ValueSet: Country 2.16.840.1.113883.3.88.12.80.63 DYNAMIC) (CONF:1137-725).

4. SHALL contain exactly one [1..1] state (ValueSet: StateValueSet 2.16.840.1.113883.3.88.12.80.1 DYNAMIC) (CONF:1137-726).

5. SHALL contain exactly one [1..1] city (ValueSet: City 2.16.840.1.114222.4.11.973) (CONF:1137-724).

a. Note: City is required if the country is US. If country is not specified, it's assumed to be US. If country is something other than US, the city MAY be present but MAY be bound to different vocabularies. The value for city element SHALL be the "display name", selected from "city" Value Set (CONF:1137-727).

6. SHALL contain exactly one [1..1] postalCode (ValueSet: PostalCode 2.16.840.1.113883.3.88.12.80.2) (CONF:1137-728).

a. Note: The expected format for the Postal Code is either NNNNN or NNNNN-NNNN (CONF:1137-729).

7. SHALL contain at least one [1..*] useablePeriod (CONF:1137-730).


conf:1137-730

Note: usablePeriod indicates patient’s address history. For example, if patient had multiple prior addresses, then start (low) and end (high) date need to be provided for each address that the patient resided in.

a. Such useablePeriods SHALL contain exactly one [1..1] low (CONF:1137-733).Note: To indicate the time when the patient began living at the address.

b. Such useablePeriods SHALL contain zero or one [0..1] high (CONF:1137-731).Note: To indicate the time when the patient stopped living at the address.

i. The high, if present, MAY contain zero or one [0..1] @nullFlavor (CONF:1137-734).Note: If the patient is currently residing at the specified address then "high" element should use nullFlavor attribute (@nullFlavor) with the value "NA" (Not applicable. Known to have no proper value); this value, in the context of address, means that patient address is CURRENT.

4.5 US Realm Patient Name (PTN.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) - Draft[name: identifier urn:hl7ii:2.16.840.1.113883.10.14.36:27Oct2014 (open)]

Table 302: US Realm Patient Name (PTN.US.FIELDED) - Birth Defects IG Specific Constraints (NEW) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

name (identifier: urn:hl7ii:2.16.840.1.113883.10.14.36:27Oct2014)family 1..1 SHALL 1137-


740given 1..* SHALL 1137-


741given 1..* SHALL 1137-

739@nullFlavor 0..1 MAY 1137-

742suffix 1..1 SHALL 1137-

744validTime 0..1 SHOUL

D1137-743

low 1..1 SHALL 1137-745

high 0..1 SHOULD

1137-746


conf:1137-734

conf:1137-731

conf:1137-733

1. Conforms to US Realm Person Name (PN.US.FIELDED) template (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1).

2. SHALL contain exactly one [1..1] family (CONF:1137-737).a. This family SHALL contain [0..0] @nullFlavor (CONF:1137-740).

3. SHALL contain at least one [1..*] given (CONF:1137-738).Note: This (the first) occurrence of given is used for the first name.

a. Such givens SHALL contain [0..0] @nullFlavor (CONF:1137-741).4. SHALL contain at least one [1..*] given (CONF:1137-739).

Note: This (the second) occurrence of given is used for the middle name or middle initial.a. Such givens MAY contain zero or one [0..1] @nullFlavor (CONF:1137-742).

5. SHALL contain exactly one [1..1] suffix (CONF:1137-744).6. SHOULD contain zero or one [0..1] validTime (CONF:1137-743).

Note: There is a possibility that the Newborn's name can be changed at a later time. So instead of replacing the existing name, need to enter the low and high to specify when the old name got changed to a new name.

a. The validTime, if present, SHALL contain exactly one [1..1] low (CONF:1137-745).b. The validTime, if present, SHOULD contain zero or one [0..1] high (CONF:1137-

746).

4.6 US Realm Person Name (PN.US.FIELDED) - Published[name: identifier urn:oid:2.16.840.1.113883.10.20.22.5.1.1 (open)]

The US Realm Clinical Document Person Name datatype flavor is a set of reusable constraints that can be used for Persons.

Table 303: US Realm Person Name (PN.US.FIELDED) Constraints Overview

XPath Card.

Verb Data Type

CONF#

Value

name (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1)name 1..1 SHALL 81-

9368

1. SHALL contain exactly one [1..1] name (CONF:81-9368).a. The content of name SHALL be either a conformant Patient Name

(PTN.US.FIELDED), or a string (CONF:81-9371).b. The string SHALL NOT contain name parts (CONF:81-9372).


conf:1137-743

conf:1137-739

conf:1137-738

5 TEMPLATE IDS IN THIS GUIDETable 304: Template List


Template Title Template Type templateIdBirth Defects Event Report Document (NEW)

document urn:hl7ii:2.16.840.1.113883.10.14:27Oct2014

US Realm Header document urn:oid:2.16.840.1.113883.10.20.22.1.1

Birth Defects Diagnosis Section (entries required) (NEW)

section urn:hl7ii:2.16.840.1.113883.10.14.2:27Oct2014

Family History Section section urn:oid:2.16.840.1.113883.10.20.22.2.15

General Status - NB BD IG Specific Constraints (NEW)


General Status Section section urn:oid:2.16.840.1.113883.10.20.2.5

Labor and Delivery Events Section (NEW)


Medications Administered Section section urn:oid:2.16.840.1.113883.10.20.22.2.38

Medications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW)


Medications Section - LD BD IG Specific Constraints


Medications Section (entries optional)

section urn:oid:2.16.840.1.113883.10.20.22.2.1

Medications Section (entries required)

section urn:oid:2.16.840.1.113883.10.20.22.2.1.1

Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)


Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)


Mother's History and Physical Section (NEW)


Mothers Social History Section (NEW)


Newborn Delivery Information Section (NEW)


Payers Section section urn:oid:2.16.840.1.113883.10.20.22.2.18

Physical Exam - LD BD IG Specific section urn:hl7ii:2.16.840.1.113883.10.14.26:27Oct2014

Physical Exam - NB BD IG Specific Constraints (NEW)


Physical Exam Section section urn:oid:2.16.840.1.113883.10.20.2.10

Plan of Care Section section urn:oid:2.16.840.1.113883.10.20.


Template Title Template Type templateId22.2.10


Template Title Template Type templateIdPlan of Care Section - Birth Defects IG Specific Constraints (NEW)


Prior Pregnancy History Section (NEW)


Problem Section (entries optional) section urn:oid:2.16.840.1.113883.10.20.22.2.5

Problem Section (entries required) section urn:oid:2.16.840.1.113883.10.20.22.2.5.1

Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)


Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)


Procedures Section - LD BD IG Specific


Procedures Section (entries optional)

section urn:oid:2.16.840.1.113883.10.20.22.2.7

Procedures Section (entries required)

section urn:oid:2.16.840.1.113883.10.20.22.2.7.1

Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)


Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)


Results Section (entries optional) section urn:oid:2.16.840.1.113883.10.20.22.2.3

Results Section (entries required) section urn:oid:2.16.840.1.113883.10.20.22.2.3.1

Social History Section section urn:oid:2.16.840.1.113883.10.20.22.2.17

Vital Signs Section - LD BD IG Specific


Vital Signs Section - NB BD IG Specific Constraints (NEW)


Vital Signs Section (entries optional)

section urn:oid:2.16.840.1.113883.10.20.22.2.4

Vital Signs Section (entries required)

section urn:oid:2.16.840.1.113883.10.20.22.2.4.1

Admission to NICU entry urn:hl7ii:2.16.840.1.113883.10.14.37:27Oct2014

Age Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.31

Alcohol Intake (glasses/week) Alcohol intake within the

entry urn:hl7ii:2.16.840.1.113883.10.14.38:27Oct2014


Template Title Template Type templateIdpregnancy periodAntibiotic Administration Procedure


Antibiotics entry urn:hl7ii:2.16.840.1.113883.10.14.40:27Oct2014

Apgar at 10 minute entry urn:hl7ii:2.16.840.1.113883.10.14.41:27Oct2014

Apgar at 5 minutes entry urn:oid:2.16.840.1.113883.10.20.17.3.5

Assisted Ventilation [required immediately following delivery]


Assisted Ventilation for 6 or more hours






Birth head circumference entry urn:oid:2.16.840.1.113883.10.20.17.3.2

Birth height entry urn:hl7ii:2.16.840.1.113883.10.14.44:27Oct2014

Birth Outcome entry urn:hl7ii:2.16.840.1.113883.10.14.45:27Oct2014

Birth weight entry urn:oid:2.16.840.1.113883.10.20.17.3.1

Cause of Death entry urn:hl7ii:2.16.840.1.113883.10.14.46:27Oct2014

CCD Result observation entry urn:oid:2.16.840.1.113883.10.20.1.31

Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor]


Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor]


Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor]


Characteristics of Labor and Delivery: Augmentation of Labor


Characteristics of Labor and Delivery: Augmentation of Labor - Medication


Characteristics of labor and delivery: Induction of labor



Template Title Template Type templateIdCharacteristics of Labor and Delivery: Meconium Staining


Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery]


Coverage Activity entry urn:oid:2.16.840.1.113883.10.20.22.4.60

Date of Death entry urn:hl7ii:2.16.840.1.113883.10.14.55:27Oct2014

Date of Last Live Birth entry urn:hl7ii:2.16.840.1.113883.10.14.56:27Oct2014

Drug Vehicle entry urn:oid:2.16.840.1.113883.10.20.22.4.24

Estimate of Gestation entry urn:hl7ii:2.16.840.1.113883.10.14.57:27Oct2014

Estimated Date of Delivery entry urn:oid:2.16.840.1.113883.10.20.15.3.1

Family History Death Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.47

Family History Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.46

Family History Organizer entry urn:oid:2.16.840.1.113883.10.20.22.4.45

Gestational age entry urn:oid:2.16.840.1.113883.10.20.17.3.3

Health Status Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.5

Highest Pressure Ulcer Stage entry urn:oid:2.16.840.1.113883.10.20.22.4.77

Immunization Medication Information

entry urn:oid:2.16.840.1.113883.10.20.22.4.54

Indication entry urn:oid:2.16.840.1.113883.10.20.22.4.19



Infant Living at Time of Report? entry urn:hl7ii:2.16.840.1.113883.10.14.58:27Oct2014

Instructions entry urn:oid:2.16.840.1.113883.10.20.22.4.20

Karyotype Determination entry urn:hl7ii:2.16.840.1.113883.10.14.59:27Oct2014

Location of Death entry urn:hl7ii:2.16.840.1.113883.10.14.60:27Oct2014


Template Title Template Type templateIdMaternal Morbidity - Admission to Intensive Care [unit]


Maternal Morbidity: [Third or fourth degree] perineal laceration


Maternal Morbidity: Maternal Transfusion


Maternal Morbidity: Ruptured Uterus


Maternal Morbidity: Unplanned Hysterectomy


Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery]


Maternal Risk Factors entry urn:hl7ii:2.16.840.1.113883.10.14.67:27Oct2014

Medication Activity entry urn:oid:2.16.840.1.113883.10.20.22.4.16



Medication Dispense entry urn:oid:2.16.840.1.113883.10.20.22.4.18

Medication Information entry urn:oid:2.16.840.1.113883.10.20.22.4.23

Medication Supply Order entry urn:oid:2.16.840.1.113883.10.20.22.4.17

Method of Delivery: [Final] Route and Method of Delivery


Method of Delivery: Fetal Presentation [at birth]


Method of Delivery: Trial of Labor Attempted


Mother's Weight at Delivery entry urn:hl7ii:2.16.840.1.113883.10.14.71:27Oct2014

Newborn given Surfactant replacement therapy?


Number of Fetal Deaths entry urn:hl7ii:2.16.840.1.113883.10.14.73:27Oct2014

Number of Pressure Ulcers Observation

entry urn:oid:2.16.840.1.113883.10.20.22.4.76

Obstetric Procedures: Cervical Cerclage


Obstetric Procedures: Tocolysis entry urn:hl7ii:2.16.840.1.113883.10.14.75:27Oct2014

Onset of Labor: Precipitous Labor entry urn:hl7ii:2.16.840.1.113883.10.14.76:27Oct2014


Template Title Template Type templateIdOnset of Labor: Premature Rupture


Onset of Labor: Prolonged Labor entry urn:hl7ii:2.16.840.1.113883.10.14.78:27Oct2014

Other Pregnancy Outcome entry urn:hl7ii:2.16.840.1.113883.10.14.79:27Oct2014

Place of Birth (type or birthing place)


Plan of Care Activity Act entry urn:oid:2.16.840.1.113883.10.20.22.4.39

Plan of Care Activity Encounter entry urn:oid:2.16.840.1.113883.10.20.22.4.40



Plan of Care Activity Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.44

Plan of Care Activity Procedure entry urn:oid:2.16.840.1.113883.10.20.22.4.41

Plan of Care Activity Substance Administration

entry urn:oid:2.16.840.1.113883.10.20.22.4.42

Plan of Care Activity Supply entry urn:oid:2.16.840.1.113883.10.20.22.4.43

Plurality (The number of babies resulting from a single pregnancy)


Policy Activity entry urn:oid:2.16.840.1.113883.10.20.22.4.61

Precondition for Substance Administration

entry urn:oid:2.16.840.1.113883.10.20.22.4.25

Pregnancy Observation entry urn:oid:2.16.840.1.113883.10.20.15.3.8

Pregnancy Outcome entry urn:hl7ii:2.16.840.1.113883.10.14.82:27Oct2014

Pressure Ulcer Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.70

Problem Concern Act (Condition) entry urn:oid:2.16.840.1.113883.10.20.22.4.3





Problem Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.4




Template Title Template Type templateIdProblem Status entry urn:oid:2.16.840.1.113883.10.20.

22.4.6Procedure Activity Act entry urn:oid:2.16.840.1.113883.10.20.

22.4.12Procedure Activity Observation entry urn:oid:2.16.840.1.113883.10.20.

22.4.13Procedure Activity Procedure entry urn:oid:2.16.840.1.113883.10.20.

22.4.14Procedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW)


Product Instance entry urn:oid:2.16.840.1.113883.10.20.22.4.37

Rank of Birth (Birth Order / Set Order)


Reaction Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.9

Result Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.2

Result Organizer entry urn:oid:2.16.840.1.113883.10.20.22.4.1

Seizure or Serious Neurologic Dysfunction


Service Delivery Location entry urn:oid:2.16.840.1.113883.10.20.22.4.32

Severity Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.8

Significant Birth Injury entry urn:hl7ii:2.16.840.1.113883.10.14.85:27Oct2014

Smoking Status Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.78

Social History Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.38

Specify number of infants in this delivery born alive when not single birth


Suspected Neonatal Sepsis entry urn:hl7ii:2.16.840.1.113883.10.14.87:27Oct2014

Tobacco Use entry urn:oid:2.16.840.1.113883.10.20.22.4.85

Vital Sign Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.27

Vital Signs Organizer entry urn:oid:2.16.840.1.113883.10.20.22.4.26

Participant - Father unspecified urn:hl7ii:2.16.840.1.113883.10.14.34:27Oct2014


Template Title Template Type templateIdParticipant - Mother unspecified urn:hl7ii:2.16.840.1.113883.10.14

.33:27Oct2014US Realm Address (AD.US.FIELDED)

unspecified urn:oid:2.16.840.1.113883.10.20.22.5.2

US Realm Address (AD.US.FIELDED) - Birth Defects IG Specific Constraints (NEW)

unspecified urn:hl7ii:2.16.840.1.113883.10.14.35:27Oct2014

US Realm Patient Name (PTN.US.FIELDED) - Birth Defects IG Specific Constraints (NEW)


US Realm Person Name (PN.US.FIELDED)

unspecified urn:oid:2.16.840.1.113883.10.20.22.5.1.1


Table 305: Template Containments


Template Title Template Type templateIdBirth Defects Event Report Document (NEW)

document urn:hl7ii:2.16.840.1.113883.10.14:27Oct2014

Birth Defects Diagnosis Section (entries required) (NEW)






Family History Section section urn:oid:2.16.840.1.113883.10.20.22.2.15

Family History Organizer entry urn:oid:2.16.840.1.113883.10.20.22.4.45

Family History Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.46

Age Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.31

Family History Death Observation

entry urn:oid:2.16.840.1.113883.10.20.22.4.47

Labor and Delivery Events Section (NEW)


Characteristics of Labor and Delivery: Meconium Staining


Maternal Morbidity - Admission to Intensive Care [unit]


Maternal Morbidity: [Third or fourth degree] perineal laceration


Maternal Morbidity: Ruptured Uterus


Medications Section - LD BD IG Specific Constraints


Characteristics of Labor and Delivery: [Epidural or spinal] Anesthesia [during labor]


Characteristics of Labor and Delivery: Antibiotics [received by the mother during labor]


Characteristics of Labor and Delivery: Augmentation of Labor - Medication


Characteristics of Labor and Delivery: Steroids [(glucocorticoids) for fetal lung maturation received by the mother prior to delivery]


Method of Delivery: Fetal entry urn:hl7ii:2.16.840.1.113883.10.14


Template Title Template Type templateIdPresentation [at birth] .69:27Oct2014Number of Fetal Deaths entry urn:hl7ii:2.16.840.1.113883.10.14

.73:27Oct2014Onset of Labor: Precipitous Labor


Onset of Labor: Prolonged Labor


Physical Exam - LD BD IG Specific


Vital Signs Section - LD BD IG Specific


Mother's Weight at Delivery entry urn:hl7ii:2.16.840.1.113883.10.14.71:27Oct2014

Plurality (The number of babies resulting from a single pregnancy)


Pregnancy Outcome entry urn:hl7ii:2.16.840.1.113883.10.14.82:27Oct2014

Procedures Section - LD BD IG Specific


Characteristics of Labor and Delivery: [Epidural or Spinal] Anesthesia [during labor]


Characteristics of Labor and Delivery: Augmentation of Labor


Characteristics of labor and delivery: Induction of labor


Maternal Morbidity: Maternal Transfusion


Maternal Morbidity: Unplanned Hysterectomy


Maternal Morbidity: Unplanned Operat[ing]ion [room procedure following delivery]


Method of Delivery: [Final] Route and Method of Delivery


Method of Delivery: Trial of Labor Attempted


Obstetric Procedures: Cervical Cerclage


Obstetric Procedures: Tocolysis


Specify number of infants in this delivery born alive when not single birth



Template Title Template Type templateIdMedications Administered Section (V2) - Birth Defects IG Specific Constraints (NEW)






Medications Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)






Mother's History and Physical Section (NEW)


Mothers Social History Section (NEW)




Prior Pregnancy History Section (NEW)


Date of Last Live Birth entry urn:hl7ii:2.16.840.1.113883.10.14.56:27Oct2014

Estimate of Gestation entry urn:hl7ii:2.16.840.1.113883.10.14.57:27Oct2014

Maternal Risk Factors entry urn:hl7ii:2.16.840.1.113883.10.14.67:27Oct2014

Other Pregnancy Outcome entry urn:hl7ii:2.16.840.1.113883.10.14.79:27Oct2014

Newborn Delivery Information Section (NEW)


Admission to NICU entry urn:hl7ii:2.16.840.1.113883.10.14.37:27Oct2014

Birth Outcome entry urn:hl7ii:2.16.840.1.113883.10.14.45:27Oct2014

Cause of Death entry urn:hl7ii:2.16.840.1.113883.10.14.46:27Oct2014

Date of Death entry urn:hl7ii:2.16.840.1.113883.10.14.55:27Oct2014

Gestational age entry urn:oid:2.16.840.1.113883.10.20.17.3.3

Infant Living at Time of Report? entry urn:hl7ii:2.16.840.1.113883.10.14.58:27Oct2014


Template Title Template Type templateIdLocation of Death entry urn:hl7ii:2.16.840.1.113883.10.14

.60:27Oct2014Medications Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)


Antibiotics entry urn:hl7ii:2.16.840.1.113883.10.14.40:27Oct2014



Newborn given Surfactant replacement therapy?




Physical Exam - NB BD IG Specific Constraints (NEW)


General Status - NB BD IG Specific Constraints (NEW)


Apgar at 10 minute entry urn:hl7ii:2.16.840.1.113883.10.14.41:27Oct2014

Apgar at 5 minutes entry urn:oid:2.16.840.1.113883.10.20.17.3.5

Vital Signs Section - NB BD IG Specific Constraints (NEW)


Birth head circumference entry urn:oid:2.16.840.1.113883.10.20.17.3.2

Birth height entry urn:hl7ii:2.16.840.1.113883.10.14.44:27Oct2014

Birth weight entry urn:oid:2.16.840.1.113883.10.20.17.3.1

Place of Birth (type or birthing place)


Problem Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)




Seizure or Serious Neurologic Dysfunction


Suspected Neonatal Sepsis entry urn:hl7ii:2.16.840.1.113883.10.14.87:27Oct2014

Procedures Section (entries required) (V2) - NB BD IG Specific Constraints (NEW)


Antibiotic Administration Procedure


Indication - BxDefects IG entry urn:hl7ii:2.16.840.1.113883.10.14


Template Title Template Type templateIdSpecific Constraint .11:27Oct2014

Assisted Ventilation [required immediately following delivery]




Assisted Ventilation for 6 or more hours




Karyotype Determination entry urn:hl7ii:2.16.840.1.113883.10.14.59:27Oct2014



Rank of Birth (Birth Order / Set Order)


Significant Birth Injury entry urn:hl7ii:2.16.840.1.113883.10.14.85:27Oct2014

Participant - Father unspecified urn:hl7ii:2.16.840.1.113883.10.14.34:27Oct2014



Participant - Mother unspecified urn:hl7ii:2.16.840.1.113883.10.14.33:27Oct2014

Payers Section section urn:oid:2.16.840.1.113883.10.20.22.2.18

Coverage Activity entry urn:oid:2.16.840.1.113883.10.20.22.4.60

Policy Activity entry urn:oid:2.16.840.1.113883.10.20.22.4.61

Plan of Care Section - Birth Defects IG Specific Constraints (NEW)




Problem Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)






Procedures Section (entries required) (V2) - Birth Defects IG Specific Constraints (NEW)



Template Title Template Type templateIdProcedure Activity Procedure (V2) - Birth Defect IG Specific Constraints (NEW)




Service Delivery Location entry urn:oid:2.16.840.1.113883.10.20.22.4.32

Results Section (entries required)

section urn:oid:2.16.840.1.113883.10.20.22.2.3.1

Result Organizer entry urn:oid:2.16.840.1.113883.10.20.22.4.1

Result Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.2



Vital Signs Section (entries required)

section urn:oid:2.16.840.1.113883.10.20.22.2.4.1

Vital Signs Organizer entry urn:oid:2.16.840.1.113883.10.20.22.4.26

Vital Sign Observation entry urn:oid:2.16.840.1.113883.10.20.22.4.27

US Realm Header document urn:oid:2.16.840.1.113883.10.20.22.1.1

CCD Result observation entry urn:oid:2.16.840.1.113883.10.20.1.31

Onset of Labor: Premature Rupture


US Realm Address (AD.US.FIELDED) - Birth Defects IG Specific Constraints (NEW)


US Realm Patient Name (PTN.US.FIELDED) - Birth Defects IG Specific Constraints (NEW)



6 VALUE SETS IN THIS GUIDETable 306: Administrative Gender (HL7 V3)

Value Set: Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1Administrative Gender based upon HL7 V3 vocabulary. This value set contains only male, female and undifferentiated concepts.Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameF AdministrativeGender 2.16.840.1.113883.5.1 FemaleM AdministrativeGender 2.16.840.1.113883.5.1 MaleUN AdministrativeGender 2.16.840.1.113883.5.1 Undifferentiated

Table 307: Race

Value Set: Race 2.16.840.1.113883.1.11.14914Concepts in the race value set include the 5 minimum categories for race specified by OMB along with a more detailed set of race categories used by the Bureau of Census. Value Set Source: http://phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.1.113883.6.238&code=1000-9Code Code System Code System OID Print Name1002-5 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 American Indian or

Alaska Native2028-9 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Asian2054-5 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Black or African

American2076-8 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Native Hawaiian or Other

Pacific Islander2106-3 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 White1006-6 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Abenaki1579-2 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Absentee Shawnee1490-2 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Acoma2126-1 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Afghanistani1740-0 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Ahtna...


http://www.hl7.org/

http://phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.1.113883.6.238&code=1000-9

http://phinvads.cdc.gov/vads/ViewCodeSystemConcept.action?oid=2.16.840.1.113883.6.238&code=1000-9

Table 308: EthnicityGroup

Value Set: EthnicityGroup 2.16.840.1.114222.4.11.837Code System: Race & Ethnicity - CDC 2.16.840.1.113883.6.238Value Set Source: http://phinvads.cdc.gov/vads/ViewValueSet.action?id=35D34BBC-617F-DD11-B38D-00188B398520Code Code System Code System OID Print Name2135-2 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Hispanic or Latino2186-5 Race & Ethnicity - CDC 2.16.840.1.113883.6.238 Not Hispanic or Latino

Table 309: HL7 BasicConfidentialityKind

Value Set: HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926A value set of HL7 Code indication the level of confidentiality an act.Value Set Source: http://www.hl7.org/documentcenter/public/standards/vocabulary/vocabulary_tables/infrastructure/vocabulary/vocabulary.htmlCode Code System Code System OID Print NameN ConfidentialityCode 2.16.840.1.113883.5.25 normalR ConfidentialityCode 2.16.840.1.113883.5.25 restrictedV ConfidentialityCode 2.16.840.1.113883.5.25 very restricted

Table 310: Marital Status

Value Set: Marital Status 2.16.840.1.113883.1.11.12212Marital Status is the domestic partnership status of a person.Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameA MaritalStatus 2.16.840.1.113883.5.2 AnnulledD MaritalStatus 2.16.840.1.113883.5.2 DivorcedT MaritalStatus 2.16.840.1.113883.5.2 Domestic partnerI MaritalStatus 2.16.840.1.113883.5.2 InterlocutoryL MaritalStatus 2.16.840.1.113883.5.2 Legally SeparatedM MaritalStatus 2.16.840.1.113883.5.2 MarriedS MaritalStatus 2.16.840.1.113883.5.2 Never MarriedP MaritalStatus 2.16.840.1.113883.5.2 PolygamousW MaritalStatus 2.16.840.1.113883.5.2 Widowed


http://phinvads.cdc.gov/vads/ViewValueSet.action?id=35D34BBC-617F-DD11-B38D-00188B398520

http://phinvads.cdc.gov/vads/ViewValueSet.action?id=35D34BBC-617F-DD11-B38D-00188B398520

http://www.hl7.org/

Table 311: Religious Affiliation

Value Set: Religious Affiliation 2.16.840.1.113883.1.11.19185A value set of codes that reflect spiritual faith affiliation.Value Set Source: http://www.hl7.org/v3ballotarchive_temp_16B8D83E-1C23-BA17-0CBFC625BE7BA72F/v3ballot/html/infrastructure/vocabulary/vocabulary.html#voc-setsCode Code System Code System OID Print Name1001 ReligiousAffiliation 2.16.840.1.113883.5.107

6Adventist

1002 ReligiousAffiliation 2.16.840.1.113883.5.1076

African Religions


Afro-Caribbean Religions


Agnosticism


Anglican


Animism


Atheism


Babi & Baha'I faiths


Baptist


Bon

...

Table 312: ResponsibleParty

Value Set: ResponsibleParty 2.16.840.1.113883.1.11.19830A value set of applicable RoleCodes indicating the role played by a party who has legal responsibility for another party.Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameRESPRSN RoleCode 2.16.840.1.113883.5.111 responsible partyEXCEST RoleCode 2.16.840.1.113883.5.111 executor of estateGUADLTM RoleCode 2.16.840.1.113883.5.111 guardian ad lidemGUARD RoleCode 2.16.840.1.113883.5.111 guardianPOWATT RoleCode 2.16.840.1.113883.5.111 power of attorneyDPOWATT RoleCode 2.16.840.1.113883.5.111 durable power of

attorneyHPOWATT RoleCode 2.16.840.1.113883.5.111 healthcare power of

attorneySPOWATT RoleCode 2.16.840.1.113883.5.111 special power of attorney


http://www.hl7.org/v3ballotarchive_temp_16B8D83E-1C23-BA17-0CBFC625BE7BA72F/v3ballot/html/infrastructure/vocabulary/vocabulary.html#voc-sets

http://www.hl7.org/v3ballotarchive_temp_16B8D83E-1C23-BA17-0CBFC625BE7BA72F/v3ballot/html/infrastructure/vocabulary/vocabulary.html#voc-sets

http://www.hl7.org/

Table 313: Language

Value Set: Language 2.16.840.1.113883.1.11.11526A value set of codes defined by Internet RFC 4646 (replacing RFC 3066). Please see ISO 639 language code set maintained by Library of Congress for enumeration of language codes.Value Set Source: http://www.ietf.org/rfc/rfc4646.txtCode Code System Code System OID Print Nameaa Language 2.16.840.1.113883.6.121 Afarab Language 2.16.840.1.113883.6.121 Abkhazianace Language 2.16.840.1.113883.6.121 Achineseach Language 2.16.840.1.113883.6.121 Acoliada Language 2.16.840.1.113883.6.121 Adangmeady Language 2.16.840.1.113883.6.121 Adyghe; Adygeiae Language 2.16.840.1.113883.6.121 Avestanaf Language 2.16.840.1.113883.6.121 Afrikaansafa Language 2.16.840.1.113883.6.121 Afro-Asiatic (Other)afh Language 2.16.840.1.113883.6.121 Afrihili...

Table 314: Telecom Use (US Realm Header)

Value Set: Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameHP AddressUse 2.16.840.1.113883.5.111

9Primary home

HV AddressUse 2.16.840.1.113883.5.1119

Vacation home

WP AddressUse 2.16.840.1.113883.5.1119

Work place

MC AddressUse 2.16.840.1.113883.5.1119

Mobile contact


http://www.hl7.org/

Table 315: PostalCode

Value Set: PostalCode 2.16.840.1.113883.3.88.12.80.2A value set of postal (ZIP) Code of an address in the United StatesValue Set Source: http://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=86671000Code Code System Code System OID Print Name19009 USPostalCodes 2.16.840.1.113883.6.231 Bryn Athyn92869-1736 USPostalCodes 2.16.840.1.113883.6.231 Orange, CA32830-8413 USPostalCodes 2.16.840.1.113883.6.231 Lake Buena Vista, FL...

Table 316: Country

Value Set: Country 2.16.840.1.113883.3.88.12.80.63This identifies the codes for the representation of names of countries, territories and areas of geographical interest.Value Set Source: http://www.iso.org/iso/country_codes/iso_3166_code_lists.htmCode Code System Code System OID Print NameAW Country 2.16.840.1.113883.3.88.

12.80.63Aruba

IL Country 2.16.840.1.113883.3.88.12.80.63

Israel

...

Table 317: LanguageAbilityMode

Value Set: LanguageAbilityMode 2.16.840.1.113883.1.11.12249This identifies the language ability of the individual. A value representing the method of expression of the language.Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameESGN LanguageAbilityMode 2.16.840.1.113883.5.60 Expressed signedESP LanguageAbilityMode 2.16.840.1.113883.5.60 Expressed spokenEWR LanguageAbilityMode 2.16.840.1.113883.5.60 Expressed writtenRSGN LanguageAbilityMode 2.16.840.1.113883.5.60 Received signedRSP LanguageAbilityMode 2.16.840.1.113883.5.60 Received spokenRWR LanguageAbilityMode 2.16.840.1.113883.5.60 Received written


http://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=86671000

http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm

http://www.hl7.org/

Table 318: LanguageAbilityProficiency

Value Set: LanguageAbilityProficiency 2.16.840.1.113883.1.11.12199Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameE LanguageAbilityProficien

cy2.16.840.1.113883.5.61 Excellent

F LanguageAbilityProficiency

2.16.840.1.113883.5.61 Fair

G LanguageAbilityProficiency

2.16.840.1.113883.5.61 Good

P LanguageAbilityProficiency

2.16.840.1.113883.5.61 Poor

Table 319: INDRoleclassCodes

Value Set: INDRoleclassCodes 2.16.840.1.113883.11.20.9.33Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NamePRS RoleClass 2.16.840.1.113883.5.110 personal relationshipNOK RoleClass 2.16.840.1.113883.5.110 next of kinCAREGIVER RoleClass 2.16.840.1.113883.5.110 caregiverAGNT RoleClass 2.16.840.1.113883.5.110 AgentGUAR RoleClass 2.16.840.1.113883.5.110 guarantorECON RoleClass 2.16.840.1.113883.5.110 emergency contact


http://www.hl7.org/

http://www.hl7.org/

Table 320: Healthcare Provider Taxonomy (HIPAA)

Value Set: Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.114222.4.11.1066The Health Care Provider Taxonomy value set is a collection of unique alphanumeric codes, ten characters in length. The code set is structured into three distinct Levels including Provider Type, Classification, and Area of Specialization. The Health Care Provider Taxonomy code set allows a single provider (individual, group, or institution) to identify their specialty category. Providers may have one or more than one value associated to them. When determining what value or values to associate with a provider, the user needs to review the requirements of the trading partner with which the value(s) are being used.Value Set Source: http://www.nucc.org/index.php?option=com_content&view=article&id=14&Itemid=125Code Code System Code System OID Print Name171100000X Healthcare Provider

Taxonomy (HIPAA)2.16.840.1.113883.6.101 Acupuncturist

363LA2100X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Nurse Practitioner - Acute Care

364SA2100X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Clinical Nurse Specialist - Acute Care

101YA0400X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Counselor - Addiction (Substance Use Disorder)

103TA0400X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Psychologist - Addiction (Substance Use Disorder)

163WA0400X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Registered Nurse - Addiction (Substance Use Disorder)

207LA0401X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Anesthesiology - Addiction Medicine

207QA0401X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Family Medicine - Addiction Medicine

207RA0401X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Internal Medicine - Addiction Medicine

2084A0401X Healthcare Provider Taxonomy (HIPAA)

2.16.840.1.113883.6.101 Psychiatry & Neurology - Addiction Medicine

...

Table 321: NullValues_UNK_NI_NA

Value Set: NullValues_UNK_NI_NA 2.16.840.1.113883.11.20.10.17This value set is a subset of the HL7 code system: NullFlavor [2.16.840.1.113883.5.1008] to restrict the allowable null flavors to unknown, No Information or Not Applicable.Code Code System Code System OID Print NameNI HL7NullFlavor 2.16.840.1.113883.5.100

8No information

NA HL7NullFlavor 2.16.840.1.113883.5.1008

Not Applicable

UNK HL7NullFlavor 2.16.840.1.113883.5.1008

Unknown


http://www.nucc.org/index.php?option=com_content&view=article&id=14&Itemid=125

http://www.nucc.org/index.php?option=com_content&view=article&id=14&Itemid=125

Table 322: AgePQ_UCUM

Value Set: AgePQ_UCUM 2.16.840.1.113883.11.20.9.21A valueSet of UCUM codes for representing age value units. Specific URL PendingValue Set Source: http://unitsofmeasure.org/ucum.htmlCode Code System Code System OID Print Namemin UCUM 2.16.840.1.113883.6.8 Minuteh UCUM 2.16.840.1.113883.6.8 Hourd UCUM 2.16.840.1.113883.6.8 Daywk UCUM 2.16.840.1.113883.6.8 Weekmo UCUM 2.16.840.1.113883.6.8 Montha UCUM 2.16.840.1.113883.6.8 Year

Table 323: Antibiotic Administration Procedure

Value Set: Antibiotic Administration Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.178PHVS_AntibioticAdministrationProcedure_NCHSCode Code System Code System OID Print Name281790008 SNOMED CT 2.16.840.1.113883.6.96 Intravenous antibiotic

therapy (procedure)307520009 SNOMED CT 2.16.840.1.113883.6.96 Intramuscular antibiotic

therapy (procedure)...

Table 324: Apgar 10 minutes post birth

Value Set: Apgar 10 minutes post birth bxdefects_OIDTo Reflect the 10 Min Apgar ScoreValue Set Source: https://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=169922007Code Code System Code System OID Print Name48332-1 LOINC 2.16.840.1.113883.6.1 Apgar panel^10M post

birth169922007 SNOMED CT 2.16.840.1.113883.6.96 Apgar at 10 minutes...

Table 325: Apgar 5 minutes post birth

Value Set: Apgar 5 minutes post birth 2.16.840.1.113883.11.20.5.17A valueSet of SNOMED and LOINC codes for the 5 minute ApgarCode Code System Code System OID Print Name169909004 SNOMED CT 2.16.840.1.113883.6.96 Apgar at 5 minute48333-9 LOINC 2.16.840.1.113883.6.1 Apgar panel^5M post

birth


http://unitsofmeasure.org/ucum.html

https://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=169922007

https://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=169922007

Table 326: Assisted Ventilation Minutes After Birth (NCHS)

Value Set: Assisted Ventilation Minutes After Birth (NCHS) 2.16.840.1.114222.4.11.7144To Reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn.Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=3DBDA20B-9C63-E411-A174-0017A477041ACode Code System Code System OID Print NamePHC1250 PHIN VADS code system 2.16.840.1.114222.4.5.2

74Assisted ventilation required immediately following delivery

Table 327: Assisted Ventilation More Than Six Hours (NCHS)

Value Set: Assisted Ventilation More Than Six Hours (NCHS) 2.16.840.1.114222.4.11.7145To Reflect that the newborn was provided assisted ventilation required for more than six hours reflecting an abnormal condition of the newborn.Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=5D073DA7-9C63-E411-A174-0017A477041ACode Code System Code System OID Print NamePHC1251 PHIN VADS code system 2.16.840.1.114222.4.5.2

74Assisted ventilation required for more than six hours


https://phinvads.cdc.gov/vads/ViewValueSet.action?id=3DBDA20B-9C63-E411-A174-0017A477041A

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=3DBDA20B-9C63-E411-A174-0017A477041A

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=5D073DA7-9C63-E411-A174-0017A477041A

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=5D073DA7-9C63-E411-A174-0017A477041A

Table 328: Birth Defects Laterality at Diagnosis

Value Set: Birth Defects Laterality at Diagnosis 2.16.840.1.113883.10.14.93Code for the side of a paired organ, or the side of the body on which the reportable Birth Defect(s) is present.Code Code System Code System OID Print Name0 Birth Defects Laterality

at Diagnosis2.16.840.1.113883.10.14.92

Condition is not in a paired organ

1 Birth Defects Laterality at Diagnosis

2.16.840.1.113883.10.14.92

The condition is in a paired organ within the right organ.


2.16.840.1.113883.10.14.92

The condition is in a paired organ within the left organ


2.16.840.1.113883.10.14.92

Unilateral involvement but side is unknown


2.16.840.1.113883.10.14.92

Bilateral involvement of both paired organs


2.16.840.1.113883.10.14.92

Condition is at the midline


2.16.840.1.113883.10.14.92

Condition is in a paired organ but the laterality of the condition is unknown

...

Table 329: ProblemAct statusCode

Value Set: ProblemAct statusCode 2.16.840.1.113883.11.20.9.19A ValueSet of HL7 actStatus codes for use on the concern actValue Set Source: http://www.hl7.orgCode Code System Code System OID Print Namecompleted ActStatus 2.16.840.1.113883.5.14 Completedaborted ActStatus 2.16.840.1.113883.5.14 Abortedactive ActStatus 2.16.840.1.113883.5.14 Activesuspended ActStatus 2.16.840.1.113883.5.14 Suspended

Table 330: Birth head circumference

Value Set: Birth head circumference 2.16.840.1.113883.11.20.5.19A valueSet of SNOMED and LOINC codes for birth head circumferenceCode Code System Code System OID Print Name169876006 SNOMED CT 2.16.840.1.113883.6.96 Birth head circumference8290-9 LOINC 2.16.840.1.113883.6.1 Circumference.occipital-

frontalât birth


http://www.hl7.org/

Table 331: Birth Outcome (VPD)

Value Set: Birth Outcome (VPD) 2.16.840.1.114222.4.11.3123Infant's birth outcome answer list.Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=30D44BBC-617F-DD11-B38D-00188B398520Code Code System Code System OID Print Name281050002 SNOMED CT 2.16.840.1.113883.6.96 LivebirthPHC500 PHIN VADS code system 2.16.840.1.114222.4.5.2

74Not a Live Birth

OTH HL7NullFlavor 2.16.840.1.113883.5.1008

Other

UNK HL7NullFlavor 2.16.840.1.113883.5.1008

Unknown

Table 332: Birth weight

Value Set: Birth weight 2.16.840.1.113883.11.20.5.15A valueSet of SNOMED and LOINC codes for birth weightCode Code System Code System OID Print Name47340003 SNOMED CT 2.16.840.1.113883.6.96 Birth weight56056-5 LOINC 2.16.840.1.113883.6.1 Body weightât birth

(reported)8339-4 LOINC 2.16.840.1.113883.6.1 Body weightât birth

(measured)

Table 333: IV Medication Administration

Value Set: IV Medication Administration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4To reflect that IV Medication Administration Route was used to administer a medicationCode Code System Code System OID Print NameIV HL7 V2.5 Route of

Administration codes2.16.840.1.113883.12.162

Intravenous

...

Table 334: Augmentation of Labor - Medication

Value Set: Augmentation of Labor - Medication 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23To reflect a medication used for the Augmentation of LaborValue Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=F750AD0D-75EC-DF11-A040-00188B39829BCode Code System Code System OID Print Name238013 RxNorm 2.16.840.1.113883.6.88 Oxytocin 10 UNT/ML

Injectable Solution...


https://phinvads.cdc.gov/vads/ViewValueSet.action?id=30D44BBC-617F-DD11-B38D-00188B398520


https://phinvads.cdc.gov/vads/ViewValueSet.action?id=F750AD0D-75EC-DF11-A040-00188B39829B

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=F750AD0D-75EC-DF11-A040-00188B39829B

Table 335: Meconium Staining

Value Set: Meconium Staining 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36To Reflect that there was moderate or heavy Meconium stainingValue Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=EBC0ADC3-95CE-DF11-AB08-0015173D1785Code Code System Code System OID Print Name249136005 SNOMED CT 2.16.840.1.113883.6.96 Fresh meconium staining

liquor (finding)408793000 SNOMED CT 2.16.840.1.113883.6.96 Meconium stained liquor

- grade II (finding)408794006 SNOMED CT 2.16.840.1.113883.6.96 Meconium stained liquor

- grade III (finding)249137001 SNOMED CT 2.16.840.1.113883.6.96 Old meconium staining

liquor (finding)289294000 SNOMED CT 2.16.840.1.113883.6.96 Thick meconium stained

liquor (finding)...

Table 336: Glucocortico Steroids

Value Set: Glucocortico Steroids 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38Steroids (glucocorticoids) for fetal lung maturation received by the mother before delivery.Code Code System Code System OID Print Name371049 RxNorm 2.16.840.1.113883.6.88 Betamethasone

Injectable Solution378340 RxNorm 2.16.840.1.113883.6.88 Betamethasone

Injectable Suspension1007039 RxNorm 2.16.840.1.113883.6.88 Betamethasone /

Betamethasone acetate371725 RxNorm 2.16.840.1.113883.6.88 Dexamethasone

Injectable Solution371721 RxNorm 2.16.840.1.113883.6.88 Dexamethasone

Injectable Suspension371724 RxNorm 2.16.840.1.113883.6.88 Dexamethasone /

Lidocaine Injectable Solution

370648 RxNorm 2.16.840.1.113883.6.88 Hydrocortisone Injectable Solution

378635 RxNorm 2.16.840.1.113883.6.88 Hydrocortisone Injectable Suspension


https://phinvads.cdc.gov/vads/ViewValueSet.action?id=EBC0ADC3-95CE-DF11-AB08-0015173D1785

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=EBC0ADC3-95CE-DF11-AB08-0015173D1785

Table 337: Problem Type

Value Set: Problem Type 2.16.840.1.113883.3.88.12.3221.7.2This value set indicates the level of medical judgment used to determine the existence of a problem.Value Set Source: http://www.loinc.org/Code Code System Code System OID Print Name75326-9 LOINC 2.16.840.1.113883.6.1 Problem HL7.CCDAR275325-1 LOINC 2.16.840.1.113883.6.1 Symptom HL7.CCDAR275324-4 LOINC 2.16.840.1.113883.6.1 Functional performance

HL7.CCDAR275323-6 LOINC 2.16.840.1.113883.6.1 Functional performance

HL7.CCDAR275323-6 LOINC 2.16.840.1.113883.6.1 Condition HL7.CCDAR229308-4 LOINC 2.16.840.1.113883.6.1 Diagnosis75322-8 LOINC 2.16.840.1.113883.6.1 Complaint HL7.CCDAR275321-0 LOINC 2.16.840.1.113883.6.1 Clinical finding

HL7.CCDAR275319-4 LOINC 2.16.840.1.113883.6.1 Cognitive function family

member HL7.CCDAR275319-4 LOINC 2.16.840.1.113883.6.1 Cognitive function family

member HL7.CCDAR2...


http://www.loinc.org/

Table 338: Problem

Value Set: Problem 2.16.840.1.113883.3.88.12.3221.7.4A value set of SNOMED-CT codes limited to terms descending from the Clinical Findings (404684003) or Situation with Explicit Context (243796009) hierarchies. Specific URL Pending

Value Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name46635009 SNOMED CT 2.16.840.1.113883.6.96 diabetes mellitus type 1234422006 SNOMED CT 2.16.840.1.113883.6.96 acute intermittent

porphyria31712002 SNOMED CT 2.16.840.1.113883.6.96 primary biliary cirrhosis302002000 SNOMED CT 2.16.840.1.113883.6.96 difficulty moving15188001 SNOMED CT 2.16.840.1.113883.6.96 hearing loss129851009 SNOMED CT 2.16.840.1.113883.6.96 alteration in bowel

elimination247472004 SNOMED CT 2.16.840.1.113883.6.96 hives39579001 SNOMED CT 2.16.840.1.113883.6.96 anaphylaxis274945004 SNOMED CT 2.16.840.1.113883.6.96 AA amyloidosis

(disorder)129851009 SNOMED CT 2.16.840.1.113883.6.96 alteration in comfort:

pain...


https://vsac.nlm.nih.gov/

Table 339: Family Member Value Set

Value Set: Family Member Value Set 2.16.840.1.113883.1.11.19579Family Relationships record the familial relationship of a person to another person. This value set is to be used when it is necessary to record family relationships (e.g., next of kin, or blood relations). This is a subset of the value set used for personal relationshipsValue Set Source: http://www.hl7.orgCode Code System Code System OID Print NameADOPT RoleCode 2.16.840.1.113883.5.111 adopted childAUNT RoleCode 2.16.840.1.113883.5.111 auntCHILD RoleCode 2.16.840.1.113883.5.111 ChildCHLDINLAW RoleCode 2.16.840.1.113883.5.111 child in-lawCOUSN RoleCode 2.16.840.1.113883.5.111 cousinDOMPART RoleCode 2.16.840.1.113883.5.111 domestic partnerFAMMEMB RoleCode 2.16.840.1.113883.5.111 Family MemberCHLDFOST RoleCode 2.16.840.1.113883.5.111 foster childGRNDCHILD RoleCode 2.16.840.1.113883.5.111 grandchildGRPRN RoleCode 2.16.840.1.113883.5.111 Grandparent...

Table 340: HealthStatus

Value Set: HealthStatus 2.16.840.1.113883.1.11.20.12Represents the general health status of the patient.Value Set Source: https://www.hl7.org/Code Code System Code System OID Print Name81323004 SNOMED CT 2.16.840.1.113883.6.96 Alive and well313386006 SNOMED CT 2.16.840.1.113883.6.96 In remission162467007 SNOMED CT 2.16.840.1.113883.6.96 Symptom free161901003 SNOMED CT 2.16.840.1.113883.6.96 Chronically ill271593001 SNOMED CT 2.16.840.1.113883.6.96 Severely ill21134002 SNOMED CT 2.16.840.1.113883.6.96 Disabled161045001 SNOMED CT 2.16.840.1.113883.6.96 Severely disabled419099009 SNOMED CT 2.16.840.1.113883.6.96 Deceased135818000 SNOMED CT 2.16.840.1.113883.6.96 General health poor135815002 SNOMED CT 2.16.840.1.113883.6.96 General health good...


http://www.hl7.org/

https://www.hl7.org/

Table 341: Vaccine Administered Value Set

Value Set: Vaccine Administered Value Set 2.16.840.1.113883.3.88.12.80.22Value Set Source: http://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.12.292Code Code System Code System OID Print Name143 CDC Vaccine Code (CVX) 2.16.840.1.113883.12.29

2Adenovirus types 4 and 7

54 CDC Vaccine Code (CVX) 2.16.840.1.113883.12.292

adenovirus, type 4


adenovirus, type 7


adenovirus, unspecified formulation


anthrax


BCG


botulinum antitoxin


cholera


CMVIG


dengue fever

...

Table 342: Patient Education

Value Set: Patient Education 2.16.840.1.113883.11.20.9.34Limited to terms descending from the Education (409073007) hierarchy. Specific URL PendingValue Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name311401005 SNOMED CT 2.16.840.1.113883.6.96 Patient Education171044003 SNOMED CT 2.16.840.1.113883.6.96 Immunization Education243072006 SNOMED CT 2.16.840.1.113883.6.96 Cancer Education...


http://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.12.292

http://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.12.292


Table 343: Karyotype Determination

Value Set: Karyotype Determination 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154Code Code System Code System OID Print Name312948004 SNOMED CT 2.16.840.1.113883.6.96 Karyotype determination

(procedure)444309000 SNOMED CT 2.16.840.1.113883.6.96 Determination of

karyotype from blood specimen (procedure)

...

Table 344: ICU Care (NCHS)

Value Set: ICU Care (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188To reflect that the patient was in ICU care reflecting a maternal morbidityCode Code System Code System OID Print Name305351004 SNOMED CT 2.16.840.1.113883.6.96 Admission to intensive

care unit397945004 SNOMED CT 2.16.840.1.113883.6.96 Unexpected admission to

intensive care unit305352006 SNOMED CT 2.16.840.1.113883.6.96 Admission to adult

intensive care unit183446009 SNOMED CT 2.16.840.1.113883.6.96 Admission to cardiac

intensive care unit183449002 SNOMED CT 2.16.840.1.113883.6.96 Admission to metabolic

intensive care unit183447000 SNOMED CT 2.16.840.1.113883.6.96 Admission to respiratory

intensive care unit183448005 SNOMED CT 2.16.840.1.113883.6.96 Admission to

neurological intensive care unit


Table 345: Fourth Degree Perineal Laceration

Value Set: Fourth Degree Perineal Laceration 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101To reflect Fourth Degree Perineal Laceration as a maternal morbidityValue Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=7DC157A2-0DC8-DF11-AB08-0015173D1785Code Code System Code System OID Print Name399031001 SNOMED CT 2.16.840.1.113883.6.96 Fourth degree perineal

laceration (disorder)16950007 SNOMED CT 2.16.840.1.113883.6.96 Fourth degree perineal

laceration involving anal mucosa (disorder)

34262005 SNOMED CT 2.16.840.1.113883.6.96 Fourth degree perineal laceration involving rectal mucosa (disorder)

199934009 SNOMED CT 2.16.840.1.113883.6.96 Fourth degree perineal tear during delivery - delivered (disorder)

199935005 SNOMED CT 2.16.840.1.113883.6.96 Fourth degree perineal tear during delivery with postnatal problem (disorder)

...

Table 346: Pregnancy Risk Factors (NCHS)

Value Set: Pregnancy Risk Factors (NCHS) 2.16.840.1.114222.4.11.7126The value set contains the list of values used to indicate selected medical risk factors of the mother during this pregnancy.Value Set Source: https://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Pregnancy+Risk+FactorsCode Code System Code System OID Print Name73211009 SNOMED CT 2.16.840.1.113883.6.96 Diabetes mellitus11687002 SNOMED CT 2.16.840.1.113883.6.96 Gestational diabetes

mellitus38341003 SNOMED CT 2.16.840.1.113883.6.96 Hypertensive disorder,

systemic arterial48194001 SNOMED CT 2.16.840.1.113883.6.96 Pregnancy-induced

hypertension15938005 SNOMED CT 2.16.840.1.113883.6.96 Eclampsia161765003 SNOMED CT 2.16.840.1.113883.6.96 History of - premature

delivery271903000 SNOMED CT 2.16.840.1.113883.6.96 History of - pregnancy65046005 SNOMED CT 2.16.840.1.113883.6.96 Infertility Therapy58533008 SNOMED CT 2.16.840.1.113883.6.96 Artificial insemination63487001 SNOMED CT 2.16.840.1.113883.6.96 Assisted fertilization...


https://phinvads.cdc.gov/vads/ViewValueSet.action?id=7DC157A2-0DC8-DF11-AB08-0015173D1785

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=7DC157A2-0DC8-DF11-AB08-0015173D1785

https://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Pregnancy+Risk+Factors

https://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Pregnancy+Risk+Factors

Table 347: MoodCodeEvnInt

Value Set: MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18Contains moodCode EVN and INTValue Set Source: http://www.hl7.orgCode Code System Code System OID Print NameEVN ActMood 2.16.840.1.113883.5.100

1Event

INT ActMood 2.16.840.1.113883.5.1001

Intent

Table 348: Medication Route FDA

Value Set: Medication Route FDA 2.16.840.1.113883.3.88.12.3221.8.7Route of Administration value set is based upon FDA Drug Registration and Listing Database (FDA Orange Book) which are used in FDA structured Product and Labelling (SPL). Specific URL PendingValue Set Source: http://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=84244000Code Code System Code System OID Print NameC38192 FDA

RouteOfAdministration2.16.840.1.113883.3.26.1.1

AURICULAR (OTIC)

C38193 FDA RouteOfAdministration

2.16.840.1.113883.3.26.1.1

BUCCAL


2.16.840.1.113883.3.26.1.1

CONJUNCTIVAL


2.16.840.1.113883.3.26.1.1

CUTANEOUS


2.16.840.1.113883.3.26.1.1

DENTAL


2.16.840.1.113883.3.26.1.1

ELECTRO-OSMOSIS


2.16.840.1.113883.3.26.1.1

ENDOCERVICAL


2.16.840.1.113883.3.26.1.1

ENDOSINUSIAL


2.16.840.1.113883.3.26.1.1

ENDOTRACHEAL


2.16.840.1.113883.3.26.1.1

ENTERAL

...


http://www.hl7.org/

http://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=84244000

Table 349: Body Site

Value Set: Body Site 2.16.840.1.113883.3.88.12.3221.8.9Contains values descending from the SNOMED CT® Anatomical Structure (91723000) hierarchy or Acquired body structure (body structure) (280115004) or Anatomical site notations for tumor staging (body structure) (258331007) or Body structure, altered from its original anatomical structure (morphologic abnormality) (118956008) or Physical anatomical entity (body structure) (91722005) This indicates the anatomical site. Specific URL PendingValue Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name362783006 SNOMED CT 2.16.840.1.113883.6.96 entire medial surface of

lower extremity (body structure)

302539009 SNOMED CT 2.16.840.1.113883.6.96 entire hand (body structure)

287679003 SNOMED CT 2.16.840.1.113883.6.96 left hip region structure (body structure)

3341006 SNOMED CT 2.16.840.1.113883.6.96 right lung structure (body structure)

87878005 SNOMED CT 2.16.840.1.113883.6.96 left ventricular structure (body structure)

49848007 SNOMED CT 2.16.840.1.113883.6.96 structure of myocardium of left ventricle (body structure)

38033009 SNOMED CT 2.16.840.1.113883.6.96 amputation stump (body structure)

305005006 SNOMED CT 2.16.840.1.113883.6.96 6/7 interchondral joint (body structure)

28726007 SNOMED CT 2.16.840.1.113883.6.96 corneal structure (body structure)

75324005 SNOMED CT 2.16.840.1.113883.6.96 70 to 79 percent of body surface (body structure)

...



Table 350: Medication Product Form Value Set

Value Set: Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11This is the physical form of the product as presented to the individual. For example: tablet, capsule, liquid or ointment. NCI concept code for pharmaceutical dosage form: C42636Value Set Source: https://www.phinvads.cdc.govCode Code System Code System OID Print NameC42887 FDA

RouteOfAdministration2.16.840.1.113883.3.26.1.1

AEROSOL


2.16.840.1.113883.3.26.1.1

AEROSOL, FOAM


2.16.840.1.113883.3.26.1.1

AEROSOL, METERED


2.16.840.1.113883.3.26.1.1

AEROSOL, POWDER


2.16.840.1.113883.3.26.1.1

AEROSOL, SPRAY


2.16.840.1.113883.3.26.1.1

BAR, CHEWABLE


2.16.840.1.113883.3.26.1.1

BEAD


2.16.840.1.113883.3.26.1.1

BEAD, IMPLANT, EXTENDED RELEASE


2.16.840.1.113883.3.26.1.1

BLOCK


2.16.840.1.113883.3.26.1.1

CAPSULE

...


https://www.phinvads.cdc.gov/

Table 351: UnitsOfMeasureCaseSensitive

Value Set: UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839The UCUM code system provides a set of structural units from which working codes are built. There is an unlimited number of possible valid UCUM codes.Value Set Source: http://unitsofmeasure.org/ucum.htmlCode Code System Code System OID Print Namemin UCUM 2.16.840.1.113883.6.8 minutehour UCUM 2.16.840.1.113883.6.8 hr% UCUM 2.16.840.1.113883.6.8 percentcm UCUM 2.16.840.1.113883.6.8 centimeterg UCUM 2.16.840.1.113883.6.8 gramg/(12.h) UCUM 2.16.840.1.113883.6.8 gram per 12 hourg/L UCUM 2.16.840.1.113883.6.8 gram per litermol UCUM 2.16.840.1.113883.6.8 mole[IU] UCUM 2.16.840.1.113883.6.8 international unitHz UCUM 2.16.840.1.113883.6.8 Hertz...

Table 352: Medication Fill Status

Value Set: Medication Fill Status 2.16.840.1.113883.3.88.12.80.64Value Set Source: https://phinvads.cdc.gov/Code Code System Code System OID Print Nameaborted ActStatus 2.16.840.1.113883.5.14 Abortedcompleted ActStatus 2.16.840.1.113883.5.14 Completed


http://unitsofmeasure.org/ucum.html

https://phinvads.cdc.gov/

Table 353: Medication Clinical Drug Name Value Set

Value Set: Medication Clinical Drug Name Value Set 2.16.840.1.113883.3.88.12.80.17Shall contain RxNorm normal forms for concepts type of “Ingredient Name” or Generic Packs. The ingredient name concepts can be found in the RxNORM file RXCONSO.RRF selecting all terms where SAB=RXNORM (selecting the normal forms), and TTY=SCD (selecting the ingredient names) or TTY=GPCK (selecting the generic packs)Value Set Source: https://phinvads.cdc.govCode Code System Code System OID Print Name433151 RxNorm 2.16.840.1.113883.6.88 (1-6)-alpha-glucomannan

2500 MG Chewable Tablet

410935 RxNorm 2.16.840.1.113883.6.88 (1-6)-alpha-glucomannan 398 MG Oral Capsule

283181 RxNorm 2.16.840.1.113883.6.88 (1-6)-alpha-glucomannan 500 MG Oral Capsule

427858 RxNorm 2.16.840.1.113883.6.88 (1-6)-alpha-glucomannan 500 MG Oral Tablet

427859 RxNorm 2.16.840.1.113883.6.88 (1-6)-alpha-glucomannan 650 MG Oral Tablet

419922 RxNorm 2.16.840.1.113883.6.88 [13C] urea 1.67 MG/ML Oral Solution

199983 RxNorm 2.16.840.1.113883.6.88 [13C] urea 125 MG Oral Suspension

763616 RxNorm 2.16.840.1.113883.6.88 {1 (0.35 ML Chondroitin Sulfates 40 MG/ML / hyaluronate 30 MG/ML Prefilled Syringe) / 1 (0.4 ML hyaluronate 10 MG/ML Prefilled Syringe) } Pack

798349 RxNorm 2.16.840.1.113883.6.88 {1 (0.5 ML Acellular Pertussis Vaccine 0.936 MG/ML / Diphtheria Toxoid Vaccine 13.4 UNT/ML / Tetanus Toxoid Vaccine 10 UNT/ML Injectable Suspension) / 1 (0.5 ML Haemophilus influenzae b, capsular polysaccharide inactivated tetanus toxoid conjugate vaccine

763623 RxNorm 2.16.840.1.113883.6.88 {1 (0.5 ML Chondroitin Sulfates 40 MG/ML / hyaluronate 30 MG/ML Prefilled Syringe) / 1 (0.55 ML hyaluronate 10 MG/ML Prefilled Syringe) } Pack

...


https://phinvads.cdc.gov/

Table 354: Route Method of Delivery - Trial of Labor

Value Set: Route Method of Delivery - Trial of Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115To Reflect the Route and Method of Delivery as Trial of LaborValue Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=69DF3853-C3C6-DF11-AB08-0015173D1785Code Code System Code System OID Print Name90306000 SNOMED CT 2.16.840.1.113883.6.96 Trial labor (finding)...

Table 355: Mother’s Delivery Weight

Value Set: Mother’s Delivery Weight 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120To Reflect the Mother's Delivery WeightCode Code System Code System OID Print Name8345-1 LOINC 2.16.840.1.113883.6.1 Body weight^post

partum69461-2 LOINC 2.16.840.1.113883.6.1 Body weight^ at delivery...

Table 356: Newborn Receiving Surfactant Replacement Therapy

Value Set: Newborn Receiving Surfactant Replacement Therapy 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11Code Code System Code System OID Print Name259034 RxNorm 2.16.840.1.113883.6.88 Beractant 25 MG/ML

Injectable Suspension379138 RxNorm 2.16.840.1.113883.6.88 Beractant Injectable

Suspension259611 RxNorm 2.16.840.1.113883.6.88 Calfactant 35 MG/ML

Inhalant Solution379477 RxNorm 2.16.840.1.113883.6.88 Calfactant Inhalant

Solution141920 RxNorm 2.16.840.1.113883.6.88 Colfosceril 13.5 MG/ML

Injectable Suspension385921 RxNorm 2.16.840.1.113883.6.88 Colfosceril Injectable

Suspension259216 RxNorm 2.16.840.1.113883.6.88 Poractant alfa 80 MG/ML

Injectable Suspension375227 RxNorm 2.16.840.1.113883.6.88 Poractant alfa Injectable

Suspension...


https://phinvads.cdc.gov/vads/ViewValueSet.action?id=69DF3853-C3C6-DF11-AB08-0015173D1785

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=69DF3853-C3C6-DF11-AB08-0015173D1785

Table 357: Pressure Ulcer Stage

Value Set: Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35This value set enumerates the type of a pressure ulcer.Value Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name421076008 SNOMED CT 2.16.840.1.113883.6.96 Pressure Ulcer Stage 1420324007 SNOMED CT 2.16.840.1.113883.6.96 Pressure Ulcer Stage 2421927004 SNOMED CT 2.16.840.1.113883.6.96 Pressure Ulcer Stage 3420597008 SNOMED CT 2.16.840.1.113883.6.96 Pressure Ulcer Stage 4421594008 SNOMED CT 2.16.840.1.113883.6.96 Nonstageable pressure

Table 358: Tocolysis

Value Set: Tocolysis 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128To Reflect Obstetric Procedures as TocolysisValue Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=447747A0-0407-E411-BAEA-0017A477041ACode Code System Code System OID Print Name103747003 SNOMED CT 2.16.840.1.113883.6.96 Tocolysis (procedure)...

Table 359: Precipitous Labor

Value Set: Precipitous Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130To Reflect Onset of labor with Precipitous LaborValue Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=5570A1A2-C5C6-DF11-AB08-0015173D1785Code Code System Code System OID Print Name199833004 SNOMED CT 2.16.840.1.113883.6.96 Precipitate labor -

delivered (disorder)51920004 SNOMED CT 2.16.840.1.113883.6.96 Precipitate labor

(disorder)199834005 SNOMED CT 2.16.840.1.113883.6.96 Precipitate labor with

antenatal problem (disorder)

...



https://phinvads.cdc.gov/vads/ViewValueSet.action?id=447747A0-0407-E411-BAEA-0017A477041A

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=447747A0-0407-E411-BAEA-0017A477041A

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=5570A1A2-C5C6-DF11-AB08-0015173D1785

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=5570A1A2-C5C6-DF11-AB08-0015173D1785

Table 360: Birthplace Setting (NCHS)

Value Set: Birthplace Setting (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.184To reflect the question as to the birthplace of the newborn (setting).Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSetConcept.action?id=9C15DD62-8C42-E411-BB47-0017A477041ACode Code System Code System OID Print Name73766-8 LOINC 2.16.840.1.113883.6.1 Place where birth

occurred [US Standard Certificate of Live Birth]

Table 361: Birth or Delivery Occurred (NCHS)

Value Set: Birth or Delivery Occurred (NCHS) 2.16.840.1.114222.4.11.7124The value set contains the list of values used to indicate the type of place where birth or delivery occurred.Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=544E9C61-9D2B-4EAE-8DEE-7A76A4D18DE0Code Code System Code System OID Print Name22232009 SNOMED CT 2.16.840.1.113883.6.96 Hospital91154008 SNOMED CT 2.16.840.1.113883.6.96 Free-standing birthing

center169813005 SNOMED CT 2.16.840.1.113883.6.96 Home birth67190003 SNOMED CT 2.16.840.1.113883.6.96 Free-standing clinic394841004 SNOMED CT 2.16.840.1.113883.6.96 Other category261665006 SNOMED CT 2.16.840.1.113883.6.96 Unknown

Table 362: Planned moodCode (Act/Encounter/Procedure)

Value Set: Planned moodCode (Act/Encounter/Procedure) 2.16.840.1.113883.11.20.9.23This value set is used to restrict the moodCode on an act, an encounter or a procedure to future moodsValue Set Source: http://hl7.org/implement/standards/fhir/v3/ActMood/Code Code System Code System OID Print NameINT ActMood 2.16.840.1.113883.5.100

1Intent

ARQ ActMood 2.16.840.1.113883.5.1001

Appointment Request

PRMS ActMood 2.16.840.1.113883.5.1001

Promise

PRP ActMood 2.16.840.1.113883.5.1001

Proposal

RQO ActMood 2.16.840.1.113883.5.1001

Request

APT ActMood 2.16.840.1.113883.5.1001

Appointment


https://phinvads.cdc.gov/vads/ViewValueSetConcept.action?id=9C15DD62-8C42-E411-BB47-0017A477041A

https://phinvads.cdc.gov/vads/ViewValueSetConcept.action?id=9C15DD62-8C42-E411-BB47-0017A477041A

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=544E9C61-9D2B-4EAE-8DEE-7A76A4D18DE0

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=544E9C61-9D2B-4EAE-8DEE-7A76A4D18DE0

http://hl7.org/implement/standards/fhir/v3/ActMood/

Table 363: Planned moodCode (Observation)

Value Set: Planned moodCode (Observation) 2.16.840.1.113883.11.20.9.25This value set is used to restrict the moodCode on an to future moods.Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameINT ActMood 2.16.840.1.113883.5.100

1Intent

PRMS ActMood 2.16.840.1.113883.5.1001

Promise

PRP ActMood 2.16.840.1.113883.5.1001

Proposal

RQO ActMood 2.16.840.1.113883.5.1001

Request

...

Table 364: Planned moodCode (SubstanceAdministration/Supply)

Value Set: Planned moodCode (SubstanceAdministration/Supply) 2.16.840.1.113883.11.20.9.24This value set is used to restrict the moodCode on a substance administration or a supply to future moods.Value Set Source: http://hl7.org/implement/standards/fhir/v3/ActMood/Code Code System Code System OID Print NameINT ActMood 2.16.840.1.113883.5.100

1Intent

PRMS ActMood 2.16.840.1.113883.5.1001

Promise

PRP ActMood 2.16.840.1.113883.5.1001

Proposal

RQO ActMood 2.16.840.1.113883.5.1001

Request

Table 365: Birth Plurality of Delivery

Value Set: Birth Plurality of Delivery 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132To Reflect the Birth Plurality of DeliveryValue Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=55A309EE-76EC-DF11-A040-00188B39829BCode Code System Code System OID Print Name57722-1 LOINC 2.16.840.1.113883.6.1 Birth

plurality:Num:Pt:Pregnancy:Ord:

...


http://www.hl7.org/

http://hl7.org/implement/standards/fhir/v3/ActMood/

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=55A309EE-76EC-DF11-A040-00188B39829B

https://phinvads.cdc.gov/vads/ViewValueSet.action?id=55A309EE-76EC-DF11-A040-00188B39829B

Table 366: HL7FinanciallyResponsiblePartyType

Value Set: HL7FinanciallyResponsiblePartyType 2.16.840.1.113883.1.11.10416RoleClass 2.16.840.1.113883.5.110 http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameGUAR RoleClass 2.16.840.1.113883.5.110 GuarantorEMP RoleClass 2.16.840.1.113883.5.110 EmployeeINVSBJ RoleClass 2.16.840.1.113883.5.110 Investigation Subject

Table 367: Coverage Role Type

Value Set: Coverage Role Type 2.16.840.1.113883.1.11.18877A value set of HL7 role Codes for role recognized through the issuance of insurance coverage to an identified covered party who has this relationship with the policy holder such as the policy holder themselves (self), spouse, child, etc.Value Set Source: http://www.hl7.org/documentcenter/public/standards/vocabulary/vocabulary_tables/infrastructure/vocabulary/vocabulary.htmlCode Code System Code System OID Print NameFAMDEP RoleCode 2.16.840.1.113883.5.111 Family dependentFSTUD RoleCode 2.16.840.1.113883.5.111 Full-time studentSELF RoleCode 2.16.840.1.113883.5.111 Self...


http://www.hl7.org/

Table 368: Health Insurance Type

Value Set: Health Insurance Type 2.16.840.1.113883.3.88.12.3221.5.2Code Code System Code System OID Print Name12 Insurance Type Code 2.16.840.1.113883.3.88.

12.3221.5.2Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

13 Insurance Type Code 2.16.840.1.113883.3.88.12.3221.5.2

Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan


Medicare Secondary, No-fault Insurance including Auto is Primary


Medicare Secondary Worker's Compensation


Medicare Secondary Public Health Service (PHS)or Other Federal Agency


Medicare Secondary Black Lung


Medicare Secondary Veteran's Administration


Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)


Medicare Secondary, Other Liability Insurance is Primary

AP Insurance Type Code 2.16.840.1.113883.3.88.12.3221.5.2

Auto Insurance Policy

...


Table 369: Pressure Point

Value Set: Pressure Point 2.16.840.1.113883.11.20.9.36This value set represents points on the body that are susceptible to pressure ulcer development. Specific URL PendingValue Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name43631005 SNOMED CT 2.16.840.1.113883.6.96 occipital region structure23747009 SNOMED CT 2.16.840.1.113883.6.96 skin structure of chin91774008 SNOMED CT 2.16.840.1.113883.6.96 structure of right

shoulder7874003 SNOMED CT 2.16.840.1.113883.6.96 structure of scapular

region of back; 272741003 = laterality; 24028007 = right (qualifier value)

368149001 SNOMED CT 2.16.840.1.113883.6.96 right elbow region structure

368148009 SNOMED CT 2.16.840.1.113883.6.96 left elbow region structure

87141009 SNOMED CT 2.16.840.1.113883.6.96 sacral vertebra structure122495006 SNOMED CT 2.16.840.1.113883.6.96 thoracic spine structure122496007 SNOMED CT 2.16.840.1.113883.6.96 lumbar spine structure287579007 SNOMED CT 2.16.840.1.113883.6.96 right hip region structure...

Table 370: TargetSite Qualifiers

Value Set: TargetSite Qualifiers 2.16.840.1.113883.11.20.9.37Specific URL PendingValue Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name255549009 SNOMED CT 2.16.840.1.113883.6.96 anterior7771000 SNOMED CT 2.16.840.1.113883.6.96 left255561001 SNOMED CT 2.16.840.1.113883.6.96 medial255551008 SNOMED CT 2.16.840.1.113883.6.96 posterior24028007 SNOMED CT 2.16.840.1.113883.6.96 right




Table 371: Problem Status

Value Set: Problem Status 2.16.840.1.113883.3.88.12.80.68A value set of SNOMED-CT codes reflecting state of existence. Value Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name55561003 SNOMED CT 2.16.840.1.113883.6.96 Active73425007 SNOMED CT 2.16.840.1.113883.6.96 Inactive413322009 SNOMED CT 2.16.840.1.113883.6.96 Resolved

Table 372: ProcedureAct statusCode

Value Set: ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22Code System: ActStatus 2.16.840.1.113883.5.14 A ValueSet of HL7 actStatus codes for use with a procedure activityValue Set Source: http://www.hl7.orgCode Code System Code System OID Print Namecompleted ActStatus 2.16.840.1.113883.5.14 Completedactive ActStatus 2.16.840.1.113883.5.14 Activeaborted ActStatus 2.16.840.1.113883.5.14 Abortedcancelled ActStatus 2.16.840.1.113883.5.14 Cancelled

Table 373: Act Priority

Value Set: Act Priority 2.16.840.1.113883.1.11.16866Value Set Source: http://www.hl7.orgCode Code System Code System OID Print NameA ActPriority 2.16.840.1.113883.5.7 ASAPCR ActPriority 2.16.840.1.113883.5.7 Callback resultsCS ActPriority 2.16.840.1.113883.5.7 Callback for schedulingCSP ActPriority 2.16.840.1.113883.5.7 Callback placer for

schedulingCSR ActPriority 2.16.840.1.113883.5.7 Contact recipient for

schedulingEL ActPriority 2.16.840.1.113883.5.7 ElectiveEM ActPriority 2.16.840.1.113883.5.7 EmergencyP ActPriority 2.16.840.1.113883.5.7 PreoperativePRN ActPriority 2.16.840.1.113883.5.7 As neededR ActPriority 2.16.840.1.113883.5.7 Routine...



http://www.hl7.org/

http://www.hl7.org/

Table 374: Result Status

Value Set: Result Status 2.16.840.1.113883.11.20.9.39Value Set Source: http://www.hl7.orgCode Code System Code System OID Print Nameaborted ActStatus 2.16.840.1.113883.5.14 abortedactive ActStatus 2.16.840.1.113883.5.14 activecancelled ActStatus 2.16.840.1.113883.5.14 cancelledcompleted ActStatus 2.16.840.1.113883.5.14 completedheld ActStatus 2.16.840.1.113883.5.14 heldsuspended ActStatus 2.16.840.1.113883.5.14 suspended


http://www.hl7.org/

Table 375: HealthcareServiceLocation

Value Set: HealthcareServiceLocation 2.16.840.1.113883.1.11.20275A comprehensive classification of locations and settings where healthcare services are provided. This value set is based on the National Healthcare Safety Network (NHSN) location code system that has been developed over a number of years through CDC's interaction with a variety of healthcare facilities and is intended to serve a variety of reporting needs where coding of healthcare service locations is required.Value Set Source: http://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Healthcare+Service+Location+%28NHSN%29Code Code System Code System OID Print Name1162-7 HL7

HealthcareServiceLocation

2.16.840.1.113883.6.259 24-Hour observation area

1184-1 HL7 HealthcareServiceLocation

2.16.840.1.113883.6.259 Administrative area


2.16.840.1.113883.6.259 Adult Mixed Acuity Unit


2.16.840.1.113883.6.259 Adult step down unit [post-critical care]


2.16.840.1.113883.6.259 Allergy clinic


2.16.840.1.113883.6.259 Ambulatory surgical setting


2.16.840.1.113883.6.259 Any Age Mixed Acuity Unit


2.16.840.1.113883.6.259 Assisted living area


2.16.840.1.113883.6.259 Behavioral health clinic


2.16.840.1.113883.6.259 Blood bank

...


http://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Healthcare+Service+Location+(NHSN)

http://phinvads.cdc.gov/vads/SearchAllVocab_search.action?searchOptions.searchText=Healthcare+Service+Location+(NHSN)

Table 376: Problem Severity

Value Set: Problem Severity 2.16.840.1.113883.3.88.12.3221.6.8This is a description of the level of the severity of the problem. Specific URL PendingValue Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name255604002 SNOMED CT 2.16.840.1.113883.6.96 Mild (qualifier value)371923003 SNOMED CT 2.16.840.1.113883.6.96 Mild to moderate

(qualifier value)6736007 SNOMED CT 2.16.840.1.113883.6.96 Moderate (severity

modifier) (qualifier value)371924009 SNOMED CT 2.16.840.1.113883.6.96 Moderate to severe

(qualifier value)24484000 SNOMED CT 2.16.840.1.113883.6.96 Severe (severity

modifier) (qualifier value)399166001 SNOMED CT 2.16.840.1.113883.6.96 Fatal (qualifier value)



Table 377: Social History Type

Value Set: Social History Type 2.16.840.1.113883.3.88.12.80.60A value set of SNOMED-CT observable entity codes containing common social history observables. Though Tobacco Use and Exposure exists in this value set, it is recommended to use the Current Smoking Status template or the Tobacco Use template to represent smoking or tobacco habits. Specific URL Pending

Value Set Source: https://vsac.nlm.nih.govCode Code System Code System OID Print Name160573003 SNOMED CT 2.16.840.1.113883.6.96 Alcohol intake

(observable entity)363908000 SNOMED CT 2.16.840.1.113883.6.96 Details of drug misuse

behavior (observable entity)

364703007 SNOMED CT 2.16.840.1.113883.6.96 Employment detail (observable entity)

256235009 SNOMED CT 2.16.840.1.113883.6.96 Exercise (observable entity)

228272008 SNOMED CT 2.16.840.1.113883.6.96 Health-related behavior (observable entity)

364393001 SNOMED CT 2.16.840.1.113883.6.96 Nutritional observable (observable entity)

425400000 SNOMED CT 2.16.840.1.113883.6.96 Toxic exposure status (observable entity)

105421008 SNOMED CT 2.16.840.1.113883.6.96 Educational achievement (observable entity)

302160007 SNOMED CT 2.16.840.1.113883.6.96 Household, family and support network detail (observable entity)

423514004 SNOMED CT 2.16.840.1.113883.6.96 Community resource details (observable entity)

...



Table 378: Neonatal Sepsis

Value Set: Neonatal Sepsis 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6To reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newbornCode Code System Code System OID Print Name276669000 SNOMED CT 2.16.840.1.113883.6.96 Bacterial sepsis of

newborn (disorder)211420008 SNOMED CT 2.16.840.1.113883.6.96 Neonatal candida

septicemia (disorder)359646002 SNOMED CT 2.16.840.1.113883.6.96 Neonatal disseminated

listeriosis (disorder)403000003 SNOMED CT 2.16.840.1.113883.6.96 Neonatal systemic

candidosis (disorder)206380000 SNOMED CT 2.16.840.1.113883.6.96 Sepsis of newborn due to

anaerobes (disorder)206379003 SNOMED CT 2.16.840.1.113883.6.96 Sepsis of newborn due to

Escherichia coli (disorder)

206378006 SNOMED CT 2.16.840.1.113883.6.96 Sepsis of newborn due to Staphylococcus aureus (disorder)

206376005 SNOMED CT 2.16.840.1.113883.6.96 Sepsis of the newborn (disorder)

41229001 SNOMED CT 2.16.840.1.113883.6.96 Septicemia of newborn (disorder)

43424001 SNOMED CT 2.16.840.1.113883.6.96 Tetanus neonatorum (disorder)

...


Table 379: Tobacco Use

Value Set: Tobacco Use 2.16.840.1.113883.11.20.9.41Contains values descending from the SNOMED CT® Finding of tobacco use and exposure (finding)(365980008) hierarchy.Value Set Source: http://vtsl.vetmed.vt.edu/TerminologyMgt/RF2Browser/ISA.cfm?SCT_ConceptID=365980008Code Code System Code System OID Print Name81703003 SNOMED CT 2.16.840.1.113883.6.96 Chews tobacco228494002 SNOMED CT 2.16.840.1.113883.6.96 Snuff user59978006 SNOMED CT 2.16.840.1.113883.6.96 Cigar smoker43381005 SNOMED CT 2.16.840.1.113883.6.96 Passive smoker228524006 SNOMED CT 2.16.840.1.113883.6.96 Exposed to tobacco

smoke at home427189007 SNOMED CT 2.16.840.1.113883.6.96 Maternal tobacco use394871007 SNOMED CT 2.16.840.1.113883.6.96 Thinking about stopping

smoking65568007 SNOMED CT 2.16.840.1.113883.6.96 Cigarette smoker160619003 SNOMED CT 2.16.840.1.113883.6.96 Rolls own cigarettes266927001 SNOMED CT 2.16.840.1.113883.6.96 Pipe smoker...

Table 380: Vital Sign Result

Value Set: Vital Sign Result 2.16.840.1.113883.3.88.12.80.62This identifies the vital sign result type. Specific URL PendingValue Set Source: http://www.loinc.org/Code Code System Code System OID Print Name8310-5 LOINC 2.16.840.1.113883.6.1 Body Temperature8462-4 LOINC 2.16.840.1.113883.6.1 BP Diastolic8480-6 LOINC 2.16.840.1.113883.6.1 BP Systolic8287-5 LOINC 2.16.840.1.113883.6.1 Head Circumference8867-4 LOINC 2.16.840.1.113883.6.1 Heart Rate8302-2 LOINC 2.16.840.1.113883.6.1 Height39156-5 LOINC 2.16.840.1.113883.6.1 BMI (Body Mass Index)2710-2 LOINC 2.16.840.1.113883.6.1 O2 % BldC Oximetry9279-1 LOINC 2.16.840.1.113883.6.1 Respiratory Rate3141-9 LOINC 2.16.840.1.113883.6.1 Weight Measured...


http://vtsl.vetmed.vt.edu/TerminologyMgt/RF2Browser/ISA.cfm?SCT_ConceptID=365980008

http://vtsl.vetmed.vt.edu/TerminologyMgt/RF2Browser/ISA.cfm?SCT_ConceptID=365980008

Table 381: PostalAddressUse

Value Set: PostalAddressUse 2.16.840.1.113883.1.11.10637A value set of HL7 Codes for address use.Value Set Source: http://www.hl7.org/documentcenter/public/standards/vocabulary/vocabulary_tables/infrastructure/vocabulary/vocabulary.htmlCode Code System Code System OID Print NameBAD AddressUse 2.16.840.1.113883.5.111

9bad address

CONF AddressUse 2.16.840.1.113883.5.1119

confidential

DIR AddressUse 2.16.840.1.113883.5.1119

direct

H AddressUse 2.16.840.1.113883.5.1119

home address

HP AddressUse 2.16.840.1.113883.5.1119

primary home

HV AddressUse 2.16.840.1.113883.5.1119

vacation home

PHYS AddressUse 2.16.840.1.113883.5.1119

physical visit address

PST AddressUse 2.16.840.1.113883.5.1119

postal address

PUB AddressUse 2.16.840.1.113883.5.1119

public

TMP AddressUse 2.16.840.1.113883.5.1119

temporary

...

Table 382: StateValueSet

Value Set: StateValueSet 2.16.840.1.113883.3.88.12.80.1Identifies addresses within the United States are recorded using the FIPS 5-2 two-letter alphabetic codes for the State, District of Columbia, or an outlying area of the United States or associated areaValue Set Source: http://www.itl.nist.gov/fipspubs/fip5-2.htmCode Code System Code System OID Print NameAL FIPS 5-2 (State) 2.16.840.1.113883.6.92 AlabamaAK FIPS 5-2 (State) 2.16.840.1.113883.6.92 AlaskaAZ FIPS 5-2 (State) 2.16.840.1.113883.6.92 Arizona...


http://www.itl.nist.gov/fipspubs/fip5-2.htm

Table 383: City

Value Set: City 2.16.840.1.114222.4.11.973US Geological Survey Geographic Names Information System - location codes.Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=19D34BBC-617F-DD11-B38D-00188B398520Code Code System Code System OID Print Name975772 U.S. Board on

Geographic Names (USGS - GNIS)

2.16.840.1.113883.6.245 New York

1512650 U.S. Board on Geographic Names (USGS - GNIS)

2.16.840.1.113883.6.245 Seattle


2.16.840.1.113883.6.245 Miami


2.16.840.1.113883.6.245 Chicago


2.16.840.1.113883.6.245 Washington

...




7 CODE SYSTEMS IN THIS GUIDETable 384: Code Systems

Name OIDActCode 2.16.840.1.113883.5.4ActMood 2.16.840.1.113883.5.1001ActPriority 2.16.840.1.113883.5.7ActReason 2.16.840.1.113883.5.8ActStatus 2.16.840.1.113883.5.14AddressUse 2.16.840.1.113883.5.1119AdministrativeGender 2.16.840.1.113883.5.1Birth Defects Diagnostic Confirmation 2.16.840.1.113883.10.14.90Birth Defects Laterality at Diagnosis 2.16.840.1.113883.10.14.92CDC Vaccine Code (CVX) 2.16.840.1.113883.12.292ConfidentialityCode 2.16.840.1.113883.5.25Country 2.16.840.1.113883.3.88.12.80.63EntityClass 2.16.840.1.113883.5.41FDA RouteOfAdministration 2.16.840.1.113883.3.26.1.1FIPS 5-2 (State) 2.16.840.1.113883.6.92Healthcare Provider Taxonomy (HIPAA) 2.16.840.1.113883.6.101HL7 HealthcareServiceLocation 2.16.840.1.113883.6.259HL7 V2.5 Route of Administration codes 2.16.840.1.113883.12.162HL7ActClass 2.16.840.1.113883.5.6HL7ActRelationshipType 2.16.840.1.113883.5.1002HL7NullFlavor 2.16.840.1.113883.5.1008HL7ParticipationType 2.16.840.1.113883.5.90ICD10 2.16.840.1.113883.6.3ICD10CM 2.16.840.1.113883.6.90Insurance Type Code 2.16.840.1.113883.3.88.12.3221.5.2Language 2.16.840.1.113883.6.121LanguageAbilityMode 2.16.840.1.113883.5.60LanguageAbilityProficiency 2.16.840.1.113883.5.61LOINC 2.16.840.1.113883.6.1MaritalStatus 2.16.840.1.113883.5.2participationFunction 2.16.840.1.113883.5.88Participationsignature 2.16.840.1.113883.5.89PHIN VADS code system 2.16.840.1.114222.4.5.274Race & Ethnicity - CDC 2.16.840.1.113883.6.238ReligiousAffiliation 2.16.840.1.113883.5.1076


Name OIDRoleClass 2.16.840.1.113883.5.110RoleCode 2.16.840.1.113883.5.111RxNorm 2.16.840.1.113883.6.88SNOMED CT 2.16.840.1.113883.6.96U.S. Board on Geographic Names (USGS - GNIS) 2.16.840.1.113883.6.245UCUM 2.16.840.1.113883.6.8USPostalCodes 2.16.840.1.113883.6.231

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