CDA R2

Evaluation and management note

Implementation Guide for CDA Release 2
Level 1 ,2 and 3
TW

0.5

97 98

(International Affiliates Organization)

__CDAR2_TW_08.27.2009_v0.5

V 0.1 2008/12/**
V 0.2 2009/01/** v0.1 Header Body

V 0.3 2009/07/06
V 0.4 2009/08/23
V 0.5 2009/08/27

ii
__CDAR2_TW_08.27.2009_v0.5

.................................................................................................................................................... v
................................................................................................................................................... vi
..................................................................................................................................................vii
1 ................................................................................................................................................ 1
1.1 .................................................................................................................................... 1
1.2 ............................................................................................................................ 1
1.3 ............................................................................................................................ 1
1.4 .................................................................................................................................... 1
1.5 ............................................................................................................................ 2
1.6 ........................................................................................................................ 2
1.6.1 .................................................................................................................... 2
1.6.2 .................................................................................................................... 2
1.7 .................................................................................................................... 2
1.8 ................................................................................................................ 3
2 CDA Header.................................................................................................................................... 6
2.1 ........................................................................................................................ 6
2.1.1 Namespace.............................................................................................................. 6
2.1.2 ............................................................................................................ 7
2.1.3 OID ............................................................................................................. 7
2.2 Header Attributes.......................................................................................................... 8
2.2.1 ClinicalDocument/typeId.................................................................................. 8
2.2.2 ClinicalDocument/templateId.......................................................................... 8
2.2.3 ClinicalDocument/realmCode............................................................................ 9
2.2.4 ClinicalDocument/id.......................................................................................... 9
2.2.5 ClinicalDocument/code...................................................................................... 9
2.2.6 ClinicalDocument/title.................................................................................. 10
2.2.7 ClinicalDocument/effectiveTime.................................................................. 10
2.2.8 ClinicalDocument/confidentialityCode...................................................... 10
2.2.9 ClinicalDocument/languageCode.................................................................... 11
2.2.10 ClinicalDocument/setId ClinicalDocument/versionNumber................ 11
2.2.11 ClinicalDocument/copyTime............................................................................ 11
2.3 Header Participants.................................................................................................... 12
2.3.1 .............................................................................................................. 14
2.4 Header Relationships.................................................................................................. 26
2.4.1 .............................................................................................................. 27
3 CDA Body...................................................................................................................................... 29

iii
__CDAR2_TW_08.27.2009_v0.5

3.1 ...................................................................................................................... 29
3.1.1 .............................................................................................................. 29
3.1.2 .............................................................................................................. 29
3.2 .......................................................................................................................... 32
3.2.1 Diagnosis 29548-5.................................................................................. 32
3.2.2 Reference lab test results 19146-0............................ 34
3.2.3 Major Procedures (Diagnostic, Surgical, and Therapeutic
Interventions) 52466-0.................................................................................................. 36
3.2.4 ADL patterns 45979-2.......................................................... 38
3.2.5 History of present illness 10164-2........................................ 40
3.2.6 History of past illness 11348-0....................................... 42
3.2.7 Family history or condition or disease and action 39155-7..
.............................................................................................................................. 44
3.2.8 Labor and delivery records 15508-5.......................... 46
3.2.9 Assessment.initial 27572-7................................................... 48
3.2.10 Newborn screening panel 54089-8......................................... 50
3.2.11 Social history 29762-2............................................................ 52
3.2.12 History of hospitalizations+History of outpatient
visits 46240-8.................................................................................................................. 54
4 CDA ............................................................................................................... 56
5 .................................................................................................................. 69
6 CDA R-MIM ............................................................................................................... 72

iv
__CDAR2_TW_08.27.2009_v0.5

1Namespace .......................................................................................................... 7
2Header Attributes .............................................................................. 8
3ClinicalDocument/typeId .............................................................................. 8
4ClinicalDocument/templateId ...................................................................... 8
5ClinicalDocument/id ...................................................................................... 9
6ClinicalDocument/code ................................................................................ 10
7 translation ............................................... 10
8ClinicalDocument/title .............................................................................. 10
9CinicalDocument/effectiveTime ................................................................ 10
10CinicalDocument/confidentialityCode .................................................. 10
11ClinicalDocument/languageCode .............................. 11
12ClinicalDocument/languageCode .............................. 11
13ClinicalDocument/setId ClinicalDocument/versionNumber .......... 11
14Participants .................................................................................... 12
15legalAuthenticator ............................................................................ 14
16legalAuthenticator .................................................................................... 15
17author .................................................................................................... 16
18author ............................................................................................................ 17
19custodian .............................................................................................. 18
20custodian ...................................................................................................... 18
21recordTarget ........................................................................................ 19
22recordTarget ................................................................................................ 22
23participant .......................................................................................... 23
24Participant .................................................................................................. 25
25Relationships ...................................................................................... 26
26componentOf .......................................................................................... 27
27componentOf .................................................................................................. 28
28CDA R2 Body ..................................................................................... 29
29 LOINC ................................................................................. 32
30 XML ............................................................................................. 33
31 LOINC ............................................................. 34
32 XML ......................................................................... 35
33 LOINC ......................................................................... 36
34 XML ..................................................................................... 37
35 LOINC ......................................................................... 38
36 XML ............................................................................. 39

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__CDAR2_TW_08.27.2009_v0.5

37 LOINC ......................................................................... 40
38 XML ..................................................................................... 41
39 LOINC ................................................................. 42
40 XML ............................................................................. 43
41 LOINC ............................................................................. 44
42 XML ......................................................................................... 45
43 LOINC ............................................................. 46
44 XML ......................................................................... 47
45 LOINC ..................................................................... 48
46 XML ................................................................................. 49
47 LOINC ..................................................................... 50
48 XML ................................................................................. 51
49 LOINC ..................................................................... 52
50 XML ................................................................................. 53
51 LOINC ................................................................. 54
52 XML ............................................................................. 55

1............................................................................................. 2
2................................................................................. 2
3LOINC ...................................................................................... 9
4 Participants ................................................................. 13
5Relationships ................................................................................ 26
6 Body ..................................................................................... 29

vi
__CDAR2_TW_08.27.2009_v0.5

CDA R2 Clinical Document Architecture Release 2
XML Extensible Markup Language
HL7 Health Level Seven
LOINC Logical Observation Identifiers Names and Codes
RMIM Refined Message Information Model
RIM Reference Information Model
DSTU Draft Standards for Trial Use
ICD-9 International Classification of Diseases 9th Revision
XSLT Extensible Stylesheet Language Transformations
OID Object Identifier
UUID Universally Unique Identifier

vii
1

1.1
CDA R2

Implementation Guide for CDA Release 2 Level 1 and
2 Care Record Summary(2006)Draft Standards for
Trial UseDSTU

1.2
(Electronic Health RecordEHR)
Electronic medical record EMR Personal health
recordPHR
CDA

XML HL7 v3
CDA R2 HL7 v3/CDA R2
HL7 Taiwan
http://groups.google.com.tw/group/hl7-taiwan?hl=zh-TW

1.3
CDA LOINC

1.4
RMIM 4/21/2005 RIM 2.07
DSTU
Level 1 CDA
Level 2 CDA ClinicalDocument structuredBody
(Section)
Level 3 (Entry) Section

level3 ICD-9

1
__CDAR2_TW_08.27.2009_v0.5

ICD-9 level3 XML

L1-1 Level 1
L2-1 Level 2

1.5
1

/
Required/Mandatory SHALL SHALL NOT
/
Best Practice/Recommendation SHOULD SHOULD NOT
/
Acceptable/Permitted MAY NEED NOT

1.6
1.6.1
CDA SHALL
templateIdtemplateId HL7 Taiwan
CDA NEED NOT template templateId
1.6.2
MAY templateId CDA
MAY templateId CDA
SHALL NOT templateId CDA

1.7

2

039_.pdf
cda.xsl An XSLT stylesheet
039_.xml CDA
039_.xls CDA

2
__CDAR2_TW_08.27.2009_v0.5

1.8

039_
V0.1


- -
Patient Basic Data [1..1]

Name [1..1]


Chart No. [1..1]



Identification [1..1]



ID Number [0..1]


Passport Number [0..1]

Administrative Sex [1..1]

Birth Date / [1..1]
YYYYMMDD
PatientComeFrom [1..1]
Bed No [1..1]

Occupation [1..1]

[1..1]

ISO639-2
Primary Language [1..1]

Religion [1..1]

Education Level [1..1]

[1..*]

[1..*]

Admission Diagnosis [1..1]

3
__CDAR2_TW_08.27.2009_v0.5

039_
V0.1


- -

[1..1]

[1..1]

RH [1..1]

[0..*]

History of Infection [0..*]

History of allergies [0..*]
[0..1]
[0..1]
[0..1]
[0..1]
Travel History [0..*]
[0..*]
[0..*]
Operation Name [0..*]

[1..1]

[1..1]

[1..1]

[1..1]

[0..*]

Present Illness [0..*]

Past Medical History [0..*]

[0..*]

[0..1]

[1..1]

[1..1]

4
__CDAR2_TW_08.27.2009_v0.5

039_
V0.1


- -

[1..1]

[1..1]

[0..*]


[0..*]


[0..*]

[1..1]

[0..1]


[0..1]

[0..1]

Nurse Sign [1..1]

5
2 CDA Header

CDA R2 RMIM

2.1
2.1.1 Namespace
CDA Release 2.0 urn:hl7-org:v3
Clinical Document
xsi:schemaLocation
ClinicalDocument
<?xml version="1.0" standalone="no"?>
<?xml-stylesheet type='text/xsl' href='CDA.xsl'?>
<ClinicalDocument classCode="DOCCLIN" moodCode="EVN" xmlns="urn:hl7-
org:v3" xmlns:voc="urn:hl7-org:v3/voc"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" >
<!--
********************************************************
CDA Header
********************************************************
-->
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
<templateId extension="level 1"
root="2.16.840.1.113883.2.33.10.39.1" />
<templateId extension="level 2"
root="2.16.840.1.113883.2.33.10.39.2" />
<!--
1. OID
-->
<id extension="c266" root="2.16.840.1.113883.19.4" />
<!---->
<code code="34768-2" codeSystem="2.16.840.1.113883.6.1"
displayName="Evaluation and management note" codeSystemName="LOINC"
/>
<title></title>
<!-- -->
<effectiveTime value="20091223198231" />
<confidentialityCode />
6
__CDAR2_TW_08.27.2009_v0.5

<!-- -->
<languageCode code="zh-TW" />
<setId />
:
:
</ClinicalDocument>
1Namespace
2.1.2
Header
Header



ID

ID
(Record Targets)

2.1.3 OID

OID OID GOID
http://oid.nat.gov.tw/OIDWeb/chmain.html

7
2.2 Header Attributes
CDA R2 RMIM Entry Point ClinicalDocument

ClinicalDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)

2Header Attributes
RIM InfrastructureRoot
ClinicalDocument
2.2.1 ClinicalDocument/typeId
ClinicalDocument/typeId CDA R2
@root @extension 3

<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
3ClinicalDocument/typeId
L1-1 ClinicalDocument/typeId @extension
"POCD_HD000040"@root 2.16.840.1.113883.1.3
2.2.2 ClinicalDocument/templateId
ClinicalDocument/templateId
templateId @root @extension
4 Level 1Level 2 Level 3
<templateId extension="level 1"
root="2.16.840.1.113883.2.33.10.39.1" />
<templateId extension="level 2"
root="2.16.840.1.113883.2.33.10.39.2" />
4ClinicalDocument/templateId
8
__CDAR2_TW_08.27.2009_v0.5

L1-2 ClinicalDocument/templateId @extension

IMPL_CDAR2_LEVEL1 @root
2.16.840.1.113883.2.33.10.1.1
2.2.3 ClinicalDocument/realmCode

ClinicalDocument/realmCode TW
2.2.4 ClinicalDocument/id
ClinicalDocument/id instance identifier
( HL7 Version 3 Abstract Data Types) root UUID
OID@root @extension OID
64 OID

L1-3 The ClinicalDocument/id/@root UUID OID

L1-4 UUID XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX X
0~9 A~F
L1-5 OID 0

L1-6 OID 64
<id extension="c266" root="2.16.840.1.113883.19.4" />
5ClinicalDocument/id
2.2.5 ClinicalDocument/code
ClinicalDocument/code
LOINC version 2.12 DOC 3

3LOINC
LOINC TYPE OF SERVICE SETTING TRAINING/PROFESSI
ONAL LEVEL
34768-2 Evaluation and management note {Setting} Nurse.general
medicine

9
__CDAR2_TW_08.27.2009_v0.5

L1-7 /ClinicalDocument/code @code 3

@codeSystem LOINC OID @codeSystemName
LOINC
<code code="34768-2" codeSystem="2.16.840.1.113883.6.1"
displayName="Evaluation and management note" codeSystemName="LOINC"
/>
6ClinicalDocument/code
2.2.5.1
translation

<code code="(loinc code)" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC">
<translation code="(translation system code)"
displayName="(translation system code displayName)"
codeSystem="(translation system OID) "/>
</code>
7 translation
2.2.6 ClinicalDocument/title
title
<title></title>
8ClinicalDocument/title
2.2.7 ClinicalDocument/effectiveTime
ClinicalDocument/effectiveTime


<effectiveTime value="20091223198231" />
9CinicalDocument/effectiveTime
2.2.8 ClinicalDocument/confidentialityCode
ClinicalDocument/confidentialityCode
()N
RV
<confidentialityCode/>
10CinicalDocument/confidentialityCode
10
__CDAR2_TW_08.27.2009_v0.5

2.2.9 ClinicalDocument/languageCode
ClinicalDocument/languageCode

L1-8 languageCode
L1-9 language nn nn-CC.
L1-10 nn ISO-639-1 language code
L1-11 CC ISO-3166
<languageCode code="zh" />
11ClinicalDocument/languageCode
<languageCode code="zh-TW" />
12ClinicalDocument/languageCode
2.2.10 ClinicalDocument/setId ClinicalDocument/versionNumber
ClinicalDocument/setId ClinicalDocument/versionNumber
ClinicalDocument/setId instance
identifier (II)@root UUID OID
@extension @root
CDA R2 4.2.3.1
13
L1-12 ClinicalDocument/setId ClinicalDocument/versionNumber

L1-13 ClinicalDocument/setId ClinicalDocument/id
@extension @root
<setId />
<versionNumber value="1" />
13ClinicalDocument/setId ClinicalDocument/versionNumber
2.2.11 ClinicalDocument/copyTime
ClinicalDocument/copyTime CDA R2

L1-14 ClinicalDocument/copyTime

11
2.3 Header Participants
HL7 RIM Participants Role Act
Role Acts Act Roles
CDA R2 RMIM ClinicalDocument 14
0..* assignedEntity ClinicalDocument
authenticator
typeCode*: <= AUTHEN classCode*: <= DOCCLIN
time*: TS [1..1] moodCode*: <= EVN
signatureCode*: CS CNE [1..1] <= ParticipationSignature id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
0..1 assignedEntity
title: ST [0..1]
legalAuthenticator effectiveTime*: TS [1..1]
typeCode*: <= LA confidentialityCode*: CE CWE [1..1]
contextControlCode*: CS CNE [1..1] <= "OP" <= x_BasicConfidentialityKind
time*: TS [1..1] languageCode: CS CNE [0..1] <= HumanLanguage
signatureCode*: CS CNE [1..1] <= ParticipationSignature setId: II [0..1]
versionNumber: INT [0..1]
0..* intendedRecipient copyTime: TS [0..1] (Deprecated)
informationRecipient
typeCode*: <= x_InformationRecipient

1..* assignedAuthor
author
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]

1..1 assignedCustodian
custodian
typeCode*: <= CST

0..1 assignedEntity
dataEnterer
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]

1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"

0..* informantChoice
informant
typeCode*: <= INF
contextControlCode*: CS CNE [1..1] <= "OP"

0..* associatedEntity
participant
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]

14Participants
Participants
4

12
__CDAR2_TW_08.27.2009_v0.5

4 Participants
CDA R2


authenticator [0..*]


legalAuthenticator [0..1]
2.3.1.1
informationRecipient [0..*]

author [1..*]
2.3.1.2

custodian [1..1]
2.3.1.3
dataEnterer [0..1]

recordTarget [1..*]
2.3.1.4

informant [0..*]


participant [0..*]
2.3.1.5
L1-15 legalAuthenticator
L1-16 author
L1-17 custodian
L1-18 recordTarget
L1-19 participant

13
2.3.1

2.3.1.1 legalAuthenticator
legalAuthenticator

Organization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass 0..1 representedOrganization AssignedEntity
0..1 assignedEntity
classCode*: <= ASSIGNED
id*: SET<II> [1..*] legalAuthenticator
code: CE CWE [0..1] <= RoleCode typeCode*: <= LA
addr: SET<AD> [0..*] contextControlCode*: CS CNE [1..1] <= "OP"
telecom: SET<TEL> [0..*] time*: TS [1..1]
signatureCode*: CS CNE [1..1] < ParticipationSignature

Person
classCode*: <= PSN 0..1 assignedPerson
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]

15legalAuthenticator
L1-20 legalAuthenticator/time

L1-21 legalAuthenticator/signatureCode @code S
L1-22 legalAuthenticator/assignedEntity
L1-23 assignedEntity/id
@root
OID
L1-24 leagalAuthenticator/assignedPerson
L1-25 assignedPerson/name
L1-26 leagalAuthenticator/representedOrganization

L1-27 representedOrganization/id

L1-28 representedOrganization/name

14
__CDAR2_TW_08.27.2009_v0.5

<legalAuthenticator typeCode="LA" contextControlCode="OP">

<!--
@value : YYYYMMDD
-->
<time value="20000408" />
<signatureCode code="S" />
<assignedEntity classCode="ASSIGNED">
<!--legalAuthenticator
@extension :
@root : OID
-->
<id extension="KP00017" root="2.16.886.111.100000.100000"
/>
<id extension="hca000111"
root="2.16.886.111.100000.100000.1" />
<id extension="hca000111"
root="2.16.886.111.100000.100000.1" />
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<!-- legalAuthenticator -->
<name></name>
</assignedPerson>
<representedOrganization classCode="ORG"
determinerCode="INSTANCE">
<!--legalAuthenticator-->
<id extension="10004331121"
root="2.16.886.111.100000.100000" />
<!--legalAuthenticator-->
<name></name>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
16legalAuthenticator

15
2.3.1.2 author
author
author

author
Organization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*] 0..1 representedOrganization 1..* assignedAuthor
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*] author
standardIndustryClassCode: CE CWE [0..1]
AssignedAuthor typeCode*: <= AUT
< OrganizationIndustryClass functionCode: CE CWE [0..1] < ParticipationFunction
classCode*: <= ASSIGNED
contextControlCode*: CS CNE [1..1] <= "OP"
id*: SET<II> [1..*]
time*: TS [1..1]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
AuthorChoice telecom: SET<TEL> [0..*]
Person
classCode*: <= PSN 0..1 assignedAuthorChoice
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]

AuthoringDevice
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1] <= ManufacturerModelName
softwareName: SC CWE [0..1] <= SoftwareName

17author
L1-29 author/time value

L1-30 author/assignedAuthor
L1-31 assignedAuthor/id
@root
OID
L1-32 assignedAuthor/assignedPerson
L1-33 assignedPerson/name
L1-34 assignedAuthor/representedOrganization
L1-35 representedOrganization/id

L1-36 representedOrganization/name

16
__CDAR2_TW_08.27.2009_v0.5

<!-- author1 -->

<author typeCode="AUT" contextControlCode="OP">
<time value="20010101" />
<assignedAuthor classCode="ASSIGNED">
<id extension="D0001" root="2.16.886.111.100000.100000" />
<id extension="D12345" root="2.16.886.111.100000.100000.1"
/>
<id extension="D12345" root="2.16.886.111.100000.100000.1"
/>
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name></name>
</assignedPerson>
<representedOrganization classCode="ORG"
determinerCode="INSTANCE">
<id extension="10004331121"
root="2.16.886.111.100000.100000" />
<name></name>
</representedOrganization>
</assignedAuthor>
</author>
18author

17
2.3.1.3 custodian
custodian id

AssignedCustodian 1..1 assignedCustodian
classCode*: <= ASSIGNED custodian
typeCode*: <= CST
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE 1..1 representedCustodianOrganization
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]

19custodian
L1-37 assignedCustodian/representedCustodianOrganization

<!-- -->
<custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG"
determinerCode="INSTANCE">
<id />
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
20custodian

18
2.3.1.4 recordTarget
recordTarget
Place
classCode*: <= PLC Organization
determinerCode*: <= INSTANCE
name: EN [0..1]
addr: AD [0..1]
1..1 birthplace

Birthplace 0..1 providerOrganization

classCode*: <= BIRTHPL

0..1 birthplace

1..* patientRole
PatientRole recordTarget
Patient
classCode*: <= PAT typeCode*: <= RCT
classCode*: <= PSN id: SET<II> [1..*] contextControlCode*: CS CNE [1..1] <= "OP"
determinerCode*: <= INSTANCE 0..1 patient addr: SET<AD> [0..*]
id: II [0..1] (Deprecated) telecom: SET<TEL> [0..*]
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus LanguageCommunication
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation (LanguageCommunication)
raceCode: CE CWE [0..1] <= Race 0..*
ethnicGroupCode: CE CWE [0..1] <= Ethnicity languageCode: CS CNE [0..1] <= HumanLanguage
languageCommunication modeCode: CE CWE [0..1] <= LanguageAbilityMode
proficiencyLevelCode: CE CWE [0..1] <= LanguageAbilityProficiency
preferenceInd: BL [0..1]
GuardianChoice
Person

0..* guardian Guardian

classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
Organization addr: SET<AD> [0..*]
1..1 guardianChoice telecom: SET<TEL> [0..*]

21recordTarget
L1-38 recordTarget/patientRole
L1-39 patientRole/id @extension
@root id OID
@root
OID
L1-40 patientRole/addr
L1-41 patientRole/telecom @use

L1-42 patientRole/telecom @value

L1-43 patientRole/patient
L1-44 patient/id @root
OID
L1-45 patient/name
L1-46 patient/administrativeGenderCode
administrativeGenderCode HL7
AdministrativeGender vocabulary domain

19
__CDAR2_TW_08.27.2009_v0.5

L1-47 patient/birthTime
YYYYMMDD
L1-48 patient/maritalStatusCode
maritalStatusCode HL7
MaritalStatus vocabulary domain
L1-49 patient/religiousAffiliationCode

L1-50 patient/ethnicGroupCode
L1-51 patient/birthplace/place

L1-52 languageCommunication/languageCode

<!-- -->
<recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole classCode="PAT">
<!--
@extension :
@root : OID
-->
<id extension="123456" root="2.16.886.111.100000.100000" />
<!-- -->
<addr>1001010</addr>
<!-- -->
<telecom use="H" value="(02) 12345678" />
<!-- -->
<telecom use="WP" value="(02) 12345678" />
<!-- -->
<telecom use="MC" value="921111998" />
<!-- -->
<telecom value="mailto:22223333@gmail.com" />
<!-- -->
<patient classCode="PSN" determinerCode="INSTANCE">
<!--
@extension :
@root : 2.16.886.101.20003.20001
-->

20
__CDAR2_TW_08.27.2009_v0.5

<id extension="A123456789"
root="2.16.886.101.20003.20001" />
<!-- -->
<name></name>
<!--
@code :
@codeSystem : 2.16.840.1.113883.5.1 (HL7
Vocabulary OID)
-->
<administrativeGenderCode code="M"
codeSystem="2.16.840.1.113883.5.1" />
<!--()
@value : YYYYMMDD)
-->
<birthTime value="20000101" />
<!--
@code :
@codeSystem : 2.16.840.1.113883.5.2 (HL7
Vocabulary OID)
-->
<maritalStatusCode code="M"
codeSystem="2.16.840.1.113883.5.2" />
<!---->
<religiousAffiliationCode code="1050"
codeSystem="2.16.840.1.113883.5.1076" />
<!---->
<ethnicGroupCode code="2135-2"
codeSystem="2.16.840.1.113883.5.50" />
<birthplace classCode="BIRTHPL">
<place classCode="PLC" determinerCode="INSTANCE">
<addr></addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="2135-2" />
</languageCommunication>
</patient>
</patientRole>

21
__CDAR2_TW_08.27.2009_v0.5

</recordTarget>
22recordTarget

22
2.3.1.5 participant
participant
participant/@typeCode

23participant

participant

L1-53 participant/@typeCode @typeCode
HL7 ParticipantionType vocabulary domain
L1-54 participant/associatedEntity
L1-55 associatedEntity/@ClassCode @classCode
HL7 RoleClass vocabulary domain
L1-56 associatedEntity/associatedPerson

L1-57 associatedPerson/name

L1-58 associatedEntity/telecom use

L1-59 associatedEntity/telecom

<!-- -->
<!--ParticipationType typeCode='NOT' => 'urgent notification
contact'-->
<participant typeCode="NOT" contextControlCode="OP">
<!--RoleClassAssociative classCode='NOK' => 'next of kin'-->
<associatedEntity classCode="NOK">
<code code="SPS" codeSystem="2.16.840.1.113883.5.111" />
<associatedPerson classCode="PSN"
determinerCode="INSTANCE">
<!-- -->
<name></name>

23
__CDAR2_TW_08.27.2009_v0.5

</associatedPerson>
</associatedEntity >
</participant>
<!-- 1 -->
<!--ParticipationType typeCode='NOT' => 'urgent notification
contact'-->
<participant typeCode="NOT" contextControlCode="OP">
<!--RoleClassAssociative classCode='ECON' => 'emergency
contact'-->
<associatedEntity classCode="ECON">
<!--1-RoleCode code='FTH' =>
Father-->
<code code="FTH" codeSystem="2.16.840.1.113883.5.111" />
<!--elecomdata typeset<TEL>2componentsuse
use='H' => homeWP =>office addressMC=>moves and stays
with its owne-->
<telecom use="H" value="22225555" />
<telecom use="WP" value="22225554" />
<telecom use="MC" value="0911111111" />
<telecom use="" value="mailto:22225555@gmail.com" />
<associatedPerson classCode="PSN"
determinerCode="INSTANCE">
<name></name>
</associatedPerson>
</associatedEntity >
</participant>
<!-- 2 -->
<!--ParticipationType typeCode='NOT' => 'urgent notification
contact'-->
<participant typeCode="NOT" contextControlCode="OP">
<!--RoleClassAssociative classCode='ECON' => 'emergency
contact'-->
<associatedEntity classCode="ECON">
<!--2-RoleCode code='FTH' =>
Father-->
<code code="MTH" codeSystem="2.16.840.1.113883.5.111" />
<!--elecomdata typeset<TEL>2componentsuse
use='H' => homeWP =>office addressMC=>moves and stays

24
__CDAR2_TW_08.27.2009_v0.5

with its owne-->

<telecom use="H" value="22225556" />
<telecom use="WP" value="22225557" />
<telecom use="MC" value="0911111112" />
<telecom use="" value="mailto:22226666@gmail.com" />
<associatedPerson classCode="PSN"
determinerCode="INSTANCE">
<name></name>
</associatedPerson>
</associatedEntity >
</participant>
24Participant

25
 2.4 Header Relationships

ClinicalDocument 0..* parentDocument

classCode*: <= DOCCLIN relatedDocument

moodCode*: <= EVN typeCode*: <= x_ActRelationshipDocument
id*: II [1..1] 0..* order
code*: CE CWE [1..1] < DocumentType
title: ST [0..1] inFulfillmentOf
effectiveTime*: TS [1..1] typeCode*: <= FLFS
confidentialityCode*: CE CWE [1..1] 0..* serviceEvent
< x_BasicConfidentialityKind documentationOf
languageCode: CS CNE [0..1] < HumanLanguage typeCode*: <= DOC
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)
componentOf
typeCode*: <= COMP
0..1 encompassingEncounter
0..* consent
authorization
typeCode*: <= AUTH
1..1 bodyChoice
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"

25Relationships
5Relationships
1
ActReloationship Act

ParentDocument


relatedDocument
relatedDocument/typeCode
ParentDocument/text ED
CDA MIME Type
inFulfillmentOf Order
ServiceEvent
documentationOf

EncompassingEncounter

componentOf
ServiceEvent

Consent
authorization
ServiceEvent

1
26
__CDAR2_TW_08.27.2009_v0.5

2.4.1
2.4.1.1 componentOf
componentOf
ServiceEvent
componentOf

0..1 assignedEntity
EncompassingEncounter responsibleParty AssignedEntity
typeCode*: <= RESP 0..1 representedOrganization
classCode*: <= ENC
moodCode*: <= EVN
componentOf id: SET<II> [0..*]
typeCode*: <= COMP 0..* assignedEntity
code: CE CWE [0..1] <= ActEncounterCode
0..1 encompassingEncounter effectiveTime*: IVL<TS> [1..1] encounterParticipant
dischargeDispositionCode: CE CWE [0..1] typeCode*: <= x_EncounterParticipant
<= EncounterDischargeDisposition time: IVL<TS> [0..1] 0..1 assignedPerson
location
typeCode*: <= LOC
0..1 healthCareFacility

HealthCareFacility
classCode*: <= SDLOC
id: SET<II> [0..*]
code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType

0..1 serviceProviderOrganization
0..1 location
Organization Place

26componentOf
L1-60 componentOf
L1-61 componentOf/encompassingEncounter
L1-62 encompassingEncounter/effectiveTime

L1-63 encompassingEncounter/location
L1-64 location/healthCareFacility/location/name

L1-65 location/addr

<!-- -->
<componentOf typeCode="COMP">
<encompassingEncounter classCode="ENC" moodCode="EVN">
<!-- -->
<effectiveTime value="20000101" />
<!-- -->
<location typeCode="LOC">
<!-- -->
27
__CDAR2_TW_08.27.2009_v0.5

<healthCareFacility classCode="SDLOC">
<location classCode="PLC" determinerCode="INSTANCE">
<!-- -->
<addr>001</addr>
</location>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
27componentOf

28
3 CDA Body

CDA R2 RMIM

3.1
Body structuredBody nonXMLBody
structuredBody
3.1.1
bodyChoice
NonXMLBody
classCode*: <= DOCBODY
moodCode*: <= EVN
text: ED [1..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage

1..1 bodyChoice
component StructuredBody
typeCode*: <= COMP classCode*: <= DOCBODY
contextConductionInd*: BL [1..1] "true" moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage

component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"

0..1 subject
component
SubjectPerson
1..* section typeCode*: <= COMP
classCode*: <= PSN contextConductionInd*: BL [1..1] "true"
determinerCode*: <= INSTANCE
0..*
name: SET<PN> [0..*] Section
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender author
birthTime: TS [0..1] 0..* section
classCode*: <= DOCSECT
0..* moodCode*: <= EVN
informant id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
RelatedSubject 0..1 relatedSubject title: ST [0..1]
0..1
classCode*: <= x_DocumentSubject subject text*: ED [0..1] 0..* clinicalStatement
code: CE CWE [0..1] <= PersonalRelationshipRoleType typeCode*: <= SBJ confidentialityCode: CE CWE [0..1] entry
addr: SET<AD> [0..*] contextControlCode*: CS CNE [1..1] <= "OP" <= x_BasicConfidentialityKind typeCode*: <= x_ActRelationshipEntry
telecom: SET<TEL> [0..*] awarenessCode: CE CWE [0..1] <= TargetAwareness languageCode: CS CNE [0..1] <= contextConductionInd*: BL [1..1] "true"
HumanLanguage

28CDA R2 Body
3.1.2

LOINC
6 Body
Section LOINC_NUM COMPONENT PROPERTY TIME_A SYSTEM SCALE_ METHO
Category SPCT TYP D_TYP
Diagnos Imp Pt ^Patient Nar
29548-5
is
Referen Find XXX Reference Nar

ce lab lab test
19146-0
test

results
Major - Pt ^Patient -

52466-0 Procedu

res
29
__CDAR2_TW_08.27.2009_v0.5

(Diagno
stic,
Surgica
l, and
Therape
utic
Interve
ntions)
ADL - Pt ^Patient Set

45979-2 pattern

s
History Find Pt ^Patient Nar Repo
of rted
10164-2
present
illness
History Find Pt ^Patient Nar Repo

11348-0 of past rted

illness
Family Arb Pt Family Ord CPHS
history
or
conditi
39155-7
on or
disease
and
action
Labor Find - ^Patient Doc
and

deliver
15508-5
y

records

Find Pt Skilled Nar

Assessm
nursing
27572-7 ent.ini
treatment
tial
plan
Newborn - Pt ^Patient -
54089-8
screeni
30
__CDAR2_TW_08.27.2009_v0.5

ng
panel
Social Find Pt ^Patient Nar
29762-2
history
History Find Pt ^Patient Nar Repo
of rted
hospita
lizatio

46240-8 ns+Hist

ory of
outpati
ent
visits

L2-1 section code

L2-2 section text
component
L2-3 text component

31
3.2
3.2.1 Diagnosis 29548-5
Section
L2-4 section code 29548-5
3.2.1.1 LOINC

29 LOINC
3.2.1.2 xml
<!--

********************************************************
Diagnosis
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="29548-5" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Diagnosis" />

32
__CDAR2_TW_08.27.2009_v0.5

<title></title>
<text>
<list>
<item>:</item>
<item>
<content ID="ICD9CM_4019">HYPERTENSION</content>
</item>
</list>
</text>
<entry>
<observation classCode="COND" moodCode="EVN">
<code code="4019"
codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM"
displayName="HYPERTENSION">
<originalText>
<reference value="#ICD9CM_4019" />
</originalText>
</code>
</observation>
</entry>
</section>
</component>
30 XML

33
3.2.2 Reference lab test results 19146-0
Section
L2-5 section code 19146-
0
3.2.2.1 LOINC

31 LOINC
3.2.2.2 xml
<!--

********************************************************
Reference lab test results
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="19146-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Reference lab test results"
/>

34
__CDAR2_TW_08.27.2009_v0.5

<title></title>
<text>
<list>
<item></item>
<item>RH</item>
</list>
</text>
</section>
</component>
32 XML

35
3.2.3 Major Procedures (Diagnostic, Surgical, and Therapeutic
Interventions) 52466-0
Section
L2-6 section code 52466-0
3.2.3.1 LOINC

33 LOINC
3.2.3.2 xml
<!--

********************************************************
Major Procedures (Diagnostic, Surgical, and Therapeutic
Interventions)
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="52466-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Major Procedures (Diagnostic,

36
__CDAR2_TW_08.27.2009_v0.5

Surgical, and Therapeutic Interventions)" />

<title></title>
<text></text>
</section>
</component>
34 XML

37
3.2.4 ADL patterns 45979-2
Section
L2-7 section code 45979-2
3.2.4.1 LOINC

35 LOINC
3.2.4.2 xml
<!--

********************************************************
ADL patterns
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="45979-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="ADL patterns" />
<title></title>
<text>

38
__CDAR2_TW_08.27.2009_v0.5

<list>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
36 XML

39
3.2.5 History of present illness 10164-2
Section
L2-8 section code 10164-2
3.2.5.1 LOINC

37 LOINC
3.2.5.2 xml
<!--

********************************************************
History of present illness
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="10164-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of present illness"
/>
<title></title>

40
__CDAR2_TW_08.27.2009_v0.5

<text></text>
</section>
</component>
38 XML

41
3.2.6 History of past illness 11348-0
Section
L2-9 section code 11348-0
3.2.6.1 LOINC

39 LOINC
3.2.6.2 xml
<!--

********************************************************
History of past illness
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="11348-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of past illness" />
<title></title>
<text>

42
__CDAR2_TW_08.27.2009_v0.5

<list>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
40 XML

43
3.2.7 Family history or condition or disease and action 39155-7
Section
L2-10 section code 39155-7
3.2.7.1 LOINC

41 LOINC
3.2.7.2 xml
<!--

********************************************************
Family history or condition or disease and action
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="39155-7" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Family history or condition
or disease and action" />
<title></title>

44
__CDAR2_TW_08.27.2009_v0.5

<text>
<list>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
42 XML

45
3.2.8 Labor and delivery records 15508-5
Section
L2-11 section code 15508-
5
3.2.8.1 LOINC

43 LOINC
3.2.8.2 xml
<!--

********************************************************
Labor and delivery records
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="15508-5" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Labor and delivery records"
/>

46
__CDAR2_TW_08.27.2009_v0.5

<title></title>
<text>
<list>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
44 XML

47
__CDAR2_TW_08.27.2009_v0.5

3.2.9 Assessment.initial 27572-7

Section
L2-12 section code 27572-7
3.2.9.1 LOINC

45 LOINC
3.2.9.2 xml
<!--

********************************************************
Assessment.initial
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="27572-7" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Assessment.initial" />
<title></title>
<text>

48
__CDAR2_TW_08.27.2009_v0.5

<list>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
46 XML

49
3.2.10 Newborn screening panel 54089-8
Section
L2-13 section code 54089-8
3.2.10.1 LOINC

47 LOINC
3.2.10.2 xml
<!--

********************************************************
Newborn screening panel
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="54089-8" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Newborn screening panel" />
<title></title>
<text></text>

50
__CDAR2_TW_08.27.2009_v0.5

</section>
</component>
48 XML

51
3.2.11 Social history 29762-2
Section
L2-14 section code 29762-2
3.2.11.1 LOINC

49 LOINC
3.2.11.2 xml
<!--

********************************************************
Social history
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Social history" />
<title></title>
<text>

52
__CDAR2_TW_08.27.2009_v0.5

<list>
<item></item>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
50 XML

53
3.2.12 History of hospitalizations+History of outpatient
visits 46240-8
Section
L2-15 section code 46240-8
3.2.12.1 LOINC

51 LOINC
3.2.12.2 xml
<!--

********************************************************
History of hospitalizations+History of outpatient visits
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of
hospitalizations+History of outpatient visits" />

54
__CDAR2_TW_08.27.2009_v0.5

<title></title>
<text>
<list>
<item>:</item>
<item>:1999/10/01 PM 10:00</item>
<item></item>
</list>
</text>
</section>
</component>
</structuredBody>
</component>
52 XML

55
4 CDA

<?xml version="1.0" standalone="no"?>

<?xml-stylesheet type='text/xsl' href='CDA.xsl'?>
<ClinicalDocument classCode="DOCCLIN" moodCode="EVN" xmlns="urn:hl7-org:v3"
xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-
instance" >
<!--
********************************************************
CDA Header
********************************************************
-->
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
<templateId extension="level 1" root="2.16.840.1.113883.2.33.10.39.1" />
<templateId extension="level 2" root="2.16.840.1.113883.2.33.10.39.2" />
<!--
1. OID
-->
<id extension="c266" root="2.16.840.1.113883.19.4" />
<!---->
<code code="34768-2" codeSystem="2.16.840.1.113883.6.1"
displayName="Evaluation and management note" codeSystemName="LOINC" />
<title></title>
<!-- -->
<effectiveTime value="20091223198231" />
<confidentialityCode />
<!-- -->
<languageCode code="zh-TW" />
<setId />
<versionNumber value="1" />
<!-- -->
<recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole classCode="PAT">
<!--
@extension :
@root : OID
-->
<id extension="123456" root="2.16.886.111.100000.100000" />
56
__CDAR2_TW_08.27.2009_v0.5

<!-- -->
<addr>1001010</addr>
<!-- -->
<telecom use="H" value="(02) 12345678" />
<!-- -->
<telecom use="WP" value="(02) 12345678" />
<!-- -->
<telecom use="MC" value="921111998" />
<!-- -->
<telecom value="mailto:22223333@gmail.com" />
<!-- -->
<patient classCode="PSN" determinerCode="INSTANCE">
<!--
@extension :
@root : 2.16.886.101.20003.20001
-->
<id extension="A123456789" root="2.16.886.101.20003.20001" />
<!-- -->
<name></name>
<!--
@code :
@codeSystem : 2.16.840.1.113883.5.1 (HL7 Vocabulary OID)
-->
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"
/>
<!--()
@value : YYYYMMDD)
-->
<birthTime value="20000101" />
<!--
@code :
@codeSystem : 2.16.840.1.113883.5.2 (HL7 Vocabulary OID)
-->
<maritalStatusCode code="M" codeSystem="2.16.840.1.113883.5.2" />
<!---->
<religiousAffiliationCode code="1050"
codeSystem="2.16.840.1.113883.5.1076" />
<!---->

57
__CDAR2_TW_08.27.2009_v0.5

<ethnicGroupCode code="2135-2" codeSystem="2.16.840.1.113883.5.50" />

<birthplace classCode="BIRTHPL">
<place classCode="PLC" determinerCode="INSTANCE">
<addr></addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="2135-2" />
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<!-- author1 -->
<author typeCode="AUT" contextControlCode="OP">
<time value="20010101" />
<assignedAuthor classCode="ASSIGNED">
<id extension="D0001" root="2.16.886.111.100000.100000" />
<id extension="D12345" root="2.16.886.111.100000.100000.1" />
<id extension="D12345" root="2.16.886.111.100000.100000.1" />
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name></name>
</assignedPerson>
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
<id extension="10004331121" root="2.16.886.111.100000.100000" />
<name></name>
</representedOrganization>
</assignedAuthor>
</author>
<!-- -->
<custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG"
determinerCode="INSTANCE">
<id />
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- legalAuthenticator -->

58
__CDAR2_TW_08.27.2009_v0.5

<legalAuthenticator typeCode="LA" contextControlCode="OP">

<!--
@value : YYYYMMDD
-->
<time value="20000408" />
<signatureCode code="S" />
<assignedEntity classCode="ASSIGNED">
<!--legalAuthenticator
@extension :
@root : OID
-->
<id extension="KP00017" root="2.16.886.111.100000.100000" />
<id extension="hca000111" root="2.16.886.111.100000.100000.1" />
<id extension="hca000111" root="2.16.886.111.100000.100000.1" />
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<!-- legalAuthenticator -->
<name></name>
</assignedPerson>
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
<!--legalAuthenticator-->
<id extension="10004331121" root="2.16.886.111.100000.100000" />
<!--legalAuthenticator-->
<name></name>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
<!-- -->
<!--ParticipationType typeCode='NOT' => 'urgent notification contact'-->
<participant typeCode="NOT" contextControlCode="OP">
<!--RoleClassAssociative classCode='NOK' => 'next of kin'-->
<associatedEntity classCode="NOK">
<code code="SPS" codeSystem="2.16.840.1.113883.5.111" />
<associatedPerson classCode="PSN" determinerCode="INSTANCE">
<!-- -->
<name></name>
</associatedPerson>
</associatedEntity >
</participant>

59
__CDAR2_TW_08.27.2009_v0.5

<!-- 1 -->
<!--ParticipationType typeCode='NOT' => 'urgent notification contact'-->
<participant typeCode="NOT" contextControlCode="OP">
<!--RoleClassAssociative classCode='ECON' => 'emergency contact'-->
<associatedEntity classCode="ECON">
<!--1-RoleCode code='FTH' => Father-->
<code code="FTH" codeSystem="2.16.840.1.113883.5.111" />
<!--elecomdata typeset<TEL>2componentsuseuse='H'
=> homeWP =>office addressMC=>moves and stays with its owne-->
<telecom use="H" value="22225555" />
<telecom use="WP" value="22225554" />
<telecom use="MC" value="0911111111" />
<telecom use="" value="mailto:22225555@gmail.com" />
<associatedPerson classCode="PSN" determinerCode="INSTANCE">
<name></name>
</associatedPerson>
</associatedEntity >
</participant>
<!-- 2 -->
<!--ParticipationType typeCode='NOT' => 'urgent notification contact'-->
<participant typeCode="NOT" contextControlCode="OP">
<!--RoleClassAssociative classCode='ECON' => 'emergency contact'-->
<associatedEntity classCode="ECON">
<!--2-RoleCode code='FTH' => Father-->
<code code="MTH" codeSystem="2.16.840.1.113883.5.111" />
<!--elecomdata typeset<TEL>2componentsuseuse='H'
=> homeWP =>office addressMC=>moves and stays with its owne-->
<telecom use="H" value="22225556" />
<telecom use="WP" value="22225557" />
<telecom use="MC" value="0911111112" />
<telecom use="" value="mailto:22226666@gmail.com" />
<associatedPerson classCode="PSN" determinerCode="INSTANCE">
<name></name>
</associatedPerson>
</associatedEntity >
</participant>
<!-- -->
<componentOf typeCode="COMP">

60
__CDAR2_TW_08.27.2009_v0.5

<encompassingEncounter classCode="ENC" moodCode="EVN">

<!-- -->
<effectiveTime value="20000101" />
<!-- -->
<location typeCode="LOC">
<!-- -->
<healthCareFacility classCode="SDLOC">
<location classCode="PLC" determinerCode="INSTANCE">
<!-- -->
<addr>001</addr>
</location>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<!--
********************************************************
CDA Body Level 2
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<!--

********************************************************
Diagnosis
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="29548-5" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Diagnosis" />
<title></title>
<text>
<list>
<item>:</item>
<item>
<content ID="ICD9CM_4019">HYPERTENSION</content>

61
__CDAR2_TW_08.27.2009_v0.5

</item>
</list>
</text>
<entry>
<observation classCode="COND" moodCode="EVN">
<code code="4019" codeSystem="2.16.840.1.113883.6.2"
codeSystemName="ICD9CM" displayName="HYPERTENSION">
<originalText>
<reference value="#ICD9CM_4019" />
</originalText>
</code>
</observation>
</entry>
</section>
</component>
<!--

********************************************************
Reference lab test results
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="19146-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Reference lab test results" />
<title></title>
<text>
<list>
<item></item>
<item>RH</item>
</list>
</text>
</section>
</component>
<!--

********************************************************
Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)

62
__CDAR2_TW_08.27.2009_v0.5

********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="52466-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Major Procedures (Diagnostic, Surgical, and
Therapeutic Interventions)" />
<title></title>
<text></text>
</section>
</component>
<!--

********************************************************
ADL patterns
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="45979-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="ADL patterns" />
<title></title>
<text>
<list>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
</list>
</text>
</section>
</component>

63
__CDAR2_TW_08.27.2009_v0.5

<!--

********************************************************
History of present illness
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="10164-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of present illness" />
<title></title>
<text></text>
</section>
</component>
<!--

********************************************************
History of past illness
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="11348-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of past illness" />
<title></title>
<text>
<list>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
<!--

64
__CDAR2_TW_08.27.2009_v0.5

********************************************************
Family history or condition or disease and action
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="39155-7" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Family history or condition or disease and
action" />
<title></title>
<text>
<list>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
<!--

********************************************************
Labor and delivery records
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="15508-5" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Labor and delivery records" />
<title></title>
<text>
<list>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>
<item></item>

65
__CDAR2_TW_08.27.2009_v0.5

<item></item>
</list>
</text>
</section>
</component>
<!--

********************************************************
Assessment.initial
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="27572-7" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Assessment.initial" />
<title></title>
<text>
<list>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
<!--

********************************************************
Newborn screening panel
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="54089-8" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Newborn screening panel" />
<title></title>
<text></text>
</section>
</component>

66
__CDAR2_TW_08.27.2009_v0.5

<!--

********************************************************
Social history
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Social history" />
<title></title>
<text>
<list>
<item></item>
<item></item>
<item></item>
</list>
</text>
</section>
</component>
<!--

********************************************************
History of hospitalizations+History of outpatient visits
********************************************************
-->
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of hospitalizations+History of
outpatient visits" />
<title></title>
<text>
<list>
<item>:</item>
<item>:1999/10/01 PM 10:00</item>
<item></item>
</list>

67
__CDAR2_TW_08.27.2009_v0.5

</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>

68
5

L1-1ClinicalDocument/typeId @extension "POCD_HD000040"

@root 2.16.840.1.113883.1.3
L1-2ClinicalDocument/templateId @extension
IMPL_CDAR2_LEVEL1@root 2.16.840.1.113883.2.33.10.1.1
L1-3The ClinicalDocument/id/@root UUID OID
L1-4UUID XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX X 0~9
A~F
L1-5OID 0
L1-6OID 64
L1-7/ClinicalDocument/code @code 3 @codeSystem
LOINC OID @codeSystemName LOINC
L1-8languageCode
L1-9language nn nn-CC.
L1-10nn ISO-639-1 language code
L1-11CC ISO-3166
L1-12ClinicalDocument/setId ClinicalDocument/versionNumber

L1-13 ClinicalDocument/setId ClinicalDocument/id

@extension @root
L1-14ClinicalDocument/copyTime
L1-15legalAuthenticator
L1-16author
L1-17custodian
L1-18recordTarget
L1-19participant
L1-20legalAuthenticator/time
L1-21legalAuthenticator/signatureCode @code S
L1-22legalAuthenticator/assignedEntity
L1-23assignedEntity/id
@root OID
L1-24leagalAuthenticator/assignedPerson
L1-25assignedPerson/name
L1-26leagalAuthenticator/representedOrganization
L1-27representedOrganization/id
L1-28representedOrganization/name

69
__CDAR2_TW_08.27.2009_v0.5

L1-29author/time value
L1-30author/assignedAuthor
L1-31assignedAuthor/id
@root OID
L1-32assignedAuthor/assignedPerson
L1-33assignedPerson/name
L1-34assignedAuthor/representedOrganization
L1-35representedOrganization/id
L1-36representedOrganization/name
L1-37assignedCustodian/representedCustodianOrganization

L1-38 recordTarget/patientRole
L1-39patientRole/id @extension @root
id OID @root
OID
L1-40patientRole/addr
L1-41patientRole/telecom @use

L1-42patientRole/telecom @value
L1-43patientRole/patient
L1-44patient/id @root
OID
L1-45patient/name
L1-46patient/administrativeGenderCode
administrativeGenderCode HL7 AdministrativeGender
vocabulary domain
L1-47patient/birthTime YYYYMMDD
L1-48patient/maritalStatusCode
maritalStatusCode HL7 MaritalStatus vocabulary domain
L1-49patient/religiousAffiliationCode
L1-50patient/ethnicGroupCode
L1-51patient/birthplace/place
L1-52languageCommunication/languageCode
L1-53participant/@typeCode @typeCode HL7
ParticipantionType vocabulary domain
L1-54participant/associatedEntity
L1-55associatedEntity/@ClassCode @classCode HL7
RoleClass vocabulary domain

70
__CDAR2_TW_08.27.2009_v0.5

L1-56associatedEntity/associatedPerson

L1-57associatedPerson/name
L1-58associatedEntity/telecom use

L1-59associatedEntity/telecom
L1-60componentOf
L1-61componentOf/encompassingEncounter
L1-62encompassingEncounter/effectiveTime
L1-63encompassingEncounter/location
L1-64location/healthCareFacility/location/name

L1-65location/addr
L2-1 section code
L2-2 section text component

L2-3 text component

L2-4 section code 29548-5
L2-5 section code 19146-0
L2-6 section code 52466-0
L2-7 section code 45979-2
L2-8 section code 10164-2
L2-9 section code 11348-0
L2-10 section code 39155-7
L2-11 section code 15508-5
L2-12 section code 27572-7
L2-13 section code 54089-8
L2-14 section code 29762-2
L2-15 section code 46240-8

71
6 CDA R-MIM

72