Att J- EHR Implementation Guide Templates

Attachment J - EHR Implementation Guide Templates

CDAR2_IG_NHCS_R1_DSTU1.2_2016AUG_Vol2

HL7 CDA® R2 Implementation Guide:
National Health Care Surveys Release 1,
DSTU Release 1.2 –
US Realm
August 2016
Draft Standard for Trial Use (DSTU)
Volume 2 — Templates and Supporting
Sponsored by:
Public Health and Emergency Response Work Group
Structured Documents Work Group
Publication of this draft standard for trial use and comment has been approved by Health Level Seven
International (HL7). This draft standard is not an accredited American National Standard. The comment period for
use of this draft standard shall end 12 months from the date of publication. Suggestions for revision should be
submitted at http://www.hl7.org/dstucomments/index.cfm.
Following this 12 month evaluation period, this draft standard, revised as necessary, will be submitted to a
normative ballot in preparation for approval by ANSI as an American National Standard. Implementations of this
draft standard shall be viable throughout the normative ballot process and for up to six months after publication of
the relevant normative standard.
Copyright © 2016 Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction of this material
in any form is strictly forbidden without the written permission of the publisher. HL7 and Health Level Seven are
registered trademarks of Health Level Seven International. Reg. U.S. Pat & TM Off.
Use of this material is governed by HL7's IP Compliance Policy

Appendix T - EHR Implementation Guide Templates

IMPORTANT NOTES:
HL7 licenses its standards and select IP free of charge. If you did not acquire a free license from HL7 for this document,
you are not authorized to access or make any use of it. To obtain a free license, please visit
http://www.HL7.org/implement/standards/index.cfm.
If you are the individual that obtained the license for this HL7 Standard, specification or other freely licensed work (in
each and every instance "Specified Material"), the following describes the permitted uses of the Material.
A. HL7 INDIVIDUAL, STUDENT AND HEALTH PROFESSIONAL MEMBERS, who register and agree to the terms of HL7’s
license, are authorized, without additional charge, to read, and to use Specified Material to develop and sell products and
services that implement, but do not directly incorporate, the Specified Material in whole or in part without paying license fees to
HL7.
INDIVIDUAL, STUDENT AND HEALTH PROFESSIONAL MEMBERS wishing to incorporate additional items of Special
Material in whole or part, into products and services, or to enjoy additional authorizations granted to HL7 ORGANIZATIONAL
MEMBERS as noted below, must become ORGANIZATIONAL MEMBERS of HL7.
B. HL7 ORGANIZATION MEMBERS, who register and agree to the terms of HL7's License, are authorized, without additional
charge, on a perpetual (except as provided for in the full license terms governing the Material), non-exclusive and worldwide
basis, the right to (a) download, copy (for internal purposes only) and share this Material with your employees and consultants
for study purposes, and (b) utilize the Material for the purpose of developing, making, having made, using, marketing,
importing, offering to sell or license, and selling or licensing, and to otherwise distribute, Compliant Products, in all cases
subject to the conditions set forth in this Agreement and any relevant patent and other intellectual property rights of third
parties (which may include members of HL7). No other license, sublicense, or other rights of any kind are granted under this
Agreement.
C. NON-MEMBERS, who register and agree to the terms of HL7’s IP policy for Specified Material, are authorized, without
additional charge, to read and use the Specified Material for evaluating whether to implement, or in implementing, the
Specified Material, and to use Specified Material to develop and sell products and services that implement, but do not directly
incorporate, the Specified Material in whole or in part.
NON-MEMBERS wishing to incorporate additional items of Specified Material in whole or part, into products and services, or
to enjoy the additional authorizations granted to HL7 ORGANIZATIONAL MEMBERS, as noted above, must become
ORGANIZATIONAL MEMBERS of HL7.
Please see http://www.HL7.org/legal/ippolicy.cfm for the full license terms governing the Material.

Ownership. Licensee agrees and acknowledges that HL7 owns all right, title, and interest, in and to the
Trademark. Licensee shall take no action contrary to, or inconsistent with, the foregoing.
Licensee agrees and acknowledges that HL7 may not own all right, title, and interest, in and to the
Materials and that the Materials may contain and/or reference intellectual property owned by third parties (“Third
Party IP”). Acceptance of these License Terms does not grant Licensee any rights with respect to Third Party IP.
Licensee alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize Third
Party IP in connection with the Materials or otherwise. Any actions, claims or suits brought by a third party resulting
from a breach of any Third Party IP right by the Licensee remains the Licensee’s liability.
Following is a non-exhaustive list of third-party terminologies that may require a separate license:
Terminology
Owner/Contact
Current Procedures Terminology (CPT)
American Medical Association
code set
http://www.ama-assn.org/ama/pub/physician-resources/solutionsmanaging-your-practice/coding-billing-insurance/cpt/cpt-productsservices/licensing.page?
SNOMED CT
International Healthcare Terminology Standards Developing
Organization (IHTSDO) http://www.ihtsdo.org/snomed-ct/getsnomed-ct or [email protected]
Logical Observation Identifiers Names &
Regenstrief Institute
Codes (LOINC)
International Classification of Diseases
World Health Organization (WHO)
(ICD) codes
NUCC Health Care Provider Taxonomy
American Medical Association. Please see 222.nucc.org. AMA
code set
licensing contact: 312-464-5022 (AMA IP services)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 2
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table of Contents
1

DOCUMENT-LEVEL TEMPLATES................................................................................... 22
1.1

2

US Realm Header (V2) .............................................................................................. 22

1.1.1

Properties ......................................................................................................... 31

1.1.2

National Health Care Surveys (V2) ..................................................................... 66

1.1.3

Properties ......................................................................................................... 69

1.1.4

Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) ..................... 73

1.1.5

Properties ......................................................................................................... 76

1.1.6

Inpatient Encounter (NHCS-IP) (V3) ................................................................... 81

1.1.7

Properties ......................................................................................................... 84

1.1.8

Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) ....................... 89

1.1.9

Properties ......................................................................................................... 92

SECTION-LEVEL TEMPLATES ....................................................................................... 98
2.1

Chief Complaint and Reason for Visit Section ........................................................... 99

2.1.1
2.2

Encounters Section (entries optional) (V2) ............................................................... 102

2.2.1

Emergency Department Encounters Section (V2) ............................................. 104

2.2.2

Inpatient Encounters Section (V2) ................................................................... 106

2.2.3

Outpatient Encounters Section (V3) ................................................................ 108

2.3

Medications Section (entries optional) (V2) .............................................................. 109

2.3.1

Immunizations Section .................................................................................... 111

2.3.2

Medications Section ........................................................................................ 113

2.4

Payers Section (V2) ................................................................................................ 114

2.4.1

Payment Sources Section ................................................................................ 116

2.5

Problems Section (V3) ............................................................................................ 118

2.6

Results Section (entries optional) (V2) ..................................................................... 122

2.7

Services and Procedures Section ............................................................................ 124

2.8

Social History Section (V2) ..................................................................................... 128

2.8.1
2.9

Patient Information Section (V3) ...................................................................... 133

Triage Section ........................................................................................................ 137

2.10

Vital Signs Section (entries optional) (V2) ........................................................ 140

2.10.1
3

Reasons for Visit Section (V2) .......................................................................... 100

Vital Signs Section (entries required) (V2) ........................................................ 141

ENTRY-LEVEL TEMPLATES ......................................................................................... 144
3.1

Admission Priority Observation .............................................................................. 144

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 3
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.2

Age Observation ..................................................................................................... 147

3.3

Assessment Scale Observation ............................................................................... 149

3.3.1

Pain Assessment Scale Observation ................................................................. 152

3.3.2

Triage Level Assigned Observation ................................................................... 154

3.4

Assessment Scale Supporting Observation .............................................................. 156

3.5

Asthma Diagnosis Observation (RETIRED) .............................................................. 158

3.6

Caregiver Characteristics ....................................................................................... 160

3.7

Cause of Injury, Poisoning, or Adverse Effect .......................................................... 163

3.8

Characteristics of Home Environment ..................................................................... 166

3.9

Clinical Note and External Document Reference ..................................................... 168

3.10

Co-morbid Condition Observation (RETIRED) ................................................. 170

3.11

Condition Control Observation ....................................................................... 172

3.12

Coverage Activity (V2) ..................................................................................... 174

3.13

Cultural and Religious Observation ................................................................ 177

3.14

Discharge Status Observation ........................................................................ 178

3.15

Drug Monitoring Act ....................................................................................... 181

3.16

Drug Vehicle .................................................................................................. 185

3.17

Encounter Activity (V2)................................................................................... 187

3.17.1

Current Emergency Department Visit (V2) ....................................................... 193

3.17.2

Current Inpatient Visit .................................................................................... 198

3.17.3

Current Outpatient Visit (V3) .......................................................................... 202

3.17.4

Hospital Admission Encounter ........................................................................ 207

3.17.5

Observation Unit Stay Encounter .................................................................... 213

3.17.6

Specialty Unit Stay Encounter ......................................................................... 215

3.18

Encounter Diagnosis (V2) ............................................................................... 218

3.19

Episode of Care Observation (V2) .................................................................... 220

3.20

Estimated Date of Delivery ............................................................................. 222

3.21

Follow-up Attempt Outcome Observation ........................................................ 224

3.22

Hospital Discharge Diagnosis (V2) .................................................................. 227

3.23

Immunization Activity (V2) ............................................................................. 230

3.24

Immunization Medication Information (V2) ..................................................... 242

3.25

Immunization Refusal Reason ........................................................................ 246

3.26

Indication (V2) ............................................................................................... 249

3.26.1

Major Reason for Visit ..................................................................................... 253

3.27

Instruction (V2) .............................................................................................. 256

3.28

Listed for Admission to Hospital Act ............................................................... 258

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 4
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.29

Medication Activity (V2) .................................................................................. 260

3.30

Medication Dispense (V2) ............................................................................... 270

3.31

Medication Free Text Sig ................................................................................ 274

3.32

Medication Information (V2) ........................................................................... 277

3.33

Medication Supply Order (V2) ......................................................................... 280

3.34

New Patient Act .............................................................................................. 283

3.35

Number of Visits in the Last 12 Months .......................................................... 285

3.36

On Oxygen on Arrival Observation .................................................................. 287

3.37

Patient Residence Observation ........................................................................ 289

3.38

Patient Seen in this ED in last 72 Hours and Discharged ................................ 291

3.39

Planned Act (V2) ............................................................................................ 293

3.39.1

Ordered Service Act ........................................................................................ 297

3.40

Planned Coverage ........................................................................................... 299

3.41

Planned Immunization Activity ....................................................................... 303

3.42

Planned Medication Activity (V2) ..................................................................... 309

3.43

Planned Observation (V2) ............................................................................... 314

3.43.1
3.44
3.44.1

Ordered Service Observation ........................................................................... 320
Planned Procedure (V2) .................................................................................. 322
Ordered Service Procedure .............................................................................. 328

3.45

Point of Origin Observation ............................................................................ 329

3.46

Policy Activity (V2) .......................................................................................... 332

3.47

Precondition for Substance Administration (V2) .............................................. 342

3.48

Pregnancy Observation ................................................................................... 343

3.49

Present on Admission Observation.................................................................. 346

3.50

Priority Preference .......................................................................................... 348

3.51

Problem Observation (V2) ............................................................................... 351

3.51.1

Admission Diagnosis Observation .................................................................... 361

3.51.2

Adverse Effect of Medical Treatment ................................................................ 362

3.51.3

Injury or Poisoning Observation (V2) ............................................................... 365

3.51.4

Patient's Reason for Visit Observation ............................................................. 369

3.51.5

Primary Diagnosis Observation (V2)................................................................. 371

3.51.6

Problem/Diagnosis/Symptom/Condition Observation (V2) .............................. 374

3.52

Problem Status (DEPRECATED) ..................................................................... 376

3.53

Procedure Activity Act (V2) ............................................................................. 377

3.53.1
3.54

Provided Service Act ........................................................................................ 386
Procedure Activity Observation (V2) ................................................................ 388

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 5
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.54.1
3.55

Procedure Activity Procedure (V2) ................................................................... 398

3.55.1

4

Provided Service Observation .......................................................................... 396
Provided Service Procedure ............................................................................. 406

3.56

Procedure Follow-Up Attempt Observation ...................................................... 408

3.57

Product Instance ............................................................................................ 411

3.58

Prognosis Observation .................................................................................... 413

3.59

Reaction Observation (V2) .............................................................................. 416

3.60

Result Observation (V2) .................................................................................. 420

3.61

Result Organizer (V2) ..................................................................................... 427

3.62

Service Delivery Location ................................................................................ 430

3.63

Severity Observation (V2) ............................................................................... 433

3.64

Smoking Status - Meaningful Use (V2) ............................................................ 436

3.65

Social History Observation (V2) ...................................................................... 440

3.66

Substance Administered Act ........................................................................... 443

3.67

Tobacco Use (V2) ............................................................................................ 445

3.68

Transport Mode to Hospital Observation ......................................................... 449

3.69

Vital Sign Observation (V2) ............................................................................. 452

3.70

Vital Signs Organizer (V2) ............................................................................... 456

PARTICIPATION AND OTHER TEMPLATES ................................................................... 460
4.1

Author Participation ............................................................................................... 460

4.2

US Realm Address (AD.US.FIELDED) ..................................................................... 463

4.3

US Realm Date and Time (DTM.US.FIELDED) ......................................................... 467

4.4

US Realm Patient Name (PTN.US.FIELDED) ............................................................ 468

4.5

US Realm Person Name (PN.US.FIELDED) .............................................................. 471

5

TEMPLATE IDS IN THIS GUIDE ................................................................................... 473

6

VALUE SETS IN THIS GUIDE ....................................................................................... 503

7

CODE SYSTEMS IN THIS GUIDE ................................................................................. 508

8

CHANGES FROM PREVIOUS VERSION ........................................................................ 510
8.1

Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) .......................... 510

8.2

Inpatient Encounter (NHCS-IP) (V3) ........................................................................ 512

8.3

Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) ............................ 513

8.4

Asthma Diagnosis Observation (RETIRED) .............................................................. 515

8.5

Co-morbid Condition Observation (RETIRED) ......................................................... 517

8.6

Current Emergency Department Visit (V2) .............................................................. 519

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 6
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.7

Current Outpatient Visit (V3) ................................................................................. 520

8.8

Emergency Department Encounters Section (V2) .................................................... 521

8.9

Inpatient Encounters Section (V2) .......................................................................... 521

8.10

Outpatient Encounters Section (V3) ................................................................ 522

8.11

Patient Information Section (V3) ..................................................................... 522

8.12

Problems Section (V3)..................................................................................... 523

8.13

Reasons for Visit Section (V2) ......................................................................... 524

Table of Figures
Figure 1: US Realm Header (V2) Example ......................................................................................... 31
Figure 2: recordTarget Example ....................................................................................................... 36
Figure 3: author Example ................................................................................................................ 39
Figure 4: dateEnterer Example ........................................................................................................ 40
Figure 5: Assigned Health Care Provider informant Example ............................................................ 41
Figure 6: Personal Relation informant Example ................................................................................ 42
Figure 7: custodian Example ........................................................................................................... 43
Figure 8: informationRecipient Example ........................................................................................... 44
Figure 9: Digital signature Example ................................................................................................. 45
Figure 10: legalAuthenticator Example ............................................................................................. 46
Figure 11: authenticator Example .................................................................................................... 48
Figure 12: Supporting Person participant Example ........................................................................... 49
Figure 13: inFulfillmentOf Example ................................................................................................. 50
Figure 14: performer Example.......................................................................................................... 52
Figure 15: documentationOf Example .............................................................................................. 53
Figure 16: authorization Example .................................................................................................... 54
Figure 17: National Health Care Surveys (V2) Example ..................................................................... 69
Figure 18: recordTarget Example ..................................................................................................... 71
Figure 19: performer Example.......................................................................................................... 72
Figure 20: encompassingEncounter Example ................................................................................... 73
Figure 21: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Example ..................... 76
Figure 22: performer Example.......................................................................................................... 77
Figure 23: componentOf/encompassingEncounter Example ............................................................. 78
Figure 24: In-Patient Encounter (NHCS-IP) (V3) Example .................................................................. 85

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 7
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 25: componentOf/encompassingEncounter Example ............................................................. 86
Figure 26: Out-Patient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Example ..................... 92
Figure 27: performer Example.......................................................................................................... 93
Figure 28: componentOf/encompassingEncounter Example ............................................................. 94
Figure 29: Chief Complaint and Reason for Visit Example .............................................................. 100
Figure 30: Reasons for Visit Section (V2) Example .......................................................................... 102
Figure 31: Emergency Department Encounters Section (V2) Example ............................................. 105
Figure 32: Inpatient Encounters Section (V2) Example ................................................................... 107
Figure 33: Outpatient Encounters Section (V3) ............................................................................... 109
Figure 34: Immunizations Section Example .................................................................................... 112
Figure 35: Medications Section Example ........................................................................................ 114
Figure 36: Payers Section (V2) Example ......................................................................................... 116
Figure 37: Payment Sources Section Example ................................................................................ 118
Figure 38: Problems Section (V3) Example ..................................................................................... 121
Figure 39: Services and Procedures Section Example ..................................................................... 127
Figure 40: Social History Section (V2) Example .............................................................................. 132
Figure 41: Patient Information Section (V2) Example ...................................................................... 136
Figure 42: Triage Section Example ................................................................................................. 139
Figure 43: Vital Signs Section (entries required) (V2) Example ........................................................ 143
Figure 44: Admission Priority Observation Example ....................................................................... 146
Figure 45: Age Observation Example .............................................................................................. 149
Figure 46: Assessment Scale Observation Example ........................................................................ 152
Figure 47: Pain Assessment Scale Observation Example ................................................................. 154
Figure 48: Triage Level Assigned Observation Example ................................................................... 156
Figure 49: Assessment Scale Supporting Observation Example....................................................... 158
Figure 50: Asthma Diagnosis Observation (V2) Example ................................................................. 159
Figure 51: Caregiver Characteristics Example ................................................................................ 162
Figure 52: Cause of Injury, Poisoning, or Adverse Effect (Free Text) Example .................................. 165
Figure 53: Cause of Injury, Poisoning, or Adverse Effect (Coded) Example ....................................... 165
Figure 54: Characteristics of Home Environment Example.............................................................. 168
Figure 55: Clinical Note and External Document Reference - Non-CDA Example ............................. 170
Figure 56: Clinical Note and External Document Reference - CDA Document (Referral) Example ..... 170
Figure 57: Co-morbid Condition Observation (V2) Example............................................................. 171

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 8
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 58: Condition Control Observation Example ........................................................................ 173
Figure 59: Coverage Activity (V2) Example ...................................................................................... 176
Figure 60: Cultural and Religious Observation Example ................................................................. 178
Figure 61: Discharge Status Observation Example ......................................................................... 180
Figure 62: Drug Monitoring Act Example........................................................................................ 185
Figure 63: Drug Vehicle Example ................................................................................................... 187
Figure 64: Encounter Activity (V2) Example ................................................................................... 192
Figure 65: Current Emergency Department Visit (V2) Example ....................................................... 197
Figure 66: Current Inpatient Visit Example .................................................................................... 201
Figure 67: Current Outpatient Visit (V3) Example .......................................................................... 206
Figure 68: Hospital Admission Encounter Example ........................................................................ 212
Figure 69: Observation Unit Stay Encounter Example .................................................................... 215
Figure 70: Special Unit Stay Encounter Example............................................................................ 218
Figure 71: Encounter Diagnosis (V2) Example ................................................................................ 220
Figure 72: Episode of Care Observation (V2) Example ..................................................................... 222
Figure 73: Estimated Date of Delivery Example .............................................................................. 224
Figure 74: Follow-up Attempt Outcome Observation ....................................................................... 227
Figure 75: Hospital Discharge Diagnosis (V2) Example ................................................................... 229
Figure 76: Immunization Activity (V2) Example .............................................................................. 241
Figure 77: Immunization Medication Information (V2) Example ...................................................... 246
Figure 78: Immunization Refusal Reason Example ......................................................................... 248
Figure 79: Indication (V2) Example ................................................................................................ 253
Figure 80: Major Reason for Visit Example ..................................................................................... 255
Figure 81: Instruction (V2) Example ............................................................................................... 258
Figure 82: Listed for Admission to Hospital Act Example ................................................................ 260
Figure 83: Medication Activity (V2) Example ................................................................................... 269
Figure 84: No Known Medications Example .................................................................................... 270
Figure 85: Medication Dispense (V2) Example ................................................................................ 273
Figure 86: Medication Free Text Sig Example ................................................................................. 276
Figure 87: Medication Information (V2) Example ............................................................................ 280
Figure 88: Medication Supply Order (V2) Example .......................................................................... 283
Figure 89: New Patient Act Example ............................................................................................... 285
Figure 90: Number of Visits in the Last 12 Months Example ........................................................... 287

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 9
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 91: On Oxygen on Arrival Observation Example ................................................................... 289
Figure 92: Patient Residence Example ............................................................................................ 291
Figure 93: Patient Seen in this ED in last 72 Hours and Discharged Example ................................. 293
Figure 94: Planned Act (V2) Example ............................................................................................. 297
Figure 95: Ordered Service Act Example ......................................................................................... 299
Figure 96: Planned Coverage Example............................................................................................ 302
Figure 97: Planned Immunization Activity ...................................................................................... 308
Figure 98: Planned Medication Activity (V2) Example...................................................................... 314
Figure 99: Planned Observation (V2) Example ................................................................................ 320
Figure 100: Ordered Service Observation Example ......................................................................... 322
Figure 101: Planned Procedure (V2) Example ................................................................................. 327
Figure 102: Ordered Service Procedure Example ............................................................................ 329
Figure 103: Point of Origin Observation Example ........................................................................... 332
Figure 104: Policy Activity (V2) Example ......................................................................................... 340
Figure 105: Precondition for Substance Administration (V2) Example ............................................. 343
Figure 106: Pregnancy Observation Example .................................................................................. 345
Figure 107: Present on Admission Observation Example ................................................................ 348
Figure 108: Priority Preference Example ......................................................................................... 350
Figure 109: Problem Observation (V2) Example .............................................................................. 356
Figure 110: No Known Problems Example ...................................................................................... 357
Figure 111: Resolved Problem and Resolved Concern Example ....................................................... 358
Figure 112: Problem with Qualifiers Example ................................................................................. 360
Figure 113: Admission Diagnosis Observation Example .................................................................. 362
Figure 114: Adverse Effect of Medical Treatment Example .............................................................. 364
Figure 115: Injury or Poisoning Observation (V2) Example .............................................................. 369
Figure 116: Patient's Reason for Visit Observation Example............................................................ 371
Figure 117: Primary Diagnosis Observation (V2) Example ............................................................... 373
Figure 118: Problem/Diagnosis/Symptom/Condition Observation (V2) Example ............................. 375
Figure 119: Procedure Activity Act Example ................................................................................... 385
Figure 120: Provided Service Act Example 1 ................................................................................... 387
Figure 121: Provided Service Act Example 2 ................................................................................... 388
Figure 122: Procedure Activity Observation (V2) Example ............................................................... 395
Figure 123: Provided Service Observation Example ......................................................................... 398

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 10
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 124: Procedure Activity Procedure (V2) Example .................................................................. 406
Figure 125: Provided Service Procedure Example ............................................................................ 408
Figure 126: Procedure Follow-Up Attempt Observation ................................................................... 411
Figure 127: Product Instance Example ........................................................................................... 413
Figure 128: Prognosis, Free Text Example ...................................................................................... 415
Figure 129: Prognosis, Coded Example .......................................................................................... 415
Figure 130: Reaction Observation (V2) Example ............................................................................. 420
Figure 131: Result Observation (V2) Example ................................................................................. 425
Figure 132: Pending Result Observation (V2) Example .................................................................... 426
Figure 133: Original Lab Units in Example................................................................ 426
Figure 134: Result Organizer (V2) Example .................................................................................... 430
Figure 135: Service Delivery Location Example ............................................................................... 433
Figure 136: Severity Observation (V2) Example .............................................................................. 435
Figure 137: Smoking Status - Meaningful Use (V2) Example ........................................................... 439
Figure 138: Social History Observation (V2) Example ..................................................................... 442
Figure 139: Substance Administered Act Example .......................................................................... 444
Figure 140: Tobacco Use (V2) Example ........................................................................................... 449
Figure 141: Transport Mode to Hospital Observation Example ........................................................ 451
Figure 142: Vital Sign Observation (V2) Example ............................................................................ 455
Figure 143: Vital Signs Organizer (V2) Example .............................................................................. 459
Figure 144: New Author Participant Example ................................................................................. 462
Figure 145: Existing Author Reference Example ............................................................................. 463
Figure 146: US Realm Address Example ........................................................................................ 466
Figure 147: US Realm Date and Time Example .............................................................................. 467
Figure 148: US Realm Patient Name Example ................................................................................ 471

Table of Tables
Table 1: US Realm Header (V2) Contexts .......................................................................................... 22
Table 2: US Realm Header (V2) Constraints Overview ....................................................................... 23
Table 3: HL7 BasicConfidentialityKind ............................................................................................. 55
Table 4: Language ........................................................................................................................... 56
Table 5: Telecom Use (US Realm Header).......................................................................................... 56
Table 6: Administrative Gender (HL7 V3) .......................................................................................... 57

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 11
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 7: Marital Status .................................................................................................................... 57
Table 8: Religious Affiliation ............................................................................................................. 58
Table 9: Race Category Excluding Nulls ........................................................................................... 58
Table 10: Ethnicity .......................................................................................................................... 59
Table 11: Personal And Legal Relationship Role Type ........................................................................ 59
Table 12: Country ............................................................................................................................ 60
Table 13: PostalCode ....................................................................................................................... 60
Table 14: PatientLanguage ............................................................................................................... 61
Table 15: LanguageAbilityMode ........................................................................................................ 62
Table 16: LanguageAbilityProficiency ............................................................................................... 62
Table 17: Race ................................................................................................................................. 63
Table 18: Healthcare Provider Taxonomy (HIPAA) ............................................................................. 64
Table 19: INDRoleclassCodes ........................................................................................................... 65
Table 20: x_ServiceEventPerformer .................................................................................................. 65
Table 21: ParticipationFunction ....................................................................................................... 65
Table 22: Detailed Ethnicity ............................................................................................................. 66
Table 23: National Health Care Surveys (V2) Constraints Overview ................................................... 68
Table 24: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Contexts ...................... 73
Table 25: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Constraints Overview ... 74
Table 26: Provider ED (NCHS) .......................................................................................................... 80
Table 27: Disposition ED (NCHS) ..................................................................................................... 81
Table 28: Inpatient Encounter (NHCS-IP) (V3) Contexts .................................................................... 81
Table 29: Inpatient Encounter (NHCS-IP) (V3) Constraints Overview ................................................. 83
Table 30: Discharge Disposition IP (NCHS) ....................................................................................... 88
Table 31: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Contexts ........................ 89
Table 32: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Constraints Overview ..... 90
Table 33: Disposition OPD (NCHS) ................................................................................................... 96
Table 34: Type of clinic/location (NCHS) .......................................................................................... 97
Table 35: Chief Complaint and Reason for Visit Section Constraints Overview................................... 99
Table 36: Reasons for Visit Section (V2) Contexts ........................................................................... 100
Table 37: Reasons for Visit Section (V2) Constraints Overview ........................................................ 101
Table 38: Encounters Section (entries optional) (V2) Contexts ......................................................... 102
Table 39: Encounters Section (entries optional) (V2) Constraints Overview ...................................... 103

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 12
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 40: Emergency Department Encounters Section (V2) Contexts .............................................. 104
Table 41: Emergency Department Encounters Section (V2) Constraints Overview ........................... 104
Table 42: Inpatient Encounters Section (V2) Contexts .................................................................... 106
Table 43: Inpatient Encounters Section (V2) Constraints Overview ................................................. 106
Table 44: Outpatient Encounters Section (V3) Contexts .................................................................. 108
Table 45: Outpatient Encounters Section (V3) Constraints Overview ............................................... 108
Table 46: Medications Section (entries optional) (V2) Contexts ........................................................ 109
Table 47: Medications Section (entries optional) (V2) Constraints Overview ..................................... 110
Table 48: Immunizations Section Contexts ..................................................................................... 111
Table 49: Immunizations Section Constraints Overview .................................................................. 111
Table 50: Medications Section Contexts ......................................................................................... 113
Table 51: Medications Section Constraints Overview ...................................................................... 113
Table 52: Payers Section (V2) Contexts ........................................................................................... 114
Table 53: Payers Section (V2) Constraints Overview ........................................................................ 115
Table 54: Payment Sources Section Contexts ................................................................................. 116
Table 55: Payment Sources Section Constraints Overview .............................................................. 117
Table 56: Problems Section (V3) Contexts ....................................................................................... 118
Table 57: Problems Section (V3) Constraints Overview .................................................................... 119
Table 58: Results Section (entries optional) (V2) Contexts ............................................................... 122
Table 59: Results Section (entries optional) (V2) Constraints Overview ............................................ 123
Table 60: Services and Procedures Section Contexts ....................................................................... 124
Table 61: Services and Procedures Section Constraints Overview .................................................... 125
Table 62: Social History Section (V2) Contexts ................................................................................ 128
Table 63: Social History Section (V2) Constraints Overview ............................................................. 129
Table 64: Patient Information Section (V3) Contexts ....................................................................... 133
Table 65: Patient Information Section (V3) Constraints Overview .................................................... 134
Table 66: Triage Section Contexts .................................................................................................. 137
Table 67: Triage Section Constraints Overview ............................................................................... 138
Table 68: Vital Signs Section (entries optional) (V2) Contexts .......................................................... 140
Table 69: Vital Signs Section (entries optional) (V2) Constraints Overview ....................................... 140
Table 70: Vital Signs Section (entries required) (V2) Contexts .......................................................... 141
Table 71: Vital Signs Section (entries required) (V2) Constraints Overview ....................................... 142
Table 72: Admission Priority Observation Contexts ......................................................................... 144

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 13
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 73: Admission Priority Observation Constraints Overview ...................................................... 145
Table 74: Priority (Type) of Admission or Visit (NCHS) ..................................................................... 146
Table 75: Age Observation Contexts ............................................................................................... 147
Table 76: Age Observation Constraints Overview ............................................................................ 147
Table 77: AgePQ_UCUM ................................................................................................................. 148
Table 78: Assessment Scale Observation Contexts .......................................................................... 149
Table 79: Assessment Scale Observation Constraints Overview ....................................................... 150
Table 80: Pain Assessment Scale Observation Contexts .................................................................. 152
Table 81: Pain Assessment Scale Observation Constraints Overview ............................................... 153
Table 82: Triage Level Assigned Observation Contexts .................................................................... 154
Table 83: Triage Level Assigned Observation Constraints Overview ................................................. 155
Table 84: Triage System (NCHS) ..................................................................................................... 156
Table 85: Assessment Scale Supporting Observation Contexts ........................................................ 156
Table 86: Assessment Scale Supporting Observation Constraints Overview ..................................... 157
Table 87: Asthma Diagnosis Observation (RETIRED) Constraints Overview ..................................... 158
Table 88: Caregiver Characteristics Contexts .................................................................................. 160
Table 89: Caregiver Characteristics Constraints Overview ............................................................... 161
Table 90: Cause of Injury, Poisoning, or Adverse Effect Contexts .................................................... 163
Table 91: Cause of Injury, Poisoning, or Adverse Effect Constraints Overview ................................. 164
Table 92: Characteristics of Home Environment Contexts ............................................................... 166
Table 93: Characteristics of Home Environment Constraints Overview ............................................ 166
Table 94: Residence and Accommodation Type ............................................................................... 167
Table 95: Clinical Note and External Document Reference Contexts ................................................ 168
Table 96: Clinical Note and External Document Reference Constraints Overview ............................. 169
Table 97: Co-morbid Condition Observation (RETIRED) Constraints Overview ................................. 171
Table 98: Condition Control Observation Constraints Overview ...................................................... 172
Table 99: Condition Control (NCHS) ............................................................................................... 173
Table 100: Coverage Activity (V2) Contexts ..................................................................................... 174
Table 101: Coverage Activity (V2) Constraints Overview .................................................................. 175
Table 102: Cultural and Religious Observation Contexts ................................................................ 177
Table 103: Cultural and Religious Observation Constraints Overview ............................................. 177
Table 104: Discharge Status Observation Contexts ......................................................................... 178
Table 105: Discharge Status Observation Constraints Overview ...................................................... 179

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 14
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 106: Hospital Discharge Status (NCHS) ................................................................................. 180
Table 107: Drug Monitoring Act Contexts ....................................................................................... 181
Table 108: Drug Monitoring Act Constraints Overview .................................................................... 182
Table 109: ActStatus ..................................................................................................................... 184
Table 110: Drug Vehicle Contexts .................................................................................................. 185
Table 111: Drug Vehicle Constraints Overview ............................................................................... 186
Table 112: Encounter Activity (V2) Contexts ................................................................................... 187
Table 113: Encounter Activity (V2) Constraints Overview ................................................................ 188
Table 114: EncounterTypeCode...................................................................................................... 191
Table 115: Current Emergency Department Visit (V2) Contexts ...................................................... 193
Table 116: Current Emergency Department Visit (V2) Constraints Overview ................................... 194
Table 117: Current Inpatient Visit Contexts ................................................................................... 198
Table 118: Current Inpatient Visit Constraints Overview ................................................................ 199
Table 119: Current Outpatient Visit (V3) Contexts .......................................................................... 202
Table 120: Current Outpatient Visit (V3) Constraints Overview ....................................................... 203
Table 121: Hospital Admission Encounter Contexts ........................................................................ 207
Table 122: Hospital Admission Encounter Constraints Overview ..................................................... 208
Table 123: Disposition (NCHS) ....................................................................................................... 211
Table 124: Observation Unit Stay Encounter Contexts ................................................................... 213
Table 125: Observation Unit Stay Encounter Constraints Overview................................................. 214
Table 126: Specialty Unit Stay Encounter Contexts ........................................................................ 215
Table 127: Specialty Unit Stay Encounter Constraints Overview ..................................................... 216
Table 128: Specialty Unit Type (NCHS) ........................................................................................... 217
Table 129: Encounter Diagnosis (V2) Contexts ............................................................................... 218
Table 130: Encounter Diagnosis (V2) Constraints Overview ............................................................ 219
Table 131: Episode of Care Observation (V2) Contexts .................................................................... 220
Table 132: Episode of Care Observation (V2) Constraints Overview ................................................. 221
Table 133: Episode of Care (NCHS) ................................................................................................ 222
Table 134: Estimated Date of Delivery Contexts ............................................................................. 222
Table 135: Estimated Date of Delivery Constraints Overview........................................................... 223
Table 136: Follow-up Attempt Outcome Observation Contexts ........................................................ 224
Table 137: Follow-up Attempt Outcome Observation Constraints Overview ..................................... 225
Table 138: Follow-up Attempt Outcome (NCHS) .............................................................................. 226

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 15
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 139: NullValues_UNK_OTH ................................................................................................... 226
Table 140: Hospital Discharge Diagnosis (V2) Contexts .................................................................. 227
Table 141: Hospital Discharge Diagnosis (V2) Constraints Overview................................................ 228
Table 142: Immunization Activity (V2) Contexts .............................................................................. 230
Table 143: Immunization Activity (V2) Constraints Overview ........................................................... 231
Table 144: MoodCodeEvnInt .......................................................................................................... 236
Table 145: Medication Route FDA .................................................................................................. 237
Table 146: Body Site ...................................................................................................................... 238
Table 147: UnitsOfMeasureCaseSensitive ....................................................................................... 239
Table 148: AdministrationUnitDoseForm ....................................................................................... 240
Table 149: Immunization Medication Information (V2) Contexts ..................................................... 242
Table 150: Immunization Medication Information (V2) Constraints Overview ................................... 243
Table 151: CVX Vaccines Administered - Vaccine Set ..................................................................... 244
Table 152: Vaccine Clinical Drug ................................................................................................... 245
Table 153: Specific Vaccine Clinical Drug ....................................................................................... 245
Table 154: Immunization Refusal Reason Contexts ........................................................................ 246
Table 155: Immunization Refusal Reason Constraints Overview...................................................... 247
Table 156: No Immunization Reason Value Set ............................................................................... 248
Table 157: Indication (V2) Contexts ................................................................................................ 249
Table 158: Indication (V2) Constraints Overview ............................................................................. 250
Table 159: Problem ........................................................................................................................ 251
Table 160: Problem Type ................................................................................................................ 252
Table 161: Major Reason for Visit Contexts .................................................................................... 253
Table 162: Major Reason for Visit Constraints Overview ................................................................. 254
Table 163: Major Reason for Visit (NCHS) ....................................................................................... 255
Table 164: Instruction (V2) Contexts .............................................................................................. 256
Table 165: Instruction (V2) Constraints Overview ........................................................................... 257
Table 166: Patient Education ......................................................................................................... 258
Table 167: Listed for Admission to Hospital Act Contexts................................................................ 258
Table 168: Listed for Admission to Hospital Act Constraints Overview ............................................. 259
Table 169: Medication Activity (V2) Contexts .................................................................................. 260
Table 170: Medication Activity (V2) Constraints Overview ............................................................... 262
Table 171: Medication Dispense (V2) Contexts ............................................................................... 270

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 16
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 172: Medication Dispense (V2) Constraints Overview............................................................. 271
Table 173: Medication Fill Status ................................................................................................... 273
Table 174: Medication Free Text Sig Contexts ................................................................................. 274
Table 175: Medication Free Text Sig Constraints Overview .............................................................. 275
Table 176: Medication Information (V2) Contexts............................................................................ 277
Table 177: Medication Information (V2) Constraints Overview ......................................................... 277
Table 178: Medication Clinical Drug .............................................................................................. 278
Table 179: Clinical Substance ........................................................................................................ 279
Table 180: Medication Supply Order (V2) Contexts ......................................................................... 280
Table 181: Medication Supply Order (V2) Constraints Overview ...................................................... 281
Table 182: New Patient Act Contexts .............................................................................................. 283
Table 183: New Patient Act Constraints Overview ........................................................................... 284
Table 184: Number of Visits in the Last 12 Months Contexts .......................................................... 285
Table 185: Number of Visits in the Last 12 Months Constraints Overview ....................................... 286
Table 186: On Oxygen on Arrival Observation Contexts .................................................................. 287
Table 187: On Oxygen on Arrival Observation Constraints Overview ............................................... 288
Table 188: Patient Residence Observation Contexts ........................................................................ 289
Table 189: Patient Residence Observation Constraints Overview ..................................................... 290
Table 190: Patient Residence (NCHS) ............................................................................................. 291
Table 191: Patient Seen in this ED in last 72 Hours and Discharged Contexts ................................ 291
Table 192: Patient Seen in this ED in last 72 Hours and Discharged Constraints Overview ............. 292
Table 193: Planned Act (V2) Contexts ............................................................................................. 293
Table 194: Planned Act (V2) Constraints Overview .......................................................................... 294
Table 195: Planned moodCode (Act/Encounter/Procedure) ............................................................. 296
Table 196: Ordered Service Act Contexts ........................................................................................ 297
Table 197: Ordered Service Act Constraints Overview ..................................................................... 298
Table 198: Planned Coverage Contexts ........................................................................................... 299
Table 199: Planned Coverage Constraints Overview ........................................................................ 300
Table 200: Payer ............................................................................................................................ 302
Table 201: Planned Immunization Activity Contexts ....................................................................... 303
Table 202: Planned Immunization Activity Constraints Overview .................................................... 304
Table 203: Planned moodCode (SubstanceAdministration/Supply) ................................................. 307
Table 204: Planned Medication Activity (V2) Contexts ..................................................................... 309

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 17
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 205: Planned Medication Activity (V2) Constraints Overview .................................................. 310
Table 206: Planned Observation (V2) Contexts ............................................................................... 314
Table 207: Planned Observation (V2) Constraints Overview ............................................................ 316
Table 208: Planned moodCode (Observation) .................................................................................. 319
Table 209: Ordered Service Observation Contexts........................................................................... 320
Table 210: Ordered Service Observation Constraints Overview ........................................................ 321
Table 211: Planned Procedure (V2) Contexts .................................................................................. 322
Table 212: Planned Procedure (V2) Constraints Overview ............................................................... 323
Table 213: Ordered Service Procedure Contexts .............................................................................. 328
Table 214: Ordered Service Procedure Constraints Overview ........................................................... 328
Table 215: Point of Origin Observation Contexts ............................................................................. 329
Table 216: Point of Origin Observation Constraints Overview .......................................................... 330
Table 217: Point of Origin (NCHS) .................................................................................................. 331
Table 218: Policy Activity (V2) Contexts .......................................................................................... 332
Table 219: Policy Activity (V2) Constraints Overview ....................................................................... 333
Table 220: HL7FinanciallyResponsiblePartyType ............................................................................ 339
Table 221: Coverage Role Type ....................................................................................................... 339
Table 222: Precondition for Substance Administration (V2) Contexts .............................................. 342
Table 223: Precondition for Substance Administration (V2) Constraints Overview ........................... 342
Table 224: Pregnancy Observation Contexts ................................................................................... 343
Table 225: Pregnancy Observation Constraints Overview ................................................................ 344
Table 226: Present on Admission Observation Contexts .................................................................. 346
Table 227: Present on Admission Observation Constraints Overview ............................................... 347
Table 228: Priority Preference Contexts .......................................................................................... 348
Table 229: Priority Preference Constraints Overview ....................................................................... 349
Table 230: Priority Level ................................................................................................................ 350
Table 231: Problem Observation (V2) Contexts ............................................................................... 351
Table 232: Problem Observation (V2) Constraints Overview ............................................................ 352
Table 233: Admission Diagnosis Observation Contexts ................................................................... 361
Table 234: Admission Diagnosis Observation Constraints Overview ................................................ 361
Table 235: Adverse Effect of Medical Treatment Contexts ............................................................... 362
Table 236: Adverse Effect of Medical Treatment Constraints Overview............................................. 363
Table 237: Injury or Poisoning Observation (V2) Contexts ............................................................... 365

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 18
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 238: Injury or Poisoning Observation (V2) Constraints Overview ............................................ 366
Table 239: Injury or Poisoning (NCHS) ........................................................................................... 368
Table 240: Patient's Reason for Visit Observation Contexts ............................................................. 369
Table 241: Patient's Reason for Visit Observation Constraints Overview .......................................... 370
Table 242: Primary Diagnosis Observation (V2) Contexts ................................................................ 371
Table 243: Primary Diagnosis Observation (V2) Constraints Overview ............................................. 372
Table 244: Problem/Diagnosis/Symptom/Condition Observation (V2) Contexts .............................. 374
Table 245: Problem/Diagnosis/Symptom/Condition Observation (V2) Constraints Overview ........... 374
Table 246: Problem Status (DEPRECATED) Contexts ...................................................................... 376
Table 247: Problem Status (DEPRECATED) Constraints Overview ................................................... 376
Table 248: Problem Status ............................................................................................................. 377
Table 249: Procedure Activity Act (V2) Contexts .............................................................................. 377
Table 250: Procedure Activity Act (V2) Constraints Overview ........................................................... 379
Table 251: Act Priority ................................................................................................................... 384
Table 252: ProcedureAct statusCode .............................................................................................. 384
Table 253: Provided Service Act Contexts ....................................................................................... 386
Table 254: Provided Service Act Constraints Overview .................................................................... 386
Table 255: Procedure Activity Observation (V2) Contexts ................................................................ 388
Table 256: Procedure Activity Observation (V2) Constraints Overview ............................................. 389
Table 257: Provided Service Observation Contexts .......................................................................... 396
Table 258: Provided Service Observation Constraints Overview ....................................................... 397
Table 259: Procedure Activity Procedure (V2) Contexts ................................................................... 398
Table 260: Procedure Activity Procedure (V2) Constraints Overview ................................................ 400
Table 261: Provided Service Procedure Contexts ............................................................................. 406
Table 262: Provided Service Procedure Constraints Overview .......................................................... 407
Table 263: Procedure Follow-Up Attempt Observation Contexts ...................................................... 408
Table 264: Procedure Follow-Up Attempt Observation Constraints Overview ................................... 409
Table 265: Product Instance Contexts ............................................................................................ 411
Table 266: Product Instance Constraints Overview ......................................................................... 412
Table 267: Prognosis Observation Contexts .................................................................................... 413
Table 268: Prognosis Observation Constraints Overview ................................................................. 414
Table 269: Reaction Observation (V2) Contexts .............................................................................. 416
Table 270: Reaction Observation (V2) Constraints Overview............................................................ 417

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 19
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 271: Result Observation (V2) Contexts .................................................................................. 420
Table 272: Result Observation (V2) Constraints Overview ............................................................... 421
Table 273: Result Status................................................................................................................ 423
Table 274: Observation Interpretation (HL7) ................................................................................... 424
Table 275: Result Organizer (V2) Contexts ..................................................................................... 427
Table 276: Result Organizer (V2) Constraints Overview................................................................... 428
Table 277: Service Delivery Location Contexts ................................................................................ 430
Table 278: Service Delivery Location Constraints Overview ............................................................. 431
Table 279: HealthcareServiceLocation ............................................................................................ 432
Table 280: Severity Observation (V2) Contexts ................................................................................ 433
Table 281: Severity Observation (V2) Constraints Overview ............................................................. 434
Table 282: Problem Severity ........................................................................................................... 435
Table 283: Smoking Status - Meaningful Use (V2) Contexts ............................................................ 436
Table 284: Smoking Status - Meaningful Use (V2) Constraints Overview ......................................... 437
Table 285: Current Smoking Status ............................................................................................... 439
Table 286: Social History Observation (V2) Contexts ....................................................................... 440
Table 287: Social History Observation (V2) Constraints Overview .................................................... 441
Table 288: Substance Administered Act Contexts ........................................................................... 443
Table 289: Substance Administered Act Constraints Overview ........................................................ 443
Table 290: Tobacco Use (V2) Contexts ............................................................................................ 445
Table 291: Tobacco Use (V2) Constraints Overview ......................................................................... 446
Table 292: Tobacco Use ................................................................................................................. 448
Table 293: Transport Mode to Hospital Observation Contexts ......................................................... 449
Table 294: Transport Mode to Hospital Observation Constraints Overview ...................................... 450
Table 295: Transport Mode to Hospital (NCHS) ............................................................................... 451
Table 296: Vital Sign Observation (V2) Contexts ............................................................................. 452
Table 297: Vital Sign Observation (V2) Constraints Overview .......................................................... 453
Table 298: Vital Sign Result ........................................................................................................... 455
Table 299: Vital Signs Organizer (V2) Contexts ............................................................................... 456
Table 300: Vital Signs Organizer (V2) Constraints Overview ............................................................ 457
Table 301: Author Participation Contexts ....................................................................................... 460
Table 302: Author Participation Constraints Overview .................................................................... 461
Table 303: US Realm Address (AD.US.FIELDED) Contexts .............................................................. 463

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 20
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 304: US Realm Address (AD.US.FIELDED) Constraints Overview ........................................... 463
Table 305: PostalAddressUse ......................................................................................................... 465
Table 306: StateValueSet ............................................................................................................... 466
Table 307: US Realm Date and Time (DTM.US.FIELDED) Contexts ................................................. 467
Table 308: US Realm Date and Time (DTM.US.FIELDED) Constraints Overview .............................. 467
Table 309: US Realm Patient Name (PTN.US.FIELDED) Contexts .................................................... 468
Table 310: US Realm Patient Name (PTN.US.FIELDED) Constraints Overview ................................. 468
Table 311: EntityNameUse ............................................................................................................. 470
Table 312: EntityPersonNamePartQualifier ..................................................................................... 471
Table 313: US Realm Person Name (PN.US.FIELDED) Contexts ...................................................... 471
Table 314: US Realm Person Name (PN.US.FIELDED) Constraints Overview ................................... 472
Table 315: Template List ................................................................................................................ 473
Table 316: Template Containments ................................................................................................ 479
Table 317: Value Sets .................................................................................................................... 503
Table 318: Code Systems ............................................................................................................... 508

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 21
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1

DOCUMENT-LEVEL TEMPLATES
Document-level templates describe the purpose and rules for constructing a conforming CDA
document. Document templates include constraints on the CDA header and indicate contained
section-level templates.
Each document-level template contains the following information:
• Scope and intended use of the document type
• Description and explanatory narrative
• Template metadata (e.g., templateId, etc.)
• Header constraints (e.g., document type, template id, participants)
• Required and optional section-level templates

1.1

US Realm Header (V2)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:201406-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 1: US Realm Header (V2) Contexts

Contained By:

Contains:
US Realm Address (AD.US.FIELDED)
US Realm Date and Time (DTM.US.FIELDED)
US Realm Person Name (PN.US.FIELDED)

This template defines constraints that represent common administrative and demographic
concepts for US Realm CDA documents. Further specification, such as
ClinicalDocument/code, are provided in document templates that conform to this template.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 22
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 2: US Realm Header (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:2014-06-09)
realmCode

1..1

SHALL

109816791

typeId

1..1

SHALL

10985361

@root

1..1

SHALL

10985250

2.16.840.1.113883.1.3

@extension

1..1

SHALL

10985251

POCD_HD000040

1..1

SHALL

10985252

@root

1..1

SHALL

109810036

2.16.840.1.113883.10.20.22.1.1

@extension

1..1

SHALL

109832503

2014-06-09

id

1..1

SHALL

10985363

code

1..1

SHALL

10985253

title

1..1

SHALL

10985254

effectiveTime

1..1

SHALL

10985256

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

confidentialityCode

1..1

SHALL

10985259

urn:oid:2.16.840.1.113883.1.11.1
6926 (HL7
BasicConfidentialityKind)

languageCode

1..1

SHALL

10985372

urn:oid:2.16.840.1.113883.1.11.1
1526 (Language)

setId

0..1

MAY

10985261

versionNumber

0..1

MAY

10985264

recordTarget

1..*

SHALL

10985266

patientRole

1..1

SHALL

10985267

id

1..*

SHALL

10985268

addr

1..*

SHALL

10985271

templateId

US

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 23
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

telecom

1..*

SHALL

10985280

@use

0..1

SHOUL
D

10985375

patient

1..1

SHALL

10985283

name

1..*

SHALL

10985284

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

administrativeGenderCode

1..1

SHALL

10986394

urn:oid:2.16.840.1.113883.1.11.1
(Administrative Gender (HL7 V3))

birthTime

1..1

SHALL

10985298

maritalStatusCode

0..1

SHOUL
D

10985303

urn:oid:2.16.840.1.113883.1.11.1
2212 (Marital Status)

religiousAffiliationCode

0..1

MAY

10985317

urn:oid:2.16.840.1.113883.1.11.1
9185 (Religious Affiliation)

raceCode

1..1

SHALL

10985322

urn:oid:2.16.840.1.113883.3.207
4.1.1.3 (Race Category Excluding
Nulls)

sdtc:raceCode

0..*

MAY

10987263

urn:oid:2.16.840.1.113883.1.11.1
4914 (Race)

ethnicGroupCode

1..1

SHALL

10985323

urn:oid:2.16.840.1.114222.4.11.8
37 (Ethnicity)

sdtc:ethnicGroupCode

0..*

MAY

109832901

urn:oid:2.16.840.1.114222.4.11.8
77 (Detailed Ethnicity)

guardian

0..*

MAY

10985325

code

0..1

SHOUL
D

10985326

urn:oid:2.16.840.1.113883.11.20.
12.1 (Personal And Legal
Relationship Role Type)

addr

0..*

SHOUL
D

10985359

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

0..*

SHOUL
D

10985382

@use

0..1

SHOUL
D

10987993

1..1

SHALL

10985385

1..*

SHALL

10985386

0..1

MAY

1098-

guardianPerson
name

birthplace

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 24
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

5395
place

1..1

SHALL

10985396

1..1

SHALL

10985397

country

0..1

SHOUL
D

10985404

urn:oid:2.16.840.1.113883.3.88.1
2.80.63 (Country)

postalCode

0..1

MAY

10985403

urn:oid:2.16.840.1.113883.3.88.1
2.80.2 (PostalCode)

1..*

SHALL

10985406

languageCode

1..1

SHALL

10985407

urn:oid:2.16.840.1.113883.11.20.
9.64 (PatientLanguage)

modeCode

0..1

MAY

10985409

urn:oid:2.16.840.1.113883.1.11.1
2249 (LanguageAbilityMode)

proficiencyLevelCode

0..1

SHOUL
D

10989965

urn:oid:2.16.840.1.113883.1.11.1
2199 (LanguageAbilityProficiency)

preferenceInd

0..1

SHOUL
D

10985414

providerOrganization

0..1

MAY

10985416

1..*

SHALL

10985417

0..1

SHOUL
D

109816820

name

1..*

SHALL

10985419

telecom

1..*

SHALL

10985420

@use

0..1

SHOUL
D

10987994

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

1..*

SHALL

10985422

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

author

1..*

SHALL

10985444

time

1..1

SHALL

10985445

assignedAuthor

1..1

SHALL

10985448

id

1..*

SHALL

10985449

id

0..1

SHOUL
D

109832882

addr

languageCommunication

id
@root

addr

2.16.840.1.113883.4.6

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 25
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@nullFlavor

0..1

MAY

109832883

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = UNK

@root

1..1

SHALL

109832884

2.16.840.1.113883.4.6

@extension

0..1

SHOUL
D

109832885

0..1

SHOUL
D

109816787

1..1

SHALL

109816788

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985452

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985428

@use

0..1

SHOUL
D

10987995

0..1

SHOUL
D

10985430

1..*

SHALL

109816789

0..1

SHOUL
D

109816783

manufacturerModelName

1..1

SHALL

109816784

softwareName

1..1

SHALL

109816785

0..1

MAY

10985441

1..1

SHALL

10985442

1..*

SHALL

10985443

0..1

SHOUL
D

109816821

2.16.840.1.113883.4.6

code

0..1

MAY

109832173

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985460

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985466

code
@code

assignedPerson
name

assignedAuthoringDevice

dataEnterer
assignedEntity
id
@root

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 26
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@use

0..1

SHOUL
D

10987996

1..1

SHALL

10985469

name

1..*

SHALL

10985470

informant

0..*

MAY

10988001

1..1

SHALL

10988002

id

1..*

SHALL

10989945

code

0..1

MAY

109832174

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10988220

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

assignedPerson

1..1

SHALL

10988221

name

1..*

SHALL

10988222

informant

0..*

MAY

109831355

1..1

SHALL

109831356

1..1

SHALL

10985519

1..1

SHALL

10985520

1..1

SHALL

10985521

1..*

SHALL

10985522

0..1

SHOUL
D

109816822

name

1..1

SHALL

10985524

telecom

1..1

SHALL

10985525

@use

0..1

SHOUL
D

10987998

assignedPerson

assignedEntity

relatedEntity
custodian
assignedCustodian

representedCustodianOrganization
id
@root

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

2.16.840.1.113883.4.6

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 27
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

addr

1..1

SHALL

10985559

informationRecipient

0..*

MAY

10985565

intendedRecipient

1..1

SHALL

10985566

id

0..*

MAY

109832399

informationRecipient

0..1

MAY

10985567

1..*

SHALL

10985568

0..1

MAY

10985577

1..1

SHALL

10985578

0..1

SHOUL
D

10985579

time

1..1

SHALL

10985580

signatureCode

1..1

SHALL

10985583

1..1

SHALL

10985584

sdtc:signatureText

0..1

MAY

109830810

assignedEntity

1..1

SHALL

10985585

1..*

SHALL

10985586

0..1

MAY

109816823

2.16.840.1.113883.4.6

code

0..1

MAY

109817000

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985589

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985595

@use

0..1

SHOUL
D

10987999

name

receivedOrganization
name
legalAuthenticator

@code

id
@root

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

urn:oid:2.16.840.1.113883.5.89
(Participationsignature) = S

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 28
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Header))
assignedPerson

1..1

SHALL

10985597

1..*

SHALL

10985598

0..*

MAY

10985607

time

1..1

SHALL

10985608

signatureCode

1..1

SHALL

10985610

1..1

SHALL

10985611

sdtc:signatureText

0..1

MAY

109830811

assignedEntity

1..1

SHALL

10985612

1..*

SHALL

10985613

0..1

SHOUL
D

109816824

0..1

MAY

109816825

0..1

MAY

109816826

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985616

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985622

@use

0..1

SHOUL
D

10988000

1..1

SHALL

10985624

name

1..*

SHALL

10985625

participant

0..*

MAY

109810003

0..1

MAY

109810004

name

authenticator

@code

id
@root
code
@code

assignedPerson

time

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

urn:oid:2.16.840.1.113883.5.89
(Participationsignature) = S

2.16.840.1.113883.4.6

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 29
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

inFulfillmentOf

0..*

MAY

10989952

order

1..1

SHALL

10989953

id

1..*

SHALL

10989954

0..*

MAY

109814835

1..1

SHALL

109814836

1..1

SHALL

109814837

1..1

SHALL

109814838

0..*

SHOUL
D

109814839

@typeCode

1..1

SHALL

109814840

functionCode

0..1

MAY

109816818

0..1

SHOUL
D

109832889

1..1

SHALL

109814841

1..*

SHALL

109814846

0..1

SHOUL
D

109814847

2.16.840.1.113883.4.6

0..1

SHOUL
D

109814842

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

0..*

MAY

109816792

1..1

SHALL

109816793

id

0..*

MAY

109816794

code

0..1

MAY

109816795

statusCode

1..1

SHALL

109816797

1..1

SHALL

109816798

0..1

MAY

10989955

1..1

SHALL

10989956

documentationOf
serviceEvent
effectiveTime
low
performer

@code
assignedEntity
id
@root
code

authorization
consent

@code
componentOf
encompassingEncounter

urn:oid:2.16.840.1.113883.1.11.1
9601 (x_ServiceEventPerformer)

urn:oid:2.16.840.1.113883.1.11.1
0267 (ParticipationFunction)

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = completed

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 30
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

id

1..*

SHALL

10989959

effectiveTime

1..1

SHALL

10989958

1.1.1 Properties
1.1.1.1 realmCode
1. SHALL contain exactly one [1..1] realmCode="US" (CONF:1098-16791).
Figure 1: US Realm Header (V2) Example

Patient Chart Summary

. . .

2. SHALL contain exactly one [1..1] typeId (CONF:1098-5361).
a. This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3"
(CONF:1098-5250).
b. This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040"
(CONF:1098-5251).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-5252) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1"
(CONF:1098-10036).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32503).
4. SHALL contain exactly one [1..1] id (CONF:1098-5363).
a. This id SHALL be a globally unique identifier for the document (CONF:1098-9991).
5. SHALL contain exactly one [1..1] code (CONF:1098-5253).
a. This code SHALL specify the particular kind of document (e.g., History and
Physical, Discharge Summary, Progress Note) (CONF:1098-9992).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 31
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

6. SHALL contain exactly one [1..1] title (CONF:1098-5254).
Note: The title can either be a locally defined name or the displayName corresponding to
clinicalDocument/code
7. SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED)
(identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5256).
8. SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from
ValueSet HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926
STATIC 2010-04-21 (CONF:1098-5259).
9. SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet
Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:1098-5372).
10. MAY contain zero or one [0..1] setId (CONF:1098-5261).
a. If setId is present versionNumber SHALL be present (CONF:1098-6380).
11. MAY contain zero or one [0..1] versionNumber (CONF:1098-5264).
a. If versionNumber is present setId SHALL be present (CONF:1098-6387).

1.1.1.2 recordTarget
The recordTarget records the administrative and demographic data of the patient whose health
information is described by the clinical document; each recordTarget must contain at least one
patientRole element
12. SHALL contain at least one [1..*] recordTarget (CONF:1098-5266).
a. Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:10985267).
i.

This patientRole SHALL contain at least one [1..*] id (CONF:1098-5268).

ii. This patientRole 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:1098-5271).
iii. This patientRole SHALL contain at least one [1..*] telecom (CONF:10985280).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10985375).
iv. This patientRole SHALL contain exactly one [1..1] patient (CONF:10985283).
1. This patient SHALL contain at least one [1..*] US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985284).
2. This patient SHALL contain exactly one [1..1]
administrativeGenderCode, which SHALL be selected from
ValueSet Administrative Gender (HL7 V3)
urn:oid:2.16.840.1.113883.1.11.1 DYNAMIC (CONF:1098-6394).
3. This patient SHALL contain exactly one [1..1] birthTime
(CONF:1098-5298).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 32
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL be precise to year (CONF:1098-5299).
b. SHOULD be precise to day (CONF:1098-5300).
For cases where information about newborn's time of birth needs to be captured.
c. MAY be precise to the minute (CONF:1098-32418).
4. This patient SHOULD contain zero or one [0..1] maritalStatusCode,
which SHALL be selected from ValueSet Marital Status
urn:oid:2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:10985303).
5. This patient MAY contain zero or one [0..1]
religiousAffiliationCode, which SHALL be selected from
ValueSet Religious Affiliation
urn:oid:2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:10985317).
6. This patient SHALL contain exactly one [1..1] raceCode, which SHALL
be selected from ValueSet Race Category Excluding Nulls
urn:oid:2.16.840.1.113883.3.2074.1.1.3 DYNAMIC (CONF:10985322).
7. This patient MAY contain zero or more [0..*] sdtc:raceCode, which
SHALL be selected from ValueSet Race
urn:oid:2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:10987263).
Note: The sdtc:raceCode is only used to record additional values
when the patient has indicated multiple races or additional race
detail beyond the five categories required for Meaningful Use Stage 2.
The prefix sdtc: SHALL be bound to the namespace “urn:hl7org:sdtc”. The use of the namespace provides a necessary extension
to CDA R2 for the use of the additional raceCode elements.
a. If sdtc:raceCode is present, then the patient SHALL contain
[1..1] raceCode (CONF:1098-31347).
8. This patient SHALL contain exactly one [1..1] ethnicGroupCode,
which SHALL be selected from ValueSet Ethnicity
urn:oid:2.16.840.1.114222.4.11.837 DYNAMIC (CONF:10985323).
9. This patient MAY contain zero or more [0..*] sdtc:ethnicGroupCode,
which SHALL be selected from ValueSet Detailed Ethnicity
urn:oid:2.16.840.1.114222.4.11.877 DYNAMIC (CONF:109832901).
10. This patient MAY contain zero or more [0..*] guardian (CONF:10985325).
a. The guardian, if present, SHOULD contain zero or one [0..1]
code, which SHALL be selected from ValueSet Personal And
Legal Relationship Role Type
urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC
(CONF:1098-5326).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 33
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. The guardian, if present, SHOULD 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:10985359).
c. The guardian, if present, SHOULD contain zero or more [0..*]
telecom (CONF:1098-5382).
i.

The telecom, if present, SHOULD contain zero or one
[0..1] @use, which SHALL be selected from ValueSet
Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:1098-7993).

d. The guardian, if present, SHALL contain exactly one [1..1]
guardianPerson (CONF:1098-5385).
i.

This guardianPerson SHALL contain at least one [1..*]
US Realm Person Name (PN.US.FIELDED)
(identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1)
(CONF:1098-5386).

11. This patient MAY contain zero or one [0..1] birthplace (CONF:10985395).
a. The birthplace, if present, SHALL contain exactly one [1..1]
place (CONF:1098-5396).
i.

This place SHALL contain exactly one [1..1] addr
(CONF:1098-5397).

1. This addr SHOULD contain zero or one [0..1] country,
which SHALL be selected from ValueSet Country
urn:oid:2.16.840.1.113883.3.88.12.80.63
DYNAMIC (CONF:1098-5404).
2. This addr MAY contain zero or one [0..1] postalCode,
which SHALL be selected from ValueSet PostalCode
urn:oid:2.16.840.1.113883.3.88.12.80.2
DYNAMIC (CONF:1098-5403).
3. If country is US, this addr SHOULD contain zero to
one [0..1] state, which SHALL be selected from
ValueSet StateValueSet
2.16.840.1.113883.3.88.12.80.1 DYNAMIC
(CONF:1098-5402).
12. This patient SHALL contain at least one [1..*]
languageCommunication (CONF:1098-5406).
a. Such languageCommunications SHALL contain exactly one
[1..1] languageCode, which SHALL be selected from ValueSet
PatientLanguage
urn:oid:2.16.840.1.113883.11.20.9.64 DYNAMIC
(CONF:1098-5407).
b. Such languageCommunications MAY contain zero or one [0..1]
modeCode, which SHALL be selected from ValueSet

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 34
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

LanguageAbilityMode
urn:oid:2.16.840.1.113883.1.11.12249 DYNAMIC
(CONF:1098-5409).
c. Such languageCommunications SHOULD contain zero or one
[0..1] proficiencyLevelCode, which SHALL be selected from
ValueSet LanguageAbilityProficiency
urn:oid:2.16.840.1.113883.1.11.12199 DYNAMIC
(CONF:1098-9965).
d. Such languageCommunications SHOULD contain zero or one
[0..1] preferenceInd (CONF:1098-5414).
v. This patientRole MAY contain zero or one [0..1] providerOrganization
(CONF:1098-5416).
1. The providerOrganization, if present, SHALL contain at least one [1..*]
id (CONF:1098-5417).
a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:1098-16820).
2. The providerOrganization, if present, SHALL contain at least one [1..*]
name (CONF:1098-5419).
3. The providerOrganization, if present, SHALL contain at least one [1..*]
telecom (CONF:1098-5420).
a. Such telecoms SHOULD contain zero or one [0..1] @use, which
SHALL be selected from ValueSet Telecom Use (US Realm
Header) urn:oid:2.16.840.1.113883.11.20.9.20
DYNAMIC (CONF:1098-7994).
4. The providerOrganization, if present, 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:1098-5422).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 35
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 2: recordTarget Example

2222 Home Street
Beaverton
OR
97867
US

Eve

Betterhalf

Eve

Everywoman

2222 Home Street
Beaverton

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 36
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

OR
97867
US

Boris
Bo
Betterhalf

4444 Home Street
Beaverton
OR
97867
US

The DoctorsTogether Physician Group

1007 Health Drive
Portland
OR
99123
US

1.1.1.3 author
The author element represents the creator of the clinical document. The author may be a
device or a person.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 37
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

13. SHALL contain at least one [1..*] author (CONF:1098-5444).
a. Such authors SHALL contain exactly one [1..1] US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5445).
b. Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:1098-5448).
i.

This assignedAuthor SHALL contain at least one [1..*] id (CONF:1098-5449).

If this assignedAuthor is an assignedPerson
ii. This assignedAuthor SHOULD contain zero or one [0..1] id (CONF:109832882) such that it
If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then
1. MAY contain zero or one [0..1] @nullFlavor="UNK" Unknown
(CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:1098-32883).
2. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6"
National Provider Identifier (CONF:1098-32884).
3. SHOULD contain zero or one [0..1] @extension (CONF:1098-32885).
Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
iii. This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:109816787).
1. The code, if present, SHALL contain exactly one [1..1] @code, which
SHOULD be selected from ValueSet Healthcare Provider Taxonomy
(HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC
(CONF:1098-16788).
iv. 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:1098-5452).
v. This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:10985428).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10987995).
vi. This assignedAuthor SHOULD contain zero or one [0..1] assignedPerson
(CONF:1098-5430).
1. The assignedPerson, if present, SHALL contain at least one [1..*] US
Realm Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:109816789).
vii. This assignedAuthor SHOULD contain zero or one [0..1]
assignedAuthoringDevice (CONF:1098-16783).
1. The assignedAuthoringDevice, if present, SHALL contain exactly one
[1..1] manufacturerModelName (CONF:1098-16784).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 38
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2. The assignedAuthoringDevice, if present, SHALL contain exactly one
[1..1] softwareName (CONF:1098-16785).
viii. There SHALL be exactly one assignedAuthor/assignedPerson or exactly one
assignedAuthor/assignedAuthoringDevice (CONF:1098-16790).
Figure 3: author Example

1004 Healthcare Drive
Portland
OR
99123
US

Patricia
Patty
Primary
M.D.

1.1.1.4 dataEnterer
The dataEnterer element represents the person who transferred the content, written or
dictated, into the clinical document. To clarify, an author provides the content found within the
header or body of a document, subject to their own interpretation; a dataEnterer adds an
author's information to the electronic system.
14. MAY contain zero or one [0..1] dataEnterer (CONF:1098-5441).
a. The dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-5442).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-5443).
1. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:1098-16821).

ii. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-32173).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 39
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

iii. This assignedEntity 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:1098-5460).
iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10985466).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10987996).
v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-5469).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985470).
Figure 4: dateEnterer Example

1007 Healthcare Drive
Portland
OR
99123
US

Ellen
Enter

1.1.1.5 informant
The informant element describes an information source for any content within the clinical
document. This informant is constrained for use when the source of information is an assigned
health care provider for the patient.
15. MAY contain zero or more [0..*] informant (CONF:1098-8001) such that it
a. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8002).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-9945).
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:1098-9946).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 40
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

ii. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-32174).
iii. This assignedEntity 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:1098-8220).
iv. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-8221).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10988222).
Figure 5: Assigned Health Care Provider informant Example

1007 Healthcare Drive
Portland
OR
99123
US

Harold
Hippocrates
M.D.

The DoctorsApart Physician Group

1.1.1.6 informant
The informant element describes an information source (who is not a provider) for any content
within the clinical document. This informant would be used when the source of information
has a personal relationship with the patient or is the patient.
16. MAY contain zero or more [0..*] informant (CONF:1098-31355) such that it
a. SHALL contain exactly one [1..1] relatedEntity (CONF:1098-31356).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 41
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 6: Personal Relation informant Example

Boris
Bo
Betterhalf

1.1.1.7 custodian
The custodian element represents the organization that is in charge of maintaining and is
entrusted with the care of the document.
There is only one custodian per CDA document. Allowing that a CDA document may not
represent the original form of the authenticated document, the custodian represents the
steward of the original source document. The custodian may be the document originator, a
health information exchange, or other responsible party.
17. SHALL contain exactly one [1..1] custodian (CONF:1098-5519).
a. This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:10985520).
i.

This assignedCustodian SHALL contain exactly one [1..1]
representedCustodianOrganization (CONF:1098-5521).
1. This representedCustodianOrganization SHALL contain at least one
[1..*] id (CONF:1098-5522).
a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:1098-16822).
2. This representedCustodianOrganization SHALL contain exactly one
[1..1] name (CONF:1098-5524).
3. This representedCustodianOrganization SHALL contain exactly one
[1..1] telecom (CONF:1098-5525).
a. This telecom SHOULD contain zero or one [0..1] @use, which
SHALL be selected from ValueSet Telecom Use (US Realm
Header) urn:oid:2.16.840.1.113883.11.20.9.20
DYNAMIC (CONF:1098-7998).
4. This representedCustodianOrganization SHALL contain exactly one
[1..1] US Realm Address (AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5559).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 42
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 7: custodian Example

Good Health HIE

1009 Healthcare Drive
Portland
OR
99123
US

1.1.1.8 informationRecipient
The informationRecipient element records the intended recipient of the information at the time
the document was created. In cases where the intended recipient of the document is the
patient's health chart, set the receivedOrganization to the scoping organization for that chart.
18. MAY contain zero or more [0..*] informationRecipient (CONF:1098-5565).
a. The informationRecipient, if present, SHALL contain exactly one [1..1]
intendedRecipient (CONF:1098-5566).
i.

This intendedRecipient MAY contain zero or more [0..*] id (CONF:109832399).

ii. This intendedRecipient MAY contain zero or one [0..1]
informationRecipient (CONF:1098-5567).
1. The informationRecipient, if present, SHALL contain at least one [1..*]
US Realm Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985568).
iii. This intendedRecipient MAY contain zero or one [0..1]
receivedOrganization (CONF:1098-5577).
1. The receivedOrganization, if present, SHALL contain exactly one [1..1]
name (CONF:1098-5578).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 43
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 8: informationRecipient Example

Sara
Specialize
M.D.

The DoctorsApart Physician Group

1.1.1.9 legalAuthenticator
The legalAuthenticator identifies the single person legally responsible for the document and
must be present if the document has been legally authenticated. A clinical document that does
not contain this element has not been legally authenticated.
The act of legal authentication requires a certain privilege be granted to the legal authenticator
depending upon local policy. Based on local practice, clinical documents may be released
before legal authentication.
All clinical documents have the potential for legal authentication, given the appropriate
credentials.
Local policies MAY choose to delegate the function of legal authentication to a device or system
that generates the clinical document. In these cases, the legal authenticator is a person
accepting responsibility for the document, not the generating device or system.
Note that the legal authenticator, if present, must be a person.
19. SHOULD contain zero or one [0..1] legalAuthenticator (CONF:1098-5579).
a. The legalAuthenticator, if present, SHALL contain exactly one [1..1] US Realm Date
and Time (DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5580).
b. The legalAuthenticator, if present, SHALL contain exactly one [1..1] signatureCode
(CONF:1098-5583).
i.

This signatureCode SHALL contain exactly one [1..1] @code="S"
(CodeSystem: Participationsignature
urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:1098-5584).

1.1.1.10 sdtc:signatureText
The sdtc:signatureText extension provides a location in CDA for a textual or multimedia
depiction of the signature by which the participant endorses and accepts responsibility for his
or her participation in the Act as specified in the Participation.typeCode. Details of what goes in
the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 44
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

c. The legalAuthenticator, if present, MAY contain zero or one [0..1]
sdtc:signatureText (CONF:1098-30810).
Note: The signature can be represented either inline or by reference according to the
ED data type. Typical cases for CDA are:
1) Electronic signature: this attribute can represent virtually any electronic
signature scheme.
2) Digital signature: this attribute can represent digital signatures by reference to a
signature data block that is constructed in accordance to a digital signature
standard, such as XML-DSIG, PKCS#7, PGP, etc.

Figure 9: Digital signature Example
omSJUEdmde9j44zmMiromSJUEdmde9j44zmMirdMDSsWdIJdksIJR3373jeu83
6edjzMMIjdMDSsWdIJdksIJR3373jeu83MNYD83jmMdomSJUEdmde9j44zmMir
... MNYD83jmMdomSJUEdmde9j44zmMir6edjzMMIjdMDSsWdIJdksIJR3373jeu83
4zmMir6edjzMMIjdMDSsWdIJdksIJR3373jeu83==

d. The legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-5585).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-5586).
1. Such ids MAY contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:1098-16823).

ii. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-17000).
iii. This assignedEntity 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:1098-5589).
iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10985595).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10987999).
v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-5597).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985598).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 45
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 10: legalAuthenticator Example

1004 Healthcare Drive
Portland
OR
99123
US

Patricia
Patty
Primary
M.D.

1.1.1.11 authenticator
The authenticator identifies a participant or participants who attest to the accuracy of the
information in the document.
20. MAY contain zero or more [0..*] authenticator (CONF:1098-5607) such that it
a. SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED)
(identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5608).
b. SHALL contain exactly one [1..1] signatureCode (CONF:1098-5610).
i.

This signatureCode SHALL contain exactly one [1..1] @code="S"
(CodeSystem: Participationsignature
urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:1098-5611).

The sdtc:signatureText extension provides a location in CDA for a textual or multimedia
depiction of the signature by which the participant endorses and accepts responsibility for his
or her participation in the Act as specified in the Participation.typeCode. Details of what goes in
the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
c. MAY contain zero or one [0..1] sdtc:signatureText (CONF:1098-30811).
Note: The signature can be represented either inline or by reference according to the
ED data type. Typical cases for CDA are:
1) Electronic signature: this attribute can represent virtually any electronic
signature scheme.
2) Digital signature: this attribute can represent digital signatures by reference to a

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 46
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

signature data block that is constructed in accordance to a digital signature
standard, such as XML-DSIG, PKCS#7, PGP, etc.
d. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-5612).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-5613).
1. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:1098-16824).

ii. This assignedEntity MAY contain zero or one [0..1] code (CONF:1098-16825).
1. The code, if present, MAY contain zero or one [0..1] @code, which
SHOULD be selected from ValueSet Healthcare Provider Taxonomy
(HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 STATIC
(CONF:1098-16826).
iii. This assignedEntity 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:1098-5616).
iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10985622).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10988000).
v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-5624).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985625).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 47
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 11: authenticator Example

1004 Healthcare Drive
Portland
OR
99123
US

Patricia
Patty
Primary
M.D.

1.1.1.12 participant
The participant element identifies supporting entities, including parents, relatives, caregivers,
insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to
the patient. A supporting person who is playing multiple roles would be recorded in multiple
participants (e.g., emergency contact and next-of-kin).
21. MAY contain zero or more [0..*] participant (CONF:1098-10003) such that it
a. MAY contain zero or one [0..1] time (CONF:1098-10004).
b. SHALL contain associatedEntity/associatedPerson AND/OR
associatedEntity/scopingOrganization (CONF:1098-10006).
c. When participant/@typeCode is IND, associatedEntity/@classCode SHOULD be
selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC
2011-09-30 (CONF:1098-10007).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 48
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 12: Supporting Person participant Example

2222 Home Street
Beaverton
OR
97867
US

Boris
Bo
Betterhalf

2222 Home Street
Beaverton
OR
97867
US

Boris
Bo
Betterhalf

1.1.1.13 inFulfillmentOf
The inFulfillmentOf element represents orders that are fulfilled by this document such as a
radiologists’ report of an x-ray.
22. MAY contain zero or more [0..*] inFulfillmentOf (CONF:1098-9952).
a. The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:10989953).
i.

This order SHALL contain at least one [1..*] id (CONF:1098-9954).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 49
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 13: inFulfillmentOf Example

1.1.1.14 documentationOf
23. MAY contain zero or more [0..*] documentationOf (CONF:1098-14835).
A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac
stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other
longitudinal providers, are recorded within the serviceEvent. If the document is about a single
encounter, the providers associated can be recorded in the
componentOf/encompassingEncounter template.
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:1098-14836).
i.

This serviceEvent SHALL contain exactly one [1..1] effectiveTime
(CONF:1098-14837).
1. This effectiveTime SHALL contain exactly one [1..1] low (CONF:109814838).

1.1.1.15 performer
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.
ii. This serviceEvent SHOULD contain zero or more [0..*] performer
(CONF:1098-14839).
1. The performer, if present, SHALL contain exactly one [1..1]
@typeCode, which SHALL be selected from ValueSet
x_ServiceEventPerformer
urn:oid:2.16.840.1.113883.1.11.19601 STATIC 2014-09-01
(CONF:1098-14840).
2. The performer, if present, MAY contain zero or one [0..1]
functionCode (CONF:1098-16818).
a. The functionCode, if present, SHOULD contain zero or one [0..1]
@code, which SHOULD be selected from ValueSet
ParticipationFunction
urn:oid:2.16.840.1.113883.1.11.10267 STATIC 2014-0901 (CONF:1098-32889).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 50
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3. The performer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:1098-14841).
a. This assignedEntity SHALL contain at least one [1..*] id
(CONF:1098-14846).
i.

Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:1098-14847).

b. This assignedEntity SHOULD contain zero or one [0..1] code,
which SHOULD be selected from ValueSet Healthcare
Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC
(CONF:1098-14842).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 51
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 14: performer Example

Primary Care Provider

1004 Healthcare Drive
Portland
OR
99123
US

Patricia
Patty
Primary
M.D.

The DoctorsTogether Physician Group

1004 Health Drive
Portland
OR
99123
US

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 52
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 15: documentationOf Example

Primary Care Provider

1004 Healthcare Drive
Portland
OR
99123
US

Patricia
Patty
Primary
M.D.

The DoctorsTogether Physician Group

1004 Health Drive
Portland
OR
99123
US

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 53
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1.1.1.16 authorization
The authorization element represents information about the patient’s consent.
The type of consent is conveyed in consent/code. Consents in the header have been finalized
(consent/statusCode must equal Completed) and should be on file. This specification does not
address how 'Privacy Consent' is represented, but does not preclude the inclusion of ‘Privacy
Consent’.
The authorization consent is used for referring to consents that are documented elsewhere in
the EHR or medical record for a health condition and/or treatment that is described in the
CDA document.
24. MAY contain zero or more [0..*] authorization (CONF:1098-16792) such that it
a. SHALL contain exactly one [1..1] consent (CONF:1098-16793).
i.

This consent MAY contain zero or more [0..*] id (CONF:1098-16794).

ii. This consent MAY contain zero or one [0..1] code (CONF:1098-16795).
Note: The type of consent (e.g., a consent to perform the related serviceEvent)
is conveyed in consent/code.
iii. This consent SHALL contain exactly one [1..1] statusCode (CONF:109816797).
1. This statusCode SHALL contain exactly one [1..1]
@code="completed" Completed (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1098-16798).
Figure 16: authorization Example

1.1.1.17 componentOf
The encompassing encounter represents the setting of the clinical encounter during which the
document act(s) or ServiceEvent(s) occurred.
In order to represent providers associated with a specific encounter, they are recorded within
the encompassingEncounter as participants.
In a CCD, the encompassingEncounter may be used when documenting a specific encounter
and its participants. All relevant encounters in a CCD may be listed in the encounters section.
25. MAY contain zero or one [0..1] componentOf (CONF:1098-9955).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 54
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. The componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:1098-9956).
i.

This encompassingEncounter SHALL contain at least one [1..*] id
(CONF:1098-9959).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:1098-9958).
Table 3: HL7 BasicConfidentialityKind
Value Set: HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926
A value set of HL7 Code indication the level of confidentiality an act.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

N

ConfidentialityCode

urn:oid:2.16.840.1.11388
3.5.25

normal

R

ConfidentialityCode

urn:oid:2.16.840.1.11388
3.5.25

restricted

V

ConfidentialityCode

urn:oid:2.16.840.1.11388
3.5.25

very restricted

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 55
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 4: Language
Value Set: Language urn:oid:2.16.840.1.113883.1.11.11526
A 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.loc.gov/standards/iso639-2/php/code_list.php
Code

Code System

Code System OID

Print Name

aa

Language

urn:oid:2.16.840.1.11388
3.6.121

Afar

ab

Language

urn:oid:2.16.840.1.11388
3.6.121

Abkhazian

ace

Language

urn:oid:2.16.840.1.11388
3.6.121

Achinese

ach

Language

urn:oid:2.16.840.1.11388
3.6.121

Acoli

ada

Language

urn:oid:2.16.840.1.11388
3.6.121

Adangme

ady

Language

urn:oid:2.16.840.1.11388
3.6.121

Adyghe; Adygei

ae

Language

urn:oid:2.16.840.1.11388
3.6.121

Avestan

af

Language

urn:oid:2.16.840.1.11388
3.6.121

Afrikaans

afa

Language

urn:oid:2.16.840.1.11388
3.6.121

Afro-Asiatic (Other)

afh

Language

urn:oid:2.16.840.1.11388
3.6.121

Afrihili

...

Table 5: Telecom Use (US Realm Header)
Value Set: Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

HP

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Primary home

HV

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Vacation home

WP

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Work place

MC

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Mobile contact

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 56
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 6: Administrative Gender (HL7 V3)
Value Set: Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1
Administrative Gender based upon HL7 V3 vocabulary. This value set contains only male, female and
undifferentiated concepts.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

F

AdministrativeGender

urn:oid:2.16.840.1.11388
3.5.1

Female

M

AdministrativeGender

urn:oid:2.16.840.1.11388
3.5.1

Male

UN

AdministrativeGender

urn:oid:2.16.840.1.11388
3.5.1

Undifferentiated

Table 7: Marital Status
Value Set: Marital Status urn:oid:2.16.840.1.113883.1.11.12212
Marital Status is the domestic partnership status of a person.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

A

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Annulled

D

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Divorced

T

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Domestic partner

I

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Interlocutory

L

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Legally Separated

M

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Married

S

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Never Married

P

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Polygamous

W

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Widowed

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 57
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 8: Religious Affiliation
Value Set: Religious Affiliation urn:oid:2.16.840.1.113883.1.11.19185
A value set of codes that reflect spiritual faith affiliation.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1001

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Adventist

1002

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

African Religions

1003

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Afro-Caribbean Religions

1004

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Agnosticism

1005

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Anglican

1006

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Animism

1007

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Atheism

1008

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Babi & Baha'I faiths

1009

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Baptist

1010

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Bon

...

Table 9: Race Category Excluding Nulls
Value Set: Race Category Excluding Nulls urn:oid:2.16.840.1.113883.3.2074.1.1.3
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1002-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

American Indian or
Alaska Native

2028-9

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Asian

2054-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Black or African
American

2076-8

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Native Hawaiian or Other
Pacific Islander

2106-3

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

White

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 58
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 10: Ethnicity
Value Set: Ethnicity urn:oid:2.16.840.1.114222.4.11.837
Code System: Race & Ethnicity - CDC 2.16.840.1.113883.6.238
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

2135-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Hispanic or Latino

2186-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Not Hispanic or Latino

Table 11: Personal And Legal Relationship Role Type
Value Set: Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1
A personal or legal relationship records the role of a person in relation to another person, or a person to himself
or herself. This value set is to be used when recording relationships based on personal or family ties or through
legal assignment of responsibility.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.11.20.12.1
Code

Code System

Code System OID

Print Name

SELF

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

self

MTH

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

mother

FTH

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

father

DAU

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

natural daughter

SON

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

natural son

DAUINLAW

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

daughter in-law

SONINLAW

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

son in-law

GUARD

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

guardian

HPOWATT

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

healthcare power of
attorney

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 59
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 12: Country
Value Set: Country urn:oid:2.16.840.1.113883.3.88.12.80.63
This 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.htm
Code

Code System

Code System OID

Print Name

AW

Country

urn:oid:2.16.840.1.11388
3.3.88.12.80.63

Aruba

IL

Country

urn:oid:2.16.840.1.11388
3.3.88.12.80.63

Israel

...

Table 13: PostalCode
Value Set: PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2
A value set of postal (ZIP) Code of an address in the United States
Value Set Source: http://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=86671000
Code

Code System

Code System OID

Print Name

19009

USPostalCodes

urn:oid:2.16.840.1.11388
3.6.231

Bryn Athyn

92869-1736

USPostalCodes

urn:oid:2.16.840.1.11388
3.6.231

Orange, CA

32830-8413

USPostalCodes

urn:oid:2.16.840.1.11388
3.6.231

Lake Buena Vista, FL

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 60
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 14: PatientLanguage
Value Set: PatientLanguage urn:oid:2.16.840.1.113883.11.20.9.64
This value set contains codes for the representation of language names as defined by the Library of Congress,
the ISO 639-2 registration authority. This value set contains a subset of the ISO 639-2 alpha-3 code set, limited
to those that have a corresponding ISO 639-1 alpha-2 code as required for representing a patient's language
under Meaningful Use Stage 2.
Value Set Source: http://www.loc.gov/standards/iso639-2/php/code_list.php
Code

Code System

Code System OID

Print Name

aar

Language

urn:oid:2.16.840.1.11388
3.6.121

Afar

abk

Language

urn:oid:2.16.840.1.11388
3.6.121

Abkhazian

afr

Language

urn:oid:2.16.840.1.11388
3.6.121

Afrikaans

aka

Language

urn:oid:2.16.840.1.11388
3.6.121

Akan

sqi

Language

urn:oid:2.16.840.1.11388
3.6.121

Albanian

amh

Language

urn:oid:2.16.840.1.11388
3.6.121

Amharic

ara

Language

urn:oid:2.16.840.1.11388
3.6.121

Arabic

arg

Language

urn:oid:2.16.840.1.11388
3.6.121

Aragonese

hye

Language

urn:oid:2.16.840.1.11388
3.6.121

Armenian

asm

Language

urn:oid:2.16.840.1.11388
3.6.121

Assamese

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 61
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 15: LanguageAbilityMode
Value Set: LanguageAbilityMode urn:oid:2.16.840.1.113883.1.11.12249
This identifies the language ability of the individual. A value representing the method of expression of the
language.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

ESGN

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Expressed signed

ESP

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Expressed spoken

EWR

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Expressed written

RSGN

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Received signed

RSP

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Received spoken

RWR

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Received written

Table 16: LanguageAbilityProficiency
Value Set: LanguageAbilityProficiency urn:oid:2.16.840.1.113883.1.11.12199
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

E

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Excellent

F

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Fair

G

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Good

P

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Poor

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 62
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 17: Race
Value Set: Race urn:oid:2.16.840.1.113883.1.11.14914
Concepts 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: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1002-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

American Indian or
Alaska Native

2028-9

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Asian

2054-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Black or African
American

2076-8

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Native Hawaiian or Other
Pacific Islander

2106-3

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

White

1006-6

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Abenaki

1579-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Absentee Shawnee

1490-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Acoma

2126-1

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Afghanistani

1740-0

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Ahtna

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 63
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 18: Healthcare Provider Taxonomy (HIPAA)
Value Set: Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066
The 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:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.1066
Code

Code System

Code System OID

Print Name

171100000X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Acupuncturist

363LA2100X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Nurse Practitioner - Acute
Care

364SA2100X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Clinical Nurse Specialist Acute Care

101YA0400X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Counselor - Addiction
(Substance Use Disorder)

103TA0400X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Psychologist - Addiction
(Substance Use Disorder)

163WA0400X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Registered Nurse Addiction (Substance Use
Disorder)

207LA0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Anesthesiology Addiction Medicine

207QA0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Family Medicine Addiction Medicine

207RA0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Internal Medicine Addiction Medicine

2084A0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Psychiatry & Neurology Addiction Medicine

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 64
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 19: INDRoleclassCodes
Value Set: INDRoleclassCodes urn:oid:2.16.840.1.113883.11.20.9.33
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

PRS

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

personal relationship

NOK

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

next of kin

CAREGIVER

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

caregiver

AGNT

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

agent

GUAR

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

guarantor

ECON

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

emergency contact

Table 20: x_ServiceEventPerformer
Value Set: x_ServiceEventPerformer urn:oid:2.16.840.1.113883.1.11.19601
Value Set Source:

http://www.hl7.org/documentcenter/public/standards/vocabulary/vocabulary_tables/in
frastructure/vocabulary/vocabulary.html
Code

Code System

Code System OID

Print Name

PRF

HL7ParticipationType

urn:oid:2.16.840.1.11388
3.5.90

performer

SPRF

HL7ParticipationType

urn:oid:2.16.840.1.11388
3.5.90

secondary performer

PPRF

HL7ParticipationType

urn:oid:2.16.840.1.11388
3.5.90

primary performer

Table 21: ParticipationFunction
Value Set: ParticipationFunction urn:oid:2.16.840.1.113883.1.11.10267
This HL7-defined value set can be used to specify the exact function an actor had in a service in all necessary
detail.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

SNRS

participationFunction

urn:oid:2.16.840.1.11388
3.5.88

Scrub nurse

participationFunction

urn:oid:2.16.840.1.11388
3.5.88

Second assistant surgeon

SASST
...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 65
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 22: Detailed Ethnicity
Value Set: Detailed Ethnicity urn:oid:2.16.840.1.114222.4.11.877
List of detailed ethnicity codes reported on a limited basis
Value Set Source: http://phinvads.cdc.gov/vads/ViewValueSet.action?id=34D34BBC-617F-

DD11-B38D-00188B398520#
Code

Code System

Code System OID

Print Name

2138-6

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Andalusian

2166-7

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Argentinean

2139-4

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Asturian

2142-8

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Belearic Islander

2167-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Bolivian

2163-4

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Canal Zone

2145-1

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Canarian

2140-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Castillian

2141-0

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Catalonian

2155-0

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Central American

...

1.1.2 National Health Care Surveys (V2)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:201504-01 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
This document-level template describes constraints that apply to three National Health Care
Surveys conducted by the Center for Disease Control and Prevention (CDC) National Center for
Health Statistics (NCHS): the National Ambulatory Medical Care Survey (NAMCS), the National
Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Hospital Care Survey
(NHCS) These surveys collect data from physicians, ambulatory care centers, and hospitals
about visits to inpatient (IP), outpatient (OP), and emergency department (ED) settings. The
data collected is analyzed to produce nationally representative statistics to answer key
questions about health care utilization, quality, and disparities that are of interest to public
health professionals, researchers, and health care policy makers. Data captured include
information on patient demographics, symptoms, diagnoses, medications, therapeutic and
diagnostic procedures, patient management, and planned future treatments. Given the

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 66
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

similarities of data collected across the surveys, the structured documents specified in this
guide are organized by setting of visit rather than by survey. This template is applicable for all
three surveys (NAMCS, NHAMCS, and NHCS) and all care settings (ED, IP, and OP).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 67
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 23: National Health Care Surveys (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01)
templateId

1..1

SHALL

1184-1

@root

1..1

SHALL

1184-2

2.16.840.1.113883.10.20.34.1.1

@extension

1..1

SHALL

1184877

2015-04-01

1..1

SHALL

1184-3

@code

1..1

SHALL

1184-4

75619-7

@codeSystem

1..1

SHALL

1184-5

2.16.840.1.113883.6.1

recordTarget

1..*

SHALL

1184-6

patientRole

1..1

SHALL

1184-7

id

0..1

SHOUL
D

11841164

id

0..1

SHOUL
D

11841162

@root

1..1

SHALL

11841165

@extension

1..1

SHOUL
D

11841166

0..1

SHOUL
D

11841163

@root

1..1

SHALL

11841167

@extension

1..1

SHOUL
D

11841168

1..1

SHALL

118411

1..1

SHALL

118412

@nullFlavor

0..1

MAY

1184643

@code

0..1

SHOUL
D

1184644

birthTime

1..1

SHALL

118413

0..*

MAY

118420

serviceEvent

1..1

SHALL

118421

performer

0..*

SHOUL
D

118422

1..1

SHALL

118453

code

id

patient
administrativeGenderCode

documentationOf

assignedEntity

2.16.840.1.113883.4.572

2.16.840.1.113883.4.1

OTH

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 68
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

code

1..1

SHALL

118456

0..1

MAY

118417

1..1

SHALL

118418

id

0..1

SHOUL
D

1184361

effectiveTime

1..1

SHALL

118423

low

1..1

SHALL

1184198

high

1..1

SHALL

11841169

1..1

SHALL

118424

1..1

SHALL

118425

componentOf
encompassingEncounter

component
structuredBody

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

1.1.3 Properties
1. Conforms to US Realm Header (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:2014-06-09).

1.1.3.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:1184-1) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.1"
(CONF:1184-2).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-877).
Figure 17: National Health Care Surveys (V2) Example

...

3. SHALL contain exactly one [1..1] code (CONF:1184-3).
a. This code SHALL contain exactly one [1..1] @code="75619-7" National healthcare
survey panel NAMCS (CONF:1184-4).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 69
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1184-5).

1.1.3.2 recordTarget
4. SHALL contain at least one [1..*] recordTarget (CONF:1184-6).
a. Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:1184-7).
i.

This patientRole SHOULD contain zero or one [0..1] id (CONF:1184-1164).
Note: Patient's Medical Record Number

ii. This patientRole SHOULD contain zero or one [0..1] id (CONF:1184-1162)
such that it
1. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.4.572" Medicare HIC number
(CONF:1184-1165).
2. SHOULD contain exactly one [1..1] @extension (CONF:1184-1166).
Note: Patient's Medicare Number
iii. This patientRole SHOULD contain zero or one [0..1] id (CONF:1184-1163)
such that it
1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.1"
SSN (CONF:1184-1167).
2. SHOULD contain exactly one [1..1] @extension (CONF:1184-1168).
Note: Patient's SSN
iv. This patientRole SHALL contain exactly one [1..1] patient (CONF:1184-11).
Use only M (male) or F (female) for administrativeGenderCode. UN (Undifferentiated) is not
allowed, in this case use @nullFlavor="OTH".
1. This patient SHALL contain exactly one [1..1]
administrativeGenderCode (CONF:1184-12).
Note: Form Element: Sex
a. This administrativeGenderCode MAY contain zero or one [0..1]
@nullFlavor="OTH" (CONF:1184-643).
b. This administrativeGenderCode SHOULD contain zero or one
[0..1] @code (CONF:1184-644).
i.

Where code is used it SHALL be either M (male) or F
(female) (CONF:1184-645).

See US Realm Header recordTarget/patientRole/patient/birthTime for further birthTime
constraints
2. This patient SHALL contain exactly one [1..1] birthTime
(CONF:1184-13).
Note: Form Element: Date of Birth
a. SHOULD be precise to month if day is not available
(CONF:1184-773).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 70
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 18: recordTarget Example

124 Any Street
Anyville
CA

97812
US

Samantha
Smith

5. MAY contain zero or more [0..*] documentationOf (CONF:1184-20).

1.1.3.3 serviceEvent
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:1184-21).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 71
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1.1.3.4 performer
i.

This serviceEvent SHOULD contain zero or more [0..*] performer
(CONF:1184-22) such that it
Note: Type of Care Providers Seen
1. SHALL contain exactly one [1..1] assignedEntity (CONF:1184-53).
a. This assignedEntity SHALL contain exactly one [1..1] code,
which SHOULD be selected from ValueSet Healthcare
Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC
(CONF:1184-56).
Figure 19: performer Example

6. MAY contain zero or one [0..1] componentOf (CONF:1184-17).

1.1.3.5 encompassingEncounter
a. The componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:1184-18).
i.

This encompassingEncounter SHOULD contain zero or one [0..1] id
(CONF:1184-361).
Note: Encounter Number

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:1184-23).
1. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1184198).
Note: Date/Time of admission/visit/arrival

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 72
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2. This effectiveTime SHALL contain exactly one [1..1] high (CONF:11841169).
Note: Date/Time of departure/discharge
Figure 20: encompassingEncounter Example

...

...

7. SHALL contain exactly one [1..1] component (CONF:1184-24).

1.1.3.6 structuredBody
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:1184-25).

1.1.4 Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.4:201607-01 (open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 24: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Contexts
Contained By:

Contains:
Emergency Department Encounters Section (V2)
Immunizations Section
Medications Section
Patient Information Section (V3)
Payment Sources Section
Problems Section (V3)
Reasons for Visit Section (V2)
Results Section (entries optional) (V2)
Services and Procedures Section
Triage Section
Vital Signs Section (entries required) (V2)

This template describes constraints that are specific to the emergency department encounter
surveys (NHCS-ED, NHAMCS-ED).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 73
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 25: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.4:2016-07-01)
templateId

1..1

SHALL

3256570

@root

1..1

SHALL

3256583

2.16.840.1.113883.10.20.34.1.4

@extension

1..1

SHALL

3256866

2016-07-01

0..*

MAY

3256667

serviceEvent

1..1

SHALL

3256668

performer

0..*

SHOUL
D

3256669

1..1

SHALL

3256670

1..1

SHALL

32561170

1..1

SHALL

3256857

1..1

SHALL

3256858

urn:oid:2.16.840.1.114222.4.11.7
419 (Provider ED (NCHS))

0..1

MAY

3256865

OTH

1..1

SHALL

3256671

1..1

SHALL

3256672

1..1

SHALL

32561057

@code

1..1

SHALL

32561058

EMER

@codeSystem

1..1

SHALL

32561059

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

3256863

urn:oid:2.16.840.1.114222.4.11.7
437 (Disposition ED (NCHS))

0..1

MAY

3256864

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = OTH

1..1

SHALL

3256571

structuredBody

1..1

SHALL

3256572

component

1..1

SHALL

3256573

documentationOf

time
low
assignedEntity
code
@nullFlavor
componentOf
encompassingEncounter
code

dischargeDispositionCode
@nullFlavor
component

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 74
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

section

1..1

SHALL

3256582

component

1..1

SHALL

3256574

section

1..1

SHALL

3256584

component

1..1

SHALL

3256575

section

1..1

SHALL

3256585

component

1..1

SHALL

3256576

section

1..1

SHALL

3256586

component

1..1

SHALL

3256577

section

1..1

SHALL

3256587

component

1..1

SHALL

3256578

section

1..1

SHALL

3256588

component

1..1

SHALL

3256579

section

1..1

SHALL

3256589

component

1..1

SHALL

3256581

section

1..1

SHALL

3256591

component

1..1

SHALL

3256759

section

1..1

SHALL

3256760

component

1..1

SHALL

3256-

Payment Sources Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.4

Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.4.1:2014-06-09

Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.14:2016-07-01

Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.2:2016-07-01

Services and Procedures Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.3

Medications Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.1

Immunizations Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.7

Triage Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.10

Emergency Department
Encounters Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.13:2016-07-01

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 75
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

809
section

1..1

SHALL

3256810

component

1..1

SHALL

32561104

section

1..1

SHALL

32561105

Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.5:2016-07-01

Results Section (entries optional)
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.3:2014-06-09

1.1.5 Properties
1. Conforms to National Health Care Surveys (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01).

1.1.5.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:3256-570) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.4"
(CONF:3256-583).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-866).
Figure 21: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Example

...

1.1.5.2 documentationOf
3. MAY contain zero or more [0..*] documentationOf (CONF:3256-667).
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:3256-668).

1.1.5.3 performer
See National Health Care Surveys template for other performer elements.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 76
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

i.

This serviceEvent SHOULD contain zero or more [0..*] performer
(CONF:3256-669) such that it
Note: Type of care provider seen
1. SHALL contain exactly one [1..1] time (CONF:3256-670).
a. This time SHALL contain exactly one [1..1] low (CONF:32561170).
Note: Date/Time of provider contact
2. SHALL contain exactly one [1..1] assignedEntity (CONF:3256-857).
a. This assignedEntity SHALL contain exactly one [1..1] code,
which SHOULD be selected from ValueSet Provider ED
(NCHS) urn:oid:2.16.840.1.114222.4.11.7419 DYNAMIC
(CONF:3256-858).
i.

This code MAY contain zero or one [0..1]
@nullFlavor="OTH" (CONF:3256-865).

Figure 22: performer Example

1.1.5.4 componentOf
4. SHALL contain exactly one [1..1] componentOf (CONF:3256-671).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 77
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

See National Health Care Surveys template for other encompassingEncounter elements.
a. This componentOf SHALL contain exactly one [1..1] encompassingEncounter
(CONF:3256-672).
i.

This encompassingEncounter SHALL contain exactly one [1..1] code
(CONF:3256-1057).
1. This code SHALL contain exactly one [1..1] @code="EMER" Emergency
(CONF:3256-1058).
2. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1059).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
dischargeDispositionCode, which SHOULD be selected from ValueSet
Disposition ED (NCHS) urn:oid:2.16.840.1.114222.4.11.7437
DYNAMIC (CONF:3256-863).
1. This dischargeDispositionCode MAY contain zero or one [0..1]
@nullFlavor="OTH" Other (CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:3256-864).
Figure 23: componentOf/encompassingEncounter Example

1.1.5.5 component
5. SHALL contain exactly one [1..1] component (CONF:3256-571).
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:3256572).
i.

This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-573) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 78
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] Payment Sources Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4)
(CONF:3256-582).
ii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-574) such that it
1. SHALL contain exactly one [1..1] Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09)
(CONF:3256-584).
iii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-575) such that it
1. SHALL contain exactly one [1..1] Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01)
(CONF:3256-585).
iv. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-576) such that it
1. SHALL contain exactly one [1..1] Problems Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
(CONF:3256-586).
v. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-577) such that it
1. SHALL contain exactly one [1..1] Services and Procedures
Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.3) (CONF:3256-587).
vi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-578) such that it
1. SHALL contain exactly one [1..1] Medications Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1)
(CONF:3256-588).
vii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-579) such that it
1. SHALL contain exactly one [1..1] Immunizations Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7)
(CONF:3256-589).
viii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-581) such that it
1. SHALL contain exactly one [1..1] Triage Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.10) (CONF:3256-591).
ix. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-759) such that it
1. SHALL contain exactly one [1..1] Emergency Department
Encounters Section (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.13:2016-07-01)
(CONF:3256-760).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 79
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

x. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-809) such that it
1. SHALL contain exactly one [1..1] Patient Information Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01)
(CONF:3256-810).
xi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-1104) such that it
1. SHALL contain exactly one [1..1] Results Section (entries
optional) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09)
(CONF:3256-1105).
Table 26: Provider ED (NCHS)
Value Set: Provider ED (NCHS) urn:oid:2.16.840.1.114222.4.11.7419
Provider types
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7419
Code

Code System

Code System OID

Print Name

405279007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Attending physician

405277009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Resident physician

309343006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Physician

442251000124100

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Licensed Practical Nurse

224535009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Registered nurse

224571005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Nurse practitioner

449161006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Physician assistant

397897005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Paramedic

310191001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Clinical psychologist

310190000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Mental health counselor

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 80
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 27: Disposition ED (NCHS)
Value Set: Disposition ED (NCHS) urn:oid:2.16.840.1.114222.4.11.7437
The final arrangement or transfer of care made when a patient completes and emergency department
encounter.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7437
Code

Code System

Code System OID

Print Name

442291000124106

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Discharge from
observation unit

63238001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Dead on arrival

445060000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Left against medical
advice

3780001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

No follow-up planned

442271000124105

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient transfer to
psychiatric hospital

25675004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient transfer to skilled
nursing facility (SNF)

223446004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return to ED

306227000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return/refer to
physician/clinic for
outpatient mental health
treatment

396150002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return/refer to
physician/clinic for
substance abuse
treatment

183664005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return/refer to
physician/clinic for
follow-up

...

1.1.6 Inpatient Encounter (NHCS-IP) (V3)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.2:201607-01 (open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 28: Inpatient Encounter (NHCS-IP) (V3) Contexts
Contained By:

Contains:
Immunizations Section
Inpatient Encounters Section (V2)
Medications Section

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 81
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Contained By:

Contains:
Patient Information Section (V3)
Payment Sources Section
Problems Section (V3)
Results Section (entries optional) (V2)
Services and Procedures Section
Vital Signs Section (entries required) (V2)

This template describes constraints that are specific to the Inpatient Encounter Surveys.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 82
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 29: Inpatient Encounter (NHCS-IP) (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.2:2016-07-01)
templateId

1..1

SHALL

3256304

@root

1..1

SHALL

3256305

2.16.840.1.113883.10.20.34.1.2

@extension

1..1

SHALL

3256767

2016-07-01

0..*

MAY

3256422

1..1

SHALL

3256423

1..1

SHALL

3256250

1..1

SHALL

3256251

1..1

SHALL

32561040

@code

1..1

SHALL

32561041

IMP

@codeSystem

1..1

SHALL

32561042

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

32561173

urn:oid:2.16.840.1.114222.4.11.7
360 (Discharge Disposition IP
(NCHS))

0..1

MAY

32561174

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = OTH

1..1

SHALL

3256244

structuredBody

1..1

SHALL

3256245

component

1..1

SHALL

3256246

section

1..1

SHALL

3256247

component

1..1

SHALL

3256248

section

1..1

SHALL

3256249

component

1..1

SHALL

3256254

documentationOf
serviceEvent
componentOf
encompassingEncounter
code

dischargeDispositionCode

@nullFlavor
component

Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.5:2016-07-01

Payment Sources Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.4

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 83
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

section

1..1

SHALL

3256255

component

1..1

SHALL

3256258

section

1..1

SHALL

3256259

component

1..1

SHALL

3256260

section

1..1

SHALL

3256261

component

1..1

SHALL

3256262

section

1..1

SHALL

3256263

component

1..1

SHALL

3256264

section

1..1

SHALL

3256265

component

1..1

SHALL

3256505

section

1..1

SHALL

3256506

component

1..1

SHALL

section

1..1

SHALL

Compo
nent3

Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.4.1:2014-06-09

Inpatient Encounters Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.12:2016-07-01

Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.2:2016-07-01

Services and Procedures Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.3

Medications Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.1

Immunizations Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.7

3256765
3256766

Results Section (entries optional)
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.3:2014-06-09

1.1.7 Properties
1. Conforms to National Health Care Surveys (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01).

1.1.7.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:3256-304) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.2"
(CONF:3256-305).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-767).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 84
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 24: In-Patient Encounter (NHCS-IP) (V3) Example

...

1.1.7.2 documentationOf
3. MAY contain zero or more [0..*] documentationOf (CONF:3256-422).
See National Health Care Surveys template for other serviceEvent elements.
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:3256-423).

1.1.7.3 componentOf
4. SHALL contain exactly one [1..1] componentOf (CONF:3256-250).
See National Health Care Surveys template for other encompassingEncounter elements.
a. This componentOf SHALL contain exactly one [1..1] encompassingEncounter
(CONF:3256-251).
i.

This encompassingEncounter SHALL contain exactly one [1..1] code
(CONF:3256-1040).
1. This code SHALL contain exactly one [1..1] @code="IMP" Inpatient
(CONF:3256-1041).
2. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1042).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
dischargeDispositionCode, which SHOULD be selected from ValueSet
Discharge Disposition IP (NCHS)
urn:oid:2.16.840.1.114222.4.11.7360 DYNAMIC (CONF:3256-1173).
1. This dischargeDispositionCode MAY contain zero or one [0..1]
@nullFlavor="OTH" Other (CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:3256-1174).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 85
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 25: componentOf/encompassingEncounter Example

5. SHALL contain exactly one [1..1] component (CONF:3256-244).

1.1.7.4 structuredBody
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:3256245).
i.

This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-246) such that it
1. SHALL contain exactly one [1..1] Patient Information Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01)
(CONF:3256-247).

ii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-248) such that it
1. SHALL contain exactly one [1..1] Payment Sources Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4)
(CONF:3256-249).
iii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-254) such that it
1. SHALL contain exactly one [1..1] Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09)
(CONF:3256-255).
iv. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-258) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 86
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] Inpatient Encounters Section
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.12:2016-07-01)
(CONF:3256-259).
v. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-260) such that it
1. SHALL contain exactly one [1..1] Problems Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
(CONF:3256-261).
vi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-262) such that it
1. SHALL contain exactly one [1..1] Services and Procedures
Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.3) (CONF:3256-263).
vii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-264) such that it
1. SHALL contain exactly one [1..1] Medications Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1)
(CONF:3256-265).
viii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-505) such that it
1. SHALL contain exactly one [1..1] Immunizations Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7)
(CONF:3256-506).
ix. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-765) such that it
1. SHALL contain exactly one [1..1] Results Section (entries
optional) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09)
(CONF:3256-766).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 87
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 30: Discharge Disposition IP (NCHS)
Value Set: Discharge Disposition IP (NCHS) urn:oid:2.16.840.1.114222.4.11.7360
The final arrangement or transfer of care made when a patient is released from an inpatient admission.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7360
Code

Code System

Code System OID

Print Name

01

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged to home or
self care

02

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
a short-term General
Hospital for Inpatient
Care

03

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged /transferred
to Skilled Nursing Facility
with Medicare
Certification
in anticipation of skilled
care

04

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
a Facility that provides
custodial or supportive
care

05

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged to a
Designated Cancer Center
or Children's Hospital

06

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
home under care of an
organized Home Health
Service Organization in
anticipation of covered
skilled care

07

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Left against Medical
advice or discontinued
care

20

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Expired

21

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
Court/Law Enforcement

43

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/Transferred
to a Federal Healthcare
Facility

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 88
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1.1.8 Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.3:201607-01 (open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 31: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Contexts
Contained By:

Contains:
Immunizations Section
Medications Section
Outpatient Encounters Section (V3)
Patient Information Section (V3)
Payment Sources Section
Problems Section (V3)
Reasons for Visit Section (V2)
Results Section (entries optional) (V2)
Services and Procedures Section
Vital Signs Section (entries required) (V2)

This template describes constraints that are specific to the outpatient encounter surveys
(NHCS-OPD, NAMCS, NHAMCS-OPD).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 89
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 32: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.3:2016-07-01)
templateId

1..1

SHALL

3256306

@root

1..1

SHALL

3256307

2.16.840.1.113883.10.20.34.1.3

@extension

1..1

SHALL

3256768

2016-07-01

0..*

MAY

3256455

serviceEvent

1..1

SHALL

3256456

performer

0..1

SHOUL
D

3256457

1..1

SHALL

3256458

@code

1..1

SHALL

3256459

PP

@codeSystem

1..1

SHALL

3256460

2.16.840.1.113883.3.88.12.3221.
4

0..1

MAY

3256917

1..1

SHALL

3256918

1..1

SHALL

32561060

@code

1..1

SHALL

32561061

AMB

@codeSystem

1..1

SHALL

32561062

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

32561171

urn:oid:2.16.840.1.114222.4.11.7
361 (Disposition OPD (NCHS))

0..1

MAY

32561172

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = OTH

0..1

MAY

3256919

1..1

SHALL

3256920

code

1..1

SHALL

3256921

component

1..1

SHALL

3256284

1..1

SHALL

3256-

documentationOf

functionCode

componentOf
encompassingEncounter
code

dischargeDispositionCode
@nullFlavor
location
healthCareFacility

structuredBody

urn:oid:2.16.840.1.114222.4.11.7
364 (Type of clinic/location
(NCHS))

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 90
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

285
component

1..1

SHALL

3256286

section

1..1

SHALL

3256287

component

1..1

SHALL

3256288

section

1..1

SHALL

3256289

component

1..1

SHALL

3256290

section

1..1

SHALL

3256291

component

1..1

SHALL

3256292

section

1..1

SHALL

3256293

component

1..1

SHALL

3256294

section

1..1

SHALL

3256295

component

1..1

SHALL

3256296

section

1..1

SHALL

3256297

component

1..1

SHALL

3256298

section

1..1

SHALL

3256299

component

1..1

SHALL

3256300

section

1..1

SHALL

3256301

component

1..1

SHALL

3256507

Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.5:2016-07-01

Payment Sources Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.4

Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.4.1:2014-06-09

Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.14:2016-07-01

Outpatient Encounters Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.8:2016-07-01

Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.2:2016-07-01

Services and Procedures Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.3

Medications Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.1

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 91
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

section

1..1

SHALL

3256508

component

1..1

SHALL

3256763

section

1..1

SHALL

3256764

Immunizations Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.7

Results Section (entries optional)
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.3:2014-06-09

1.1.9 Properties
1. Conforms to National Health Care Surveys (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01).

1.1.9.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:3256-306) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.3"
(CONF:3256-307).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-768).
Figure 26: Out-Patient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Example

/>
/>
(V3) -->
/>

1.1.9.2 documentationOf
3. MAY contain zero or more [0..*] documentationOf (CONF:3256-455).
See National Health Care Surveys template for other serviceEvent elements.
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:3256-456).

1.1.9.3 performer
i.

This serviceEvent SHOULD contain zero or one [0..1] performer (CONF:3256457) such that it
Note: Patient's Primary Care Provider

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 92
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] functionCode (CONF:3256-458).
Note: Form Element: Patient's Primary Care Provider
a. This functionCode SHALL contain exactly one [1..1]
@code="PP" Primary Care Provider (CONF:3256-459).
b. This functionCode SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.3.88.12.3221.4"
(CONF:3256-460).
Figure 27: performer Example

1.1.9.4 componentOf
4. MAY contain zero or one [0..1] componentOf (CONF:3256-917).
a. The componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:3256-918).
i.

This encompassingEncounter SHALL contain exactly one [1..1] code
(CONF:3256-1060).
1. This code SHALL contain exactly one [1..1] @code="AMB" Ambulatory
(outpatient) (CONF:3256-1061).
2. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1062).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
dischargeDispositionCode, which SHOULD be selected from ValueSet
Disposition OPD (NCHS) urn:oid:2.16.840.1.114222.4.11.7361
DYNAMIC (CONF:3256-1171).
1. This dischargeDispositionCode MAY contain zero or one [0..1]
@nullFlavor="OTH" Other (CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:3256-1172).
iii. This encompassingEncounter MAY contain zero or one [0..1] location
(CONF:3256-919).
Note: Type of clinic/location where visit occurred
1. The location, if present, SHALL contain exactly one [1..1]
healthCareFacility (CONF:3256-920).
a. This healthCareFacility SHALL contain exactly one [1..1] code,
which SHOULD be selected from ValueSet Type of

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 93
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

clinic/location (NCHS)
urn:oid:2.16.840.1.114222.4.11.7364 DYNAMIC
(CONF:3256-921).
Figure 28: componentOf/encompassingEncounter Example

1.1.9.5 component
5. SHALL contain exactly one [1..1] component (CONF:3256-284).
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:3256285).
i.

This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-286) such that it
1. SHALL contain exactly one [1..1] Patient Information Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01)
(CONF:3256-287).

ii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-288) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 94
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] Payment Sources Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4)
(CONF:3256-289).
iii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-290) such that it
1. SHALL contain exactly one [1..1] Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09)
(CONF:3256-291).
iv. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-292) such that it
1. SHALL contain exactly one [1..1] Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01)
(CONF:3256-293).
v. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-294) such that it
1. SHALL contain exactly one [1..1] Outpatient Encounters Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.8:2016-07-01)
(CONF:3256-295).
vi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-296) such that it
1. SHALL contain exactly one [1..1] Problems Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
(CONF:3256-297).
vii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-298) such that it
1. SHALL contain exactly one [1..1] Services and Procedures
Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.3) (CONF:3256-299).
viii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-300) such that it
1. SHALL contain exactly one [1..1] Medications Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1)
(CONF:3256-301).
ix. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-507) such that it
1. SHALL contain exactly one [1..1] Immunizations Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7)
(CONF:3256-508).
x. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-763) such that it
1. SHALL contain exactly one [1..1] Results Section (entries
optional) (V2) (identifier:

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 95
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09)
(CONF:3256-764).
Table 33: Disposition OPD (NCHS)
Value Set: Disposition OPD (NCHS) urn:oid:2.16.840.1.114222.4.11.7361
The final arrangement or transfer of care made when a patient completes an outpatient visit.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7361
Code

Code System

Code System OID

Print Name

PHC1395

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return to referring
physician/provider

449221000124102

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Refer to other
physician/provider

PHC1396

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return in less than 1
week

PHC1397

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return in 1 week to less
than 2 months

PHC1398

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return in 2 months or
greater

PHC1406

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return at unspecified
time

91310009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return as needed (p.r.n.)

183452005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Refer to E.R./Admit to
hospital

65537008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Routine discharge to
customary residence

PHC1399

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Discharge to observation
status

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 96
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 34: Type of clinic/location (NCHS)
Value Set: Type of clinic/location (NCHS) urn:oid:2.16.840.1.114222.4.11.7364
The kind of place or hospital department where a procedure, treatment, or service may be performed or
provided.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7364
Code

Code System

Code System OID

Print Name

1162-7

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

24-Hour Observation
Area

1210-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Adult Mixed Acuity Unit

1099-1

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Adult Step Down Unit
(post-critical care)

1110-6

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Allergy Clinic

1166-8

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Ambulatory Surgery
Center

1212-0

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Any Age Mixed Acuity
Unit

1106-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Assisted Living Area

1145-2

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Behavioral Health Clinic

1022-3

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Bone Marrow Transplant
SCA

1026-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Burn Critical Care

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 97
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2

SECTION-LEVEL TEMPLATES
This chapter contains the section-level templates referenced by one or more of the document
types of this guide. These templates describe the purpose of each section and the section-level
constraints.
Section-level templates are always included in a document. One and only one of each section
type is allowed in a given document instance. Please see the document context tables to
determine the sections that are contained in a given document type. Please see the
conformance verb in the conformance statements to determine if it is required (SHALL),
strongly recommended (SHOULD) or optional (MAY).
Each section-level template contains the following:
• Template metadata (e.g., templateId, etc.)
• Description and explanatory narrative
• LOINC section code
• Section title
• Requirements for a text element
• Entry-level template names and Ids for referenced templates (required and optional)
Narrative Text
The text element within the section stores the narrative to be rendered, as described in the
CDA R2 specification, and is referred to as the CDA narrative block.
The content model of the CDA narrative block schema is hand crafted to meet requirements of
human readability and rendering. The schema is registered as a MIME type (text/x-hl7text+xml), which is the fixed media type for the text element.
As noted in the CDA R2 specification, the document originator is responsible for ensuring that
the narrative block contains the complete, human readable, attested content of the section.
Structured entries support computer processing and computation and are not a replacement
for the attestable, human-readable content of the CDA narrative block. The special case of
structured entries with an entry relationship of "DRIV" (is derived from) indicates to the
receiving application that the source of the narrative block is the structured entries, and that
the contents of the two are clinically equivalent.
As for all CDA documents—even when a report consisting entirely of structured entries is
transformed into CDA—the encoding application must ensure that the authenticated content
(narrative plus multimedia) is a faithful and complete rendering of the clinical content of the
structured source data. As a general guideline, a generated narrative block should include the
same human readable content that would be available to users viewing that content in the
originating system. Although content formatting in the narrative block need not be identical to
that in the originating system, the narrative block should use elements from the CDA narrative
block schema to provide sufficient formatting to support human readability when rendered
according to the rules defined in Section Narrative Block (§ 4.3.5 ) of the CDA R2 specification.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 98
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

By definition, a receiving application cannot assume that all clinical content in a section (i.e.,
in the narrative block and multimedia) is contained in the structured entries unless the entries
in the section have an entry relationship of "DRIV".
Additional specification information for the CDA narrative block can be found in the CDA R2
specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and 6.

2.1

Chief Complaint and Reason for Visit Section
[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.13 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
This section records the patient's chief complaint (the patient’s own description) and/or the
reason for the patient's visit (the provider’s description of the reason for visit). Local policy
determines whether the information is divided into two sections or recorded in one section
serving both purposes.
Table 35: Chief Complaint and Reason for Visit Section Constraints Overview

XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.13)
templateId

1..1

SHALL

817840

1..1

SHALL

8110383

1..1

SHALL

8115449

@code

1..1

SHALL

8115450

46239-0

@codeSystem

1..1

SHALL

8126473

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

817842

text

1..1

SHALL

817843

@root
code

2.16.840.1.113883.10.20.22.2.13

1. SHALL contain exactly one [1..1] templateId (CONF:81-7840) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.13"
(CONF:81-10383).
2. SHALL contain exactly one [1..1] code (CONF:81-15449).
a. This code SHALL contain exactly one [1..1] @code="46239-0" Chief Complaint and
Reason for Visit (CONF:81-15450).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:81-26473).
3. SHALL contain exactly one [1..1] title (CONF:81-7842).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 99
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4. SHALL contain exactly one [1..1] text (CONF:81-7843).
Figure 29: Chief Complaint and Reason for Visit Example

CHIEF COMPLAINT
Back Pain

2.1.1 Reasons for Visit Section (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 36: Reasons for Visit Section (V2) Contexts
Contained By:

Contains:

Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Patient's Reason for Visit Observation

This section records the patient's chief complaint (the NHCS calls this the "patient's reason for
visit") in the patient's own words and/or the reason for the patient's visit in the provider's
words. It can also contain a coded reason for visit in the contained Patient's Reason for Visit
Observation.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 100
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 37: Reasons for Visit Section (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01)
templateId

1..1

SHALL

32561066

@root

1..1

SHALL

32561068

2.16.840.1.113883.10.20.34.2.14

@extension

0..1

MAY

32561161

2016-07-01

0..*

MAY

32561085

1..1

SHALL

32561086

entry
observation

Patient's Reason for Visit
Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.41:2015-04-01

1. Conforms to Chief Complaint and Reason for Visit Section template (identifier:
urn:oid:2.16.840.1.113883.10.20.22.2.13).
2. SHALL contain exactly one [1..1] templateId (CONF:3256-1066) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.14"
(CONF:3256-1068).
b. MAY contain zero or one [0..1] @extension="2016-07-01" (CONF:3256-1161).
3. MAY contain zero or more [0..*] entry (CONF:3256-1085).
a. The entry, if present, SHALL contain exactly one [1..1] Patient's Reason for
Visit Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.41:2015-04-01) (CONF:32561086).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 101
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 30: Reasons for Visit Section (V2) Example

Reasons for Visit

Patient's Reason for Visit (Chief Complaint)
Providers Reason for Visit

Having trouble breathing
Dyspnea

...

2.2

Encounters Section (entries optional) (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 38: Encounters Section (entries optional) (V2) Contexts

Contained By:

Contains:
Encounter Activity (V2)

This section lists and describes any healthcare encounters pertinent to the patient’s current
health status or historical health history. An encounter is an interaction, regardless of the
setting, between a patient and a practitioner who is vested with primary responsibility for
diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments,
or non-face-to-face interactions. It is also a contact between a patient and a practitioner who

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 102
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

has primary responsibility (exercising independent judgment) for assessing and treating the
patient at a given contact. This section may contain all encounters for the time period being
summarized, but should include notable encounters.
Table 39: Encounters Section (entries optional) (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09)
templateId

1..1

SHALL

10987940

@root

1..1

SHALL

109810386

2.16.840.1.113883.10.20.22.2.22

@extension

1..1

SHALL

109832547

2014-06-09

1..1

SHALL

109815461

@code

1..1

SHALL

109815462

46240-8

@codeSystem

1..1

SHALL

109831136

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

10987942

text

1..1

SHALL

10987943

entry

0..*

SHOUL
D

10987951

1..1

SHALL

109815465

code

encounter

Encounter Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.49:2014-06-09

1. SHALL contain exactly one [1..1] templateId (CONF:1098-7940) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.22"
(CONF:1098-10386).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32547).
2. SHALL contain exactly one [1..1] code (CONF:1098-15461).
a. This code SHALL contain exactly one [1..1] @code="46240-8" Encounters
(CONF:1098-15462).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31136).
3. SHALL contain exactly one [1..1] title (CONF:1098-7942).
4. SHALL contain exactly one [1..1] text (CONF:1098-7943).
5. SHOULD contain zero or more [0..*] entry (CONF:1098-7951) such that it
a. SHALL contain exactly one [1..1] Encounter Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09) (CONF:109815465).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 103
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.2.1 Emergency Department Encounters Section (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.13:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 40: Emergency Department Encounters Section (V2) Contexts
Contained By:

Contains:

Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Current Emergency Department Visit (V2)
Hospital Admission Encounter
Observation Unit Stay Encounter

This section contains emergency department encounter information such as the current
encounter, and any hospital admission or observation unit stays that might occur.
Table 41: Emergency Department Encounters Section (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.13:2016-07-01)
templateId

1..1

SHALL

32561050

@root

1..1

SHALL

32561052

2.16.840.1.113883.10.20.34.2.13

@extension

1..1

SHALL

32561053

2016-07-01

1..1

SHALL

32561049

1..1

SHALL

32561051

0..*

MAY

32561111

1..1

SHALL

32561113

0..*

MAY

32561112

1..1

SHALL

32561114

entry
encounter

entry
encounter

entry
encounter

Current Emergency Department
Visit (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.40:2016-07-01

Hospital Admission Encounter
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.18

Observation Unit Stay Encounter
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.33

1. Conforms to Encounters Section (entries optional) (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 104
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2. SHALL contain exactly one [1..1] templateId (CONF:3256-1050) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.13"
(CONF:3256-1052).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1053).
3. SHALL contain exactly one [1..1] entry (CONF:3256-1049) such that it
a. SHALL contain exactly one [1..1] Current Emergency Department Visit (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.40:2016-07-01)
(CONF:3256-1051).
4. MAY contain zero or more [0..*] entry (CONF:3256-1111) such that it
a. SHALL contain exactly one [1..1] Hospital Admission Encounter (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.18) (CONF:3256-1113).
5. MAY contain zero or more [0..*] entry (CONF:3256-1112) such that it
a. SHALL contain exactly one [1..1] Observation Unit Stay Encounter
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.33) (CONF:32561114).
Figure 31: Emergency Department Encounters Section (V2) Example

Emergency Department Encounters
...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 105
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.2.2 Inpatient Encounters Section (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.12:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 42: Inpatient Encounters Section (V2) Contexts
Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)

Current Inpatient Visit
Specialty Unit Stay Encounter

This section contains information about the inpatient encounter such as current visit and any
specialty unit stay encounters.
Table 43: Inpatient Encounters Section (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.12:2016-07-01)
templateId

1..1

SHALL

32561044

@root

1..1

SHALL

32561046

2.16.840.1.113883.10.20.34.2.12

@extension

1..1

SHALL

32561047

2016-07-01

0..1

SHOUL
D

32561043

1..1

SHALL

32561045

0..*

MAY

32561064

1..1

SHALL

32561065

entry
encounter

entry
encounter

Current Inpatient Visit (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.39:2015-04-01

Specialty Unit Stay Encounter
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.38:2015-04-01

1. Conforms to Encounters Section (entries optional) (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09).
2. SHALL contain exactly one [1..1] templateId (CONF:3256-1044) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.12"
(CONF:3256-1046).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1047).
3. SHOULD contain zero or one [0..1] entry (CONF:3256-1043) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 106
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] Current Inpatient Visit (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.39:2015-04-01) (CONF:32561045).
4. MAY contain zero or more [0..*] entry (CONF:3256-1064) such that it
a. SHALL contain exactly one [1..1] Specialty Unit Stay Encounter (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.38:2015-04-01) (CONF:32561065).
Figure 32: Inpatient Encounters Section (V2) Example

Inpatient Encounters Section
...

...

/>
/>

/>
/>

/>
/>

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 107
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.2.3 Outpatient Encounters Section (V3)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.8:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 44: Outpatient Encounters Section (V3) Contexts
Contained By:

Contains:

Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)

Current Outpatient Visit (V3)

This section contains information about the current outpatient encounter.
Table 45: Outpatient Encounters Section (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.8:2016-07-01)
templateId

1..1

SHALL

3256431

@root

1..1

SHALL

3256432

2.16.840.1.113883.10.20.34.2.8

@extension

1..1

SHALL

32561048

2016-07-01

1..1

SHALL

3256439

1..1

SHALL

3256440

entry
encounter

Current Outpatient Visit (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.10:2016-07-01

1. Conforms to Encounters Section (entries optional) (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09).
2. SHALL contain exactly one [1..1] templateId (CONF:3256-431) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.8"
(CONF:3256-432).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1048).
3. SHALL contain exactly one [1..1] entry (CONF:3256-439) such that it
a. SHALL contain exactly one [1..1] Current Outpatient Visit (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.10:2016-07-01) (CONF:3256-440).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 108
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 33: Outpatient Encounters Section (V3)

Outpatient Encounters
...

...

2.3

Medications Section (entries optional) (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 46: Medications Section (entries optional) (V2) Contexts

Contained By:

Contains:
Medication Activity (V2)

The Medications Section contains a patient's current medications and pertinent medication
history. At a minimum, the currently active medications are listed. An entire medication history
is an option. The section can describe a patient's prescription and dispense history and
information about intended drug monitoring.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 109
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 47: Medications Section (entries optional) (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09)
templateId

1..1

SHALL

10987791

@root

1..1

SHALL

109810432

2.16.840.1.113883.10.20.22.2.1

@extension

1..1

SHALL

109832500

2014-06-09

1..1

SHALL

109815385

@code

1..1

SHALL

109815386

10160-0

@codeSystem

1..1

SHALL

109830824

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

10987793

text

1..1

SHALL

10987794

entry

0..*

SHOUL
D

10987795

1..1

SHALL

109810076

code

substanceAdministration

Medication Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.16:2014-06-09

1. SHALL contain exactly one [1..1] templateId (CONF:1098-7791) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.1"
(CONF:1098-10432).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32500).
2. SHALL contain exactly one [1..1] code (CONF:1098-15385).
a. This code SHALL contain exactly one [1..1] @code="10160-0" History of medication
use (CONF:1098-15386).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30824).
3. SHALL contain exactly one [1..1] title (CONF:1098-7793).
4. SHALL contain exactly one [1..1] text (CONF:1098-7794).
5. SHOULD contain zero or more [0..*] entry (CONF:1098-7795) such that it
a. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109810076).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 110
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.3.1 Immunizations Section
[section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.7 (open)]
Draft as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm
Table 48: Immunizations Section Contexts
Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Immunization Activity (V2)
Planned Immunization Activity

This section contains immunizations that were ordered, supplied, administered, or continued
during this visit.
A continued immunization has an effectiveTime/low that is less than the
encompassingEncounter/effectiveTime/low (date/time of admission/visit/arrival) and a new
immunization has an effectiveTime/low that is equal to or greater than the
encompassingEncounter/effectiveTime/low.
When recording Immunization Medication Information contained in the Planned Immunization
Activity template, if the lot number is not known, use lotNumberText/@nullFlavor="NA".
Table 49: Immunizations Section Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7)
templateId
@root
entry
substanceAdministration

entry
substanceAdministration

1..1

SHALL

1106501

1..1

SHALL

1106504

0..*

SHOUL
D

1106499

1..1

SHALL

1106502

0..*

SHOUL
D

1106500

1..1

SHALL

1106503

2.16.840.1.113883.10.20.34.2.7

Immunization Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.52:2014-06-09

Planned Immunization Activity
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.120

1. Conforms to Medications Section (entries optional) (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09).
2. SHALL contain exactly one [1..1] templateId (CONF:1106-501) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 111
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.7"
(CONF:1106-504).
3. SHOULD contain zero or more [0..*] entry (CONF:1106-499) such that it
a. SHALL contain exactly one [1..1] Immunization Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2014-06-09) (CONF:1106-502).
4. SHOULD contain zero or more [0..*] entry (CONF:1106-500) such that it
a. SHALL contain exactly one [1..1] Planned Immunization Activity (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.120) (CONF:1106-503).
Figure 34: Immunizations Section Example

Immunizations

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 112
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.3.2 Medications Section
[section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.1 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 50: Medications Section Contexts
Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Medication Activity (V2)
Planned Medication Activity (V2)

This section contains medications (other than immunizations) that were ordered, supplied,
administered, or continued during this visit. It includes Rx and OTC drugs, allergy shots,
oxygen, anesthetics, chemotherapy, and dietary supplements.
A continued medication has an effectiveTime/low that is less than the
encompassingEncounter/effectiveTime/low (date/time of admission/visit/arrival) and a new
medication has an effectiveTime/low that is equal to or greater than the
encompassingEncounter/effectiveTime/low.
Table 51: Medications Section Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1)
templateId
@root
entry
substanceAdministration

entry
substanceAdministration

1..1

SHALL

1106356

1..1

SHALL

1106357

0..*

SHOUL
D

1106348

1..1

SHALL

1106349

0..*

SHOUL
D

1106350

1..1

SHALL

1106351

2.16.840.1.113883.10.20.34.2.1

Medication Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.16:2014-06-09

Planned Medication Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.42:2014-06-09

1. Conforms to Medications Section (entries optional) (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09).
2. SHALL contain exactly one [1..1] templateId (CONF:1106-356) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 113
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.1"
(CONF:1106-357).
3. SHOULD contain zero or more [0..*] entry (CONF:1106-348) such that it
a. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:1106-349).
4. SHOULD contain zero or more [0..*] entry (CONF:1106-350) such that it
a. SHALL contain exactly one [1..1] Planned Medication Activity (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09)
(CONF:1106-351).
Figure 35: Medications Section Example

Medications

...

...

...

2.4

Payers Section (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.18:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 52: Payers Section (V2) Contexts

Contained By:

Contains:
Coverage Activity (V2)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 114
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

The Payers Section contains data on the patient’s payers, whether "third party" insurance, selfpay, 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 53: Payers Section (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.18:2014-06-09)
templateId

1..1

SHALL

10987924

@root

1..1

SHALL

109810434

2.16.840.1.113883.10.20.22.2.18

@extension

1..1

SHALL

109832597

2014-06-09

1..1

SHALL

109815395

@code

1..1

SHALL

109815396

48768-6

@codeSystem

1..1

SHALL

109832149

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

10987926

text

1..1

SHALL

10987927

entry

0..*

SHOUL
D

10987959

act

1..1

SHALL

109815501

code

Coverage Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.60:2014-06-09

1. SHALL contain exactly one [1..1] templateId (CONF:1098-7924) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.18"
(CONF:1098-10434).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32597).
2. SHALL contain exactly one [1..1] code (CONF:1098-15395).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 115
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This code SHALL contain exactly one [1..1] @code="48768-6" Payers (CONF:109815396).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32149).
3. SHALL contain exactly one [1..1] title (CONF:1098-7926).
4. SHALL contain exactly one [1..1] text (CONF:1098-7927).
5. SHOULD contain zero or more [0..*] entry (CONF:1098-7959) such that it
a. SHALL contain exactly one [1..1] Coverage Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.60:2014-06-09) (CONF:109815501).
Figure 36: Payers Section (V2) Example

Insurance Providers

. . .

...

2.4.1 Payment Sources Section
[section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.4 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 54: Payment Sources Section Contexts
Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Planned Coverage

This section contains the expected sources of payment for this visit.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 116
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 55: Payment Sources Section Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4)
templateId

1..1

SHALL

1106199

1..1

SHALL

1106200

entry

0..*

SHOUL
D

1106201

act

1..1

SHALL

1106202

@root

2.16.840.1.113883.10.20.34.2.4

Planned Coverage (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.129

1. Conforms to Payers Section (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.18:2014-06-09).
2. SHALL contain exactly one [1..1] templateId (CONF:1106-199) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.4"
(CONF:1106-200).
3. SHOULD contain zero or more [0..*] entry (CONF:1106-201) such that it
a. SHALL contain exactly one [1..1] Planned Coverage (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:1106-202).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 117
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 37: Payment Sources Section Example

Payment Sources Section

...

...

...

2.5

Problems Section (V3)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 56: Problems Section (V3) Contexts

Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Admission Diagnosis Observation
Adverse Effect of Medical Treatment
Injury or Poisoning Observation (V2)
Primary Diagnosis Observation (V2)
Problem/Diagnosis/Symptom/Condition Observation
(V2)

This section contains problems, including current diagnoses, chronic conditions and
symptoms.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 118
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 57: Problems Section (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
templateId

1..1

SHALL

325667

@root

1..1

SHALL

325668

2.16.840.1.113883.10.20.34.2.2

@extension

0..1

MAY

32561175

2016-07-01

1..1

SHALL

3256509

@code

1..1

SHALL

3256510

11450-4

@codeSystem

1..1

SHALL

3256511

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

3256512

text

1..1

SHALL

3256513

entry

1..1

SHALL

325674

1..1

SHALL

325675

0..1

MAY

3256875

1..1

SHALL

3256876

0..*

SHOUL
D

3256332

1..1

SHALL

3256333

0..*

MAY

3256415

1..1

SHALL

3256416

0..1

MAY

3256497

1..1

SHALL

3256-

code

observation

entry
observation

entry
observation

entry
observation

entry
observation

Primary Diagnosis Observation
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.6:2015-04-01

Admission Diagnosis Observation
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.34:2015-04-01

Problem/Diagnosis/Symptom/Co
ndition Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.1:2015-04-01

Injury or Poisoning Observation
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.17:2015-04-01

Adverse Effect of Medical

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 119
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

498

Treatment (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.14

1. SHALL contain exactly one [1..1] templateId (CONF:3256-67) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.2"
(CONF:3256-68).
b. MAY contain zero or one [0..1] @extension="2016-07-01" (CONF:3256-1175).
2. SHALL contain exactly one [1..1] code (CONF:3256-509).
a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem List
(CONF:3256-510).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:3256-511).
3. SHALL contain exactly one [1..1] title (CONF:3256-512).
4. SHALL contain exactly one [1..1] text (CONF:3256-513).
If no other means of determination is possible, use first listed diagnosis as the primary
diagnosis.
5. SHALL contain exactly one [1..1] entry (CONF:3256-74) such that it
a. SHALL contain exactly one [1..1] Primary Diagnosis Observation (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.6:2015-04-01)
(CONF:3256-75).
6. MAY contain zero or one [0..1] entry (CONF:3256-875) such that it
a. SHALL contain exactly one [1..1] Admission Diagnosis Observation
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.34:2015-04-01)
(CONF:3256-876).
b. If the document is an Inpatient Encounter then this entry SHALL be present
(CONF:3256-887).
7. SHOULD contain zero or more [0..*] entry (CONF:3256-332) such that it
a. SHALL contain exactly one [1..1] Problem/Diagnosis/Symptom/Condition
Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.1:2015-04-01) (CONF:3256-333).
8. MAY contain zero or more [0..*] entry (CONF:3256-415) such that it
a. SHALL contain exactly one [1..1] Injury or Poisoning Observation (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.17:2015-04-01)
(CONF:3256-416).
i.

If this is an Outpatient Observation then this entry MAY be present
(CONF:3256-1110).

9. MAY contain zero or one [0..1] entry (CONF:3256-497) such that it
a. SHALL contain exactly one [1..1] Adverse Effect of Medical Treatment
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.14) (CONF:3256-498).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 120
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 38: Problems Section (V3) Example

Problems
...

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 121
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

...

2.6

Results Section (entries optional) (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 58: Results Section (entries optional) (V2) Contexts

Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Result Organizer (V2)

This section contains the results of observations generated by laboratories, imaging and other
procedures. The scope includes observations of hematology, chemistry, serology, virology,
toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography,
nuclear medicine, pathology, and procedure observations.
This section often includes notable results such as abnormal values or relevant trends. It can
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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 122
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 59: Results Section (entries optional) (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09)
templateId

1..1

SHALL

10987116

@root

1..1

SHALL

10989136

2.16.840.1.113883.10.20.22.2.3

@extension

1..1

SHALL

109832591

2014-06-09

1..1

SHALL

109815431

@code

1..1

SHALL

109815432

30954-2

@codeSystem

1..1

SHALL

109831041

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

10988891

text

1..1

SHALL

10987118

entry

0..*

SHOUL
D

10987119

1..1

SHALL

109815515

code

organizer

Result Organizer (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.1:2014-06-09

1. SHALL contain exactly one [1..1] templateId (CONF:1098-7116) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.3"
(CONF:1098-9136).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32591).
2. SHALL contain exactly one [1..1] code (CONF:1098-15431).
a. This code SHALL contain exactly one [1..1] @code="30954-2" Relevant diagnostic
tests and/or laboratory data (CONF:1098-15432).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31041).
3. SHALL contain exactly one [1..1] title (CONF:1098-8891).
4. SHALL contain exactly one [1..1] text (CONF:1098-7118).
5. SHOULD contain zero or more [0..*] entry (CONF:1098-7119) such that it
a. SHALL contain exactly one [1..1] Result Organizer (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.1:2014-06-09) (CONF:109815515).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 123
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.7

Services and Procedures Section
[section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.3 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 60: Services and Procedures Section Contexts

Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Ordered Service Act
Ordered Service Observation
Ordered Service Procedure
Provided Service Act
Provided Service Observation
Provided Service Procedure

This section contains services and procedures such as examinations, blood tests, imaging,
other tests, non-medication treatment, and health education ordered for or provided to the
patient.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 124
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 61: Services and Procedures Section Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.3)
templateId

1..1

SHALL

110676

1..1

SHALL

110686

entry

0..*

MAY

110682

act

1..1

SHALL

1106275

entry

0..*

MAY

110684

act

1..1

SHALL

110685

entry

0..*

MAY

1106276

1..1

SHALL

1106277

0..*

MAY

1106278

1..1

SHALL

1106279

0..*

MAY

1106280

1..1

SHALL

1106281

0..*

MAY

1106282

1..1

SHALL

1106283

@root

observation

entry
observation

entry
procedure

entry
procedure

2.16.840.1.113883.10.20.34.2.3

Provided Service Act (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.20

Ordered Service Act (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.19

Provided Service Observation
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.3

Ordered Service Observation
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.2

Provided Service Procedure
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.12

Ordered Service Procedure
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.11

1. SHALL contain exactly one [1..1] templateId (CONF:1106-76) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.3"
(CONF:1106-86).
2. MAY contain zero or more [0..*] entry (CONF:1106-82) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 125
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] Provided Service Act (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.20) (CONF:1106-275).
Note: Form Element Categories (Services): Provided Other Tests and Procedures
(except Excision of Tissue), Provided Non-medication treatment, Provided Health
Education/Counseling
3. MAY contain zero or more [0..*] entry (CONF:1106-84) such that it
a. SHALL contain exactly one [1..1] Ordered Service Act (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.19) (CONF:1106-85).
Note: Form Element Categories (Services): Ordered Other Tests and Procedures
(except Excision of Tissue), Ordered Non-medication treatment, Ordered Health
Education/Counseling
4. MAY contain zero or more [0..*] entry (CONF:1106-276) such that it
a. SHALL contain exactly one [1..1] Provided Service Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.3) (CONF:1106-277).
Note: Form Element Categories (Services): Provided Examinations, Provided Blood
Tests, Provided Imaging
5. MAY contain zero or more [0..*] entry (CONF:1106-278) such that it
a. SHALL contain exactly one [1..1] Ordered Service Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.2) (CONF:1106-279).
Note: Form Element Categories (Services): Ordered Examinations, Ordered Blood
Tests, Ordered Imaging
6. MAY contain zero or more [0..*] entry (CONF:1106-280) such that it
a. SHALL contain exactly one [1..1] Provided Service Procedure (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.12) (CONF:1106-281).
Note: Form Element (Services): Provided Excision of Tissue
7. MAY contain zero or more [0..*] entry (CONF:1106-282) such that it
a. SHALL contain exactly one [1..1] Ordered Service Procedure (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.11) (CONF:1106-283).
Note: Form Element (Services): Ordered Excision of Tissue

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 126
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 39: Services and Procedures Section Example

Services and Procedures Section

...

...

...

...

...

/>

/>

/>

/>

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 127
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

...

...

...

2.8

Social History Section (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 62: Social History Section (V2) Contexts

Contained By:

Contains:
Caregiver Characteristics
Characteristics of Home Environment
Cultural and Religious Observation
Pregnancy Observation
Smoking Status - Meaningful Use (V2)
Social History Observation (V2)
Tobacco Use (V2)

This section contains social history data that influence a patient’s physical, psychological or
emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status,
race, ethnicity, and religious affiliation, is captured in the header.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 128
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 63: Social History Section (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2014-06-09)
templateId

1..1

SHALL

10987936

@root

1..1

SHALL

109810449

2.16.840.1.113883.10.20.22.2.17

@extension

1..1

SHALL

109832494

2014-06-09

1..1

SHALL

109814819

@code

1..1

SHALL

109814820

29762-2

@codeSystem

1..1

SHALL

109830814

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

10987938

text

1..1

SHALL

10987939

entry

0..*

MAY

10987953

1..1

SHALL

109814821

0..*

MAY

10989132

1..1

SHALL

109814822

0..*

SHOUL
D

109814823

1..1

SHALL

109814824

0..*

MAY

109816816

1..1

SHALL

109816817

0..*

MAY

109828361

1..1

SHALL

109828362

code

observation

entry
observation

entry
observation

entry
observation

entry
observation

Social History Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.38:2014-06-09

Pregnancy Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
15.3.8

Smoking Status - Meaningful Use
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.78:2014-06-09

Tobacco Use (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.85:2014-06-09

Caregiver Characteristics
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.72

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 129
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

entry
observation

entry
observation

0..*

MAY

109828366

1..1

SHALL

109828367

0..*

MAY

109828825

1..1

SHALL

109828826

Cultural and Religious
Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.111

Characteristics of Home
Environment (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.109

1. SHALL contain exactly one [1..1] templateId (CONF:1098-7936) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.17"
(CONF:1098-10449).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32494).
2. SHALL contain exactly one [1..1] code (CONF:1098-14819).
a. This code SHALL contain exactly one [1..1] @code="29762-2" Social History
(CONF:1098-14820).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30814).
3. SHALL contain exactly one [1..1] title (CONF:1098-7938).
4. SHALL contain exactly one [1..1] text (CONF:1098-7939).
5. MAY contain zero or more [0..*] entry (CONF:1098-7953) such that it
a. SHALL contain exactly one [1..1] Social History Observation (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2014-06-09)
(CONF:1098-14821).
6. MAY contain zero or more [0..*] entry (CONF:1098-9132) such that it
a. SHALL contain exactly one [1..1] Pregnancy Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.15.3.8) (CONF:1098-14822).
7. SHOULD contain zero or more [0..*] entry (CONF:1098-14823) such that it
a. SHALL contain exactly one [1..1] Smoking Status - Meaningful Use (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09)
(CONF:1098-14824).
8. MAY contain zero or more [0..*] entry (CONF:1098-16816) such that it
a. SHALL contain exactly one [1..1] Tobacco Use (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09) (CONF:109816817).
9. MAY contain zero or more [0..*] entry (CONF:1098-28361) such that it
a. SHALL contain exactly one [1..1] Caregiver Characteristics (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.72) (CONF:1098-28362).
10. MAY contain zero or more [0..*] entry (CONF:1098-28366) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 130
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] Cultural and Religious Observation
(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.111) (CONF:109828367).
11. MAY contain zero or more [0..*] entry (CONF:1098-28825) such that it
a. SHALL contain exactly one [1..1] Characteristics of Home Environment
(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.109) (CONF:109828826).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 131
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 40: Social History Section (V2) Example

SOCIAL HISTORY

. . .

...

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 132
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.8.1 Patient Information Section (V3)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 64: Patient Information Section (V3) Contexts
Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Patient Residence Observation
Pregnancy Observation
Smoking Status - Meaningful Use (V2)
Tobacco Use (V2)

This section contains patient information such as tobacco use, pregnancy status, and type of
patient residence.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 133
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 65: Patient Information Section (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01)
templateId

1..1

SHALL

3256203

@root

1..1

SHALL

3256204

2.16.840.1.113883.10.20.34.2.5

@extension

1..1

SHALL

32561108

2016-07-01

0..*

MAY

3256205

1..1

SHALL

3256206

0..1

MAY

32561106

1..1

SHALL

32561107

0..1

MAY

3256207

1..1

SHALL

3256208

0..1

MAY

3256676

1..1

SHALL

3256677

entry
observation

entry
observation

entry
observation

entry
observation

Tobacco Use (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.85:2014-06-09

Smoking Status - Meaningful Use
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.78:2014-06-09

Pregnancy Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
15.3.8

Patient Residence Observation
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.25

1. Conforms to Social History Section (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2014-06-09).
2. SHALL contain exactly one [1..1] templateId (CONF:3256-203) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.5"
(CONF:3256-204).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1108).
3. MAY contain zero or more [0..*] entry (CONF:3256-205) such that it
a. SHALL contain exactly one [1..1] Tobacco Use (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09) (CONF:3256-206).
b. If the document is an Outpatient Encounter then at least one of this entry SHALL be
present (CONF:3256-663).
4. MAY contain zero or one [0..1] entry (CONF:3256-1106) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 134
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] Smoking Status - Meaningful Use (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09)
(CONF:3256-1107).
i.

If the document is an Outpatient Encounter then this entry SHALL be present
(CONF:3256-1109).

5. MAY contain zero or one [0..1] entry (CONF:3256-207) such that it
a. SHALL contain exactly one [1..1] Pregnancy Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.15.3.8) (CONF:3256-208).
b. If the patient is male, then this section SHALL NOT contain this entry.
If the document is an Inpatient Encounter or an Outpatient Encounter then this
entry MAY be present (CONF:3256-514).
6. MAY contain zero or one [0..1] entry (CONF:3256-676) such that it
a. SHALL contain exactly one [1..1] Patient Residence Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.25) (CONF:3256-677).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 135
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 41: Patient Information Section (V2) Example

Patient Information
..

...

...

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 136
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.9

Triage Section
[section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.10 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 66: Triage Section Contexts

Contained By:

Contains:

Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

On Oxygen on Arrival Observation
Pain Assessment Scale Observation
Triage Level Assigned Observation

This section contains triage information such as triage index, pain scale and whether the
patient was on oxygen on arrival.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 137
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 67: Triage Section Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.10)
templateId

1..1

SHALL

1106646

1..1

SHALL

1106647

1..1

SHALL

1106648

@code

0..1

MAY

1106649

54094-8

@codeSystem

0..1

MAY

1106650

2.16.840.1.113883.6.1

title

1..1

SHALL

1106651

text

1..1

SHALL

1106652

entry

1..1

SHALL

1106622

1..1

SHALL

1106624

1..1

SHALL

1106623

1..1

SHALL

1106625

1..1

SHALL

1106716

1..1

SHALL

1106717

@root
code

observation

entry
observation

entry
observation

2.16.840.1.113883.10.20.34.2.10

Triage Level Assigned Observation
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.23

Pain Assessment Scale
Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.22

On Oxygen on Arrival
Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.29

1. SHALL contain exactly one [1..1] templateId (CONF:1106-646) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.10"
(CONF:1106-647).
2. SHALL contain exactly one [1..1] code (CONF:1106-648).
a. This code MAY contain zero or one [0..1] @code="54094-8" Triage Note (CONF:1106649).
b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1"
(CONF:1106-650).
3. SHALL contain exactly one [1..1] title (CONF:1106-651).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 138
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4. SHALL contain exactly one [1..1] text (CONF:1106-652).
5. SHALL contain exactly one [1..1] entry (CONF:1106-622) such that it
a. SHALL contain exactly one [1..1] Triage Level Assigned Observation
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.23) (CONF:1106-624).
6. SHALL contain exactly one [1..1] entry (CONF:1106-623) such that it
a. SHALL contain exactly one [1..1] Pain Assessment Scale Observation
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.22) (CONF:1106-625).
7. SHALL contain exactly one [1..1] entry (CONF:1106-716) such that it
a. SHALL contain exactly one [1..1] On Oxygen on Arrival Observation
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.29) (CONF:1106-717).
Figure 42: Triage Section Example

Triage Section

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 139
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2.10 Vital Signs Section (entries optional) (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.4:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 68: Vital Signs Section (entries optional) (V2) Contexts
Contained By:

Contains:
Vital Signs Organizer (V2)

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, pulse oximetry, temperature, and body surface area. 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 69: Vital Signs Section (entries optional) (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.4:2014-06-09)
templateId

1..1

SHALL

10987268

@root

1..1

SHALL

109810451

2.16.840.1.113883.10.20.22.2.4

@extension

1..1

SHALL

109832584

2014-06-09

1..1

SHALL

109815242

@code

1..1

SHALL

109815243

8716-3

@codeSystem

1..1

SHALL

109830902

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

10989966

text

1..1

SHALL

10987270

entry

0..*

SHOUL
D

10987271

1..1

SHALL

109815517

code

organizer

Vital Signs Organizer (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.26:2014-06-09

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 140
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] templateId (CONF:1098-7268) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.4"
(CONF:1098-10451).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32584).
2. SHALL contain exactly one [1..1] code (CONF:1098-15242).
a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CONF:109815243).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30902).
3. SHALL contain exactly one [1..1] title (CONF:1098-9966).
4. SHALL contain exactly one [1..1] text (CONF:1098-7270).
5. SHOULD contain zero or more [0..*] entry (CONF:1098-7271) such that it
a. SHALL contain exactly one [1..1] Vital Signs Organizer (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09) (CONF:109815517).

2.10.1 Vital Signs Section (entries required) (V2)
[section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 70: Vital Signs Section (entries required) (V2) Contexts
Contained By:

Contains:

Inpatient Encounter (NHCS-IP) (V3) (required)
Outpatient Encounter (NHCS-OPD, NAMCS,
NHAMCS-OPD) (V3) (required)
Emergency Department Encounter (NHCS-ED,
NHAMCS-ED) (V3) (required)

Vital Signs Organizer (V2)

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, pulse oximetry, temperature, and body surface area. 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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 141
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 71: Vital Signs Section (entries required) (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09)
@nullFlavor

0..1

MAY

109832874

templateId

1..1

SHALL

10987273

@root

1..1

SHALL

109810452

2.16.840.1.113883.10.20.22.2.4.
1

@extension

1..1

SHALL

109832585

2014-06-09

1..1

SHALL

109815962

@code

1..1

SHALL

109815963

8716-3

@codeSystem

1..1

SHALL

109830903

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

10989967

text

1..1

SHALL

10987275

entry

1..*

SHALL

10987276

1..1

SHALL

109815964

code

organizer

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = NI

Vital Signs Organizer (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.26:2014-06-09

1. Conforms to Vital Signs Section (entries optional) (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.4:2014-06-09).
2. MAY contain zero or one [0..1] @nullFlavor="NI" No information (CodeSystem:
HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:1098-32874).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7273) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.4.1"
(CONF:1098-10452).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32585).
4. SHALL contain exactly one [1..1] code (CONF:1098-15962).
a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CONF:109815963).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30903).
5. SHALL contain exactly one [1..1] title (CONF:1098-9967).
6. SHALL contain exactly one [1..1] text (CONF:1098-7275).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 142
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

If section/@nullFlavor is not present:
7. SHALL contain at least one [1..*] entry (CONF:1098-7276) such that it
a. SHALL contain exactly one [1..1] Vital Signs Organizer (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09) (CONF:109815964).
Figure 43: Vital Signs Section (entries required) (V2) Example

VITAL SIGNS

. . .

. . .

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 143
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3

ENTRY-LEVEL TEMPLATES
This chapter describes the clinical statement entry templates used within the sections of the
document. Entry templates contain constraints that are required for conformance.
Entry-level templates are always in sections.
Each entry-level template description contains the following information:
• Key template metadata (e.g., templateId, etc.)
• Description and explanatory narrative.
• Required CDA acts, participants and vocabularies.
• Optional CDA acts, participants and vocabularies.
Several entry-level templates require an effectiveTime:
The effectiveTime of an observation is the time interval over which the observation is known to
be true. The low and high values should be as precise as possible, but no more precise than
known. While CDA has multiple mechanisms to record this time interval (e.g., by low and high
values, low and width, high and width, or center point and width), we constrain most to use
only the low/high form. The low value is the earliest point for which the condition is known to
have existed. The high value, when present, indicates the time at which the observation was no
longer known to be true. The full description of effectiveTime and time intervals is contained in
the CDA R2 normative edition.
ID in entry templates:
Entry-level templates may also describe an id element, which is an identifier for that entry.
This id may be referenced within the document, or by the system receiving the document. The
id assigned must be globally unique.

3.1

Admission Priority Observation
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.35:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 72: Admission Priority Observation Contexts

Contained By:

Contains:

Current Inpatient Visit (optional)

This template represents the priority of this admission or visit.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 144
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 73: Admission Priority Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.35:2015-04-01)
@classCode

1..1

SHALL

1184884

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184885

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184878

@root

1..1

SHALL

1184880

2.16.840.1.113883.10.20.34.3.35

@extension

1..1

SHALL

1184881

2015-04-01

1..1

SHALL

1184879

@code

1..1

SHALL

1184882

78020-5

@codeSystem

1..1

SHALL

1184883

2.16.840.1.113883.6.1

1..1

SHALL

1184886

urn:oid:2.16.840.1.114222.4.11.7
365 (Priority (Type) of Admission
or Visit (NCHS))

code

value

CD

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-884).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-885).
3. SHALL contain exactly one [1..1] templateId (CONF:1184-878) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.35"
(CONF:1184-880).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-881).
4. SHALL contain exactly one [1..1] code (CONF:1184-879).
a. This code SHALL contain exactly one [1..1] @code="78020-5" Admission priority
(CONF:1184-882).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1184-883).
5. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Priority (Type) of Admission or Visit (NCHS)
urn:oid:2.16.840.1.114222.4.11.7365 DYNAMIC (CONF:1184-886).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 145
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 74: Priority (Type) of Admission or Visit (NCHS)
Value Set: Priority (Type) of Admission or Visit (NCHS) urn:oid:2.16.840.1.114222.4.11.7365
The kind or importance of the process which resulted in the patient’s being admitted as an inpatient.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7365
Code

Code System

Code System OID

Print Name

183452005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Emergency

448381000124100

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Urgent hospital
admission

8715000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Elective

447941000124106

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Hospital admission of
newborn

183497001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Non-urgent Trauma
Admission

183463008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Admit Trauma
Emergency

...

Figure 44: Admission Priority Observation Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 146
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.2

Age Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.31 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 75: Age Observation Contexts

Contained By:

Contains:

Problem Observation (V2) (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 76: 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

817613

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

817614

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

817899

1..1

SHALL

8110487

1..1

SHALL

817615

@code

1..1

SHALL

8116776

445518008

@codeSystem

1..1

SHALL

8126499

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) =
2.16.840.1.113883.6.96

1..1

SHALL

8115965

1..1

SHALL

8115966

1..1

SHALL

PQ

817617

1..1

SHALL

CS

817618

@root
code

statusCode
@code
value
@unit

2.16.840.1.113883.10.20.22.4.31

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

urn:oid:2.16.840.1.113883.11.20.
9.21 (AgePQ_UCUM)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 147
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-7613).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-7614).
3. SHALL contain exactly one [1..1] templateId (CONF:81-7899) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.31"
(CONF:81-10487).
4. SHALL contain exactly one [1..1] code (CONF:81-7615).
a. This code SHALL contain exactly one [1..1] @code="445518008" Age At Onset
(CONF:81-16776).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT
urn:oid:2.16.840.1.113883.6.96) (CONF:81-26499).
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 urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8115966).
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 urn:oid:2.16.840.1.113883.11.20.9.21 DYNAMIC
(CONF:81-7618).
Table 77: AgePQ_UCUM
Value Set: AgePQ_UCUM urn:oid:2.16.840.1.113883.11.20.9.21
A value set of UCUM codes for representing age value units.
Value Set Source: http://unitsofmeasure.org/ucum.html
Code

Code System

Code System OID

Print Name

min

UCUM

urn:oid:2.16.840.1.11388
3.6.8

Minute

h

UCUM

urn:oid:2.16.840.1.11388
3.6.8

Hour

d

UCUM

urn:oid:2.16.840.1.11388
3.6.8

Day

wk

UCUM

urn:oid:2.16.840.1.11388
3.6.8

Week

mo

UCUM

urn:oid:2.16.840.1.11388
3.6.8

Month

a

UCUM

urn:oid:2.16.840.1.11388
3.6.8

Year

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 148
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 45: Age Observation Example

3.3

Assessment Scale Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.69 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 78: Assessment Scale Observation Contexts

Contained By:

Contains:
Assessment Scale Supporting Observation

An assessment scale is a collection of observations that together yield a summary evaluation of
a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk),
APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam
(assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow
Coma Scale (assesses coma and impaired consciousness).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 149
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 79: Assessment Scale Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69)
@classCode

1..1

SHALL

8114434

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8114435

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

8114436

1..1

SHALL

8114437

id

1..*

SHALL

8114438

code

1..1

SHALL

8114439

derivationExpr

0..1

MAY

8114637

statusCode

1..1

SHALL

8114444

1..1

SHALL

8119088

effectiveTime

1..1

SHALL

8114445

value

1..1

SHALL

8114450

interpretationCode

0..*

MAY

8114459

0..*

MAY

8114888

author

0..*

MAY

8114460

entryRelationship

0..*

SHOUL
D

8114451

@typeCode

1..1

SHALL

8116741

COMP

observation

1..1

SHALL

8116742

Assessment Scale Supporting
Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.86

referenceRange

0..*

MAY

8116799

1..1

SHALL

8116800

0..1

SHOUL
D

8116801

0..1

SHOUL

81-

@root

@code

translation

observationRange
text
reference

2.16.840.1.113883.10.20.22.4.69

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 150
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@value

0..1

D

16802

MAY

8116803

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-14434).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-14435).
3. SHALL contain exactly one [1..1] templateId (CONF:81-14436) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.69"
(CONF:81-14437).
4. SHALL contain at least one [1..*] id (CONF:81-14438).
5. SHALL contain exactly one [1..1] code (CONF:81-14439).
a. SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT
(CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:8114440).
Such derivation expression can contain a text calculation of how the components total up to
the summed score
6. MAY contain zero or one [0..1] derivationExpr (CONF:81-14637).
7. SHALL contain exactly one [1..1] statusCode (CONF:81-14444).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119088).
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)
8. SHALL contain exactly one [1..1] effectiveTime (CONF:81-14445).
9. SHALL contain exactly one [1..1] value (CONF:81-14450).
10. MAY contain zero or more [0..*] interpretationCode (CONF:81-14459).
a. The interpretationCode, if present, MAY contain zero or more [0..*] translation
(CONF:81-14888).
11. MAY contain zero or more [0..*] author (CONF:81-14460).
12. SHOULD contain zero or more [0..*] entryRelationship (CONF:81-14451) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:8116741).
b. SHALL contain exactly one [1..1] Assessment Scale Supporting Observation
(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.86) (CONF:81-16742).
The referenceRange/observationRange/text, if present, MAY contain a description of the scale
(e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
13. MAY contain zero or more [0..*] referenceRange (CONF:81-16799).
a. The referenceRange, if present, SHALL contain exactly one [1..1] observationRange
(CONF:81-16800).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 151
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little
pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
i.

This observationRange SHOULD contain zero or one [0..1] text (CONF:8116801).
1. The text, if present, SHOULD contain zero or one [0..1] reference
(CONF:81-16802).
a. The reference, if present, MAY contain zero or one [0..1]
@value (CONF:81-16803).
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:81-16804).

Figure 46: Assessment Scale Observation Example

Text description of the calculation

. . .

3.3.1 Pain Assessment Scale Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.22 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 80: Pain Assessment Scale Observation Contexts
Contained By:

Contains:

Triage Section (required)

This template represents pain severity on a scale of 0 to 10 where 0 is no pain and 10 is the
worst pain imaginable. To record "unknown" use nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 152
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 81: Pain Assessment Scale Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.22)
@classCode

1..1

SHALL

1106598

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106599

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106592

1..1

SHALL

1106595

1..1

SHALL

1106593

@code

1..1

SHALL

1106596

72514-3

@codeSystem

1..1

SHALL

1106597

2.16.840.1.113883.6.1

1..1

SHALL

@nullFlavor

0..1

MAY

1106653

@value

0..1

SHOUL
D

1106600

@root
code

value

INT

2.16.840.1.113883.10.20.34.3.22

1106594
UNK

1. Conforms to Assessment Scale Observation template (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.69).
2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-598).
3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-599).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-592) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.22"
(CONF:1106-595).
5. SHALL contain exactly one [1..1] code (CONF:1106-593).
a. This code SHALL contain exactly one [1..1] @code="72514-3" Pain severity - 0-10
verbal numeric rating [#] - Reported (CONF:1106-596).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1106-597).
6. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1106-594).
Note: Form element: Pain scale (0-10)
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" Unknown
(CONF:1106-653).
b. This value SHOULD contain zero or one [0..1] @value (CONF:1106-600).
i.

SHALL be >= 0 and SHALL be <=10 (CONF:1106-654).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 153
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 47: Pain Assessment Scale Observation Example

3.3.2 Triage Level Assigned Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.23 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 82: Triage Level Assigned Observation Contexts
Contained By:

Contains:

Triage Section (required)

This template represents the triage level assigned by a triage nurse upon arrival at the
emergency department (ED). The triage system used is recorded in the code element and the
level is recorded in the value element.
If the triage system used is not covered by the list of codes, use code/nullFlavor="OTH". If the
triage system is known but the triage level is unknown, use value/nullFlavor="UNK". If the
triage system is unknown, use code/nullFlavor="UNK" and value/nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 154
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 83: Triage Level Assigned Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.23)
@classCode

1..1

SHALL

1106620

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106621

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106617

1..1

SHALL

1106618

2.16.840.1.113883.10.20.34.3.23

1..1

SHALL

1106655

urn:oid:2.16.840.1.114222.4.11.7
401 (Triage System (NCHS))

0..1

MAY

1106854

1..1

SHALL

@nullFlavor

0..1

MAY

1106657

@value

1..1

SHOUL
D

1106659

@root
code
@nullFlavor
value

INT

1106619

1. Conforms to Assessment Scale Observation template (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.69).
2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-620).
3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-621).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-617) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.23"
(CONF:1106-618).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Triage
System (NCHS) urn:oid:2.16.840.1.114222.4.11.7401 DYNAMIC (CONF:1106-655).
a. This code MAY contain zero or one [0..1] @nullFlavor (CONF:1106-854).
i.

NullFlavor SHALL be "UNK" Unknown or "OTH" Other (CONF:1106-855).

6. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1106-619).
a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:1106-657).
i.

NullFlavor SHALL be "UNK" Unknown, "OTH" Other, or "NA" Not Applicable
(CONF:1106-658).

b. This value SHOULD contain exactly one [1..1] @value (CONF:1106-659).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 155
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 84: Triage System (NCHS)
Value Set: Triage System (NCHS) urn:oid:2.16.840.1.114222.4.11.7401
These values describe different types of triage systems.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7401
Code

Code System

Code System OID

Print Name

75614-8

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Three level triage system

75615-5

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Four level triage system

75616-3

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Five level triage system

75910-0

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Canadian triage and
acuity scale CTAS

75636-1

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Emergency severity index

...

Figure 48: Triage Level Assigned Observation Example

3.4

Assessment Scale Supporting Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.86 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 85: Assessment Scale Supporting Observation Contexts

Contained By:

Contains:

Assessment Scale Observation (optional)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 156
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

An Assessment Scale Supporting Observation represents the components of a scale used in an
Assessment Scale Observation. The individual parts that make up the component may be a
group of cognitive or functional status observations.
Table 86: Assessment Scale Supporting Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.86)
@classCode

1..1

SHALL

8116715

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8116716

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

8116722

1..1

SHALL

8116723

id

1..*

SHALL

8116724

code

1..1

SHALL

8119178

1..1

SHALL

8119179

1..1

SHALL

8116720

1..1

SHALL

8119089

1..*

SHALL

8116754

@root

@code
statusCode
@code
value

2.16.840.1.113883.10.20.22.4.86

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-16715).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-16716).
3. SHALL contain exactly one [1..1] templateId (CONF:81-16722) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.86"
(CONF:81-16723).
4. SHALL contain at least one [1..*] id (CONF:81-16724).
5. SHALL contain exactly one [1..1] code (CONF:81-19178).
a. This code SHALL contain exactly one [1..1] @code (CONF:81-19179).
i.

Such that the @code SHALL be from LOINC (CodeSystem:
2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem:
2.16.840.1.113883.6.96) and represents components of the scale (CONF:8119180).

6. SHALL contain exactly one [1..1] statusCode (CONF:81-16720).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 157
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119089).
7. SHALL contain at least one [1..*] value (CONF:81-16754).
a. If xsi:type="CD", MAY have a translation code to further specify the source if the
instrument has an applicable code system and value set for the integer
(CONF:14639) (CONF:81-16755).
Figure 49: Assessment Scale Supporting Observation Example

3.5

Asthma Diagnosis Observation (RETIRED)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.5:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
This template represents a diagnosis of Asthma.
Retired as per STU Comment:
http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=925
Asthma Diagnoses are now represented using the Problem/Diagnosis/Symptom/Condition
Observation.
Table 87: Asthma Diagnosis Observation (RETIRED) Constraints Overview

X Card.
P
a
t
h

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.5:2016-07-01)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 158
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 50: Asthma Diagnosis Observation (V2) Example

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 159
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.6

Caregiver Characteristics
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.72 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 88: Caregiver Characteristics Contexts

Contained By:

Contains:

Social History Section (V2) (optional)

This clinical statement represents a caregiver’s willingness to provide care and the abilities of
that caregiver to provide assistance to a patient in relation to a specific need.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 160
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 89: Caregiver Characteristics Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.72)
@classCode

1..1

SHALL

8114219

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

8114220

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

8114221

1..1

SHALL

8114222

id

1..*

SHALL

8114223

code

1..1

SHALL

8114230

statusCode

1..1

SHALL

8114233

1..1

SHALL

8119090

value

1..1

SHALL

participant

1..*

SHALL

8114227

@typeCode

1..1

SHALL

8126451

time

0..1

MAY

8114830

low

1..1

SHALL

8114831

high

0..1

MAY

8114832

participantRole

1..1

SHALL

8114228

@classCode

1..1

SHALL

8114229

@root

@code

CD

2.16.840.1.113883.10.20.22.4.72

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

8114599

IND

CAREGIVER

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-14219).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-14220).
3. SHALL contain exactly one [1..1] templateId (CONF:81-14221) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.72"
(CONF:81-14222).
4. SHALL contain at least one [1..*] id (CONF:81-14223).
5. SHALL contain exactly one [1..1] code (CONF:81-14230).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 161
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This code MAY be drawn from LOINC (CodeSystem: LOINC
2.16.840.1.113883.6.1) or MAY be bound to ASSERTION (CodeSystem: ActCode
2.16.840.1.113883.5.4 STATIC) (CONF:81-26513).
6. SHALL contain exactly one [1..1] statusCode (CONF:81-14233).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119090).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:81-14599).
a. The code SHALL be selected from LOINC (codeSystem: 2.16.840.1.113883.6.1) or
SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:81-14600).
8. SHALL contain at least one [1..*] participant (CONF:81-14227).
a. Such participants SHALL contain exactly one [1..1] @typeCode="IND" (CONF:8126451).
b. Such participants MAY contain zero or one [0..1] time (CONF:81-14830).
i.

The time, if present, SHALL contain exactly one [1..1] low (CONF:81-14831).

ii. The time, if present, MAY contain zero or one [0..1] high (CONF:81-14832).
c. Such participants SHALL contain exactly one [1..1] participantRole (CONF:8114228).
i.

This participantRole SHALL contain exactly one [1..1]
@classCode="CAREGIVER" (CONF:81-14229).
Figure 51: Caregiver Characteristics Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 162
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.7

Cause of Injury, Poisoning, or Adverse Effect
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.27 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 90: Cause of Injury, Poisoning, or Adverse Effect Contexts

Contained By:

Contains:

Adverse Effect of Medical Treatment (optional)
Injury or Poisoning Observation (V2) (optional)

This template represents the cause of injury, poisoning, or adverse effect. The place and events
that preceded the injury, poisoning, or adverse effect (e.g., allergy to penicillin, bee sting,
pedestrian hit by car driven by drunk driver, spouse beaten with fists by spouse, heroin
overdose, infected shunt, etc.) should be described and recorded. Proper names of people or
places should not be recorded. For a motor vehicle crash, indicate if it occurred on the street or
highway versus a driveway or parking lot.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 163
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 91: Cause of Injury, Poisoning, or Adverse Effect Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.27)
@classCode

1..1

SHALL

1106626

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106627

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106628

1..1

SHALL

1106629

id

1..*

SHALL

1106630

code

1..1

SHALL

1106631

@code

1..1

SHALL

1106632

69543-7

@codeSystem

1..1

SHALL

1106633

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

1106634

1..1

SHALL

1106635

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

1106636

urn:oid:2.16.840.1.113883.6.3
(ICD10)

@nullFlavor

0..1

MAY

1106859

OTH

originalText

0..1

MAY

1106861

@root

statusCode
@code
value

CD

2.16.840.1.113883.10.20.34.3.27

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-626).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-627).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-628).
a. This templateId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.34.3.27" (CONF:1106-629).
4. SHALL contain at least one [1..*] id (CONF:1106-630).
5. SHALL contain exactly one [1..1] code (CONF:1106-631).
a. This code SHALL contain exactly one [1..1] @code="69543-7" Cause of Injury (NCHS)
(CONF:1106-632).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1106-633).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 164
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

6. SHALL contain exactly one [1..1] statusCode (CONF:1106-634).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-635).
If no code is available use nullFlavor="OTH" and enter the value as free text in
code/originalText.
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be
selected from CodeSystem ICD10 (urn:oid:2.16.840.1.113883.6.3) (CONF:1106-636).
a. This value MAY contain zero or one [0..1] @nullFlavor="OTH" (CONF:1106-859).
b. This value MAY contain zero or one [0..1] originalText (CONF:1106-861).
c. Value MAY be selected from ICD-9/10/CM (based on the current version in US
realm) (CONF:1106-860).
Figure 52: Cause of Injury, Poisoning, or Adverse Effect (Free Text) Example

Husband put arsenic in patient's tea

Figure 53: Cause of Injury, Poisoning, or Adverse Effect (Coded) Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 165
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.8

Characteristics of Home Environment
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.109 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 92: Characteristics of Home Environment Contexts

Contained By:

Contains:

Social History Section (V2) (optional)

This template represents the patient's home environment including, but not limited to, type of
residence (trailer, single family home, assisted living), living arrangement (e.g., alone, with
parents), and housing status (e.g., evicted, homeless, home owner).
Table 93: Characteristics of Home Environment Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.109)
@classCode

1..1

SHALL

109827890

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

109827891

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109827892

1..1

SHALL

109827893

id

1..*

SHALL

109827894

code

1..1

SHALL

109831352

@code

1..1

SHALL

109831353

75274-1

@codeSystem

1..1

SHALL

109831354

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

109827901

1..1

SHALL

109827902

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

109828823

urn:oid:2.16.840.1.113883.11.20.
9.49 (Residence and
Accommodation Type)

@root

statusCode
@code
value

CD

2.16.840.1.113883.10.20.22.4.10
9

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-27890).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-27891).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 166
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3. SHALL contain exactly one [1..1] templateId (CONF:1098-27892) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.109"
(CONF:1098-27893).
4. SHALL contain at least one [1..*] id (CONF:1098-27894).
5. SHALL contain exactly one [1..1] code (CONF:1098-31352).
a. This code SHALL contain exactly one [1..1] @code="75274-1" Characteristics of
residence (CONF:1098-31353).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31354).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-27901).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109827902).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be
selected from ValueSet Residence and Accommodation Type
urn:oid:2.16.840.1.113883.11.20.9.49 DYNAMIC (CONF:1098-28823).
Table 94: Residence and Accommodation Type
Value Set: Residence and Accommodation Type urn:oid:2.16.840.1.113883.11.20.9.49
A value set of SNOMED-CT codes descending from "365508006" "Residence and accommodation
circumstances - finding" reflecting type of residence, status of accommodations, living situation and
environment.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.11.20.9.49
Code

Code System

Code System OID

Print Name

424661000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

cluttered living space
(finding)

160708008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

stairs in house (finding)

160751007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

eviction from dwelling
(finding)

423859003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

crowded living space
(finding)

160720000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

harassment by landlord
(finding)

105529008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

lives alone (finding)

60585007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

slum area living (finding)

365508006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

unsatisfactory living
conditions (finding)

422491004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

housing contains exposed
wiring (finding)

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 167
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 54: Characteristics of Home Environment Example

3.9

Clinical Note and External Document Reference
[externalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:201607-01 (open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 95: Clinical Note and External Document Reference Contexts

Contained By:

Contains:

Current Outpatient Visit (V3) (optional)
Current Emergency Department Visit (V2) (optional)

This template represents relevant clinical (e.g., physicians', nurses', P.A.s', N.P.s' and C.N.M.s')
notes for this visit, such as Triage, Intake, History of Present Illness, Clinical Impression and
Discharge. If the current visit is the result of a referral, the referral document can be referenced
using this template.
These notes or documents can be CDA documents or they can be other types of documents
such as PDF.
The following (non-exhaustive) table lists some LOINC code examples for relevant document
types:
Document type

LOINC code

History of Present Illness Narrative

10164-2

Evaluation and Plan Note

51847-2

Evaluation Note

51848-0

Hospital Discharge Dx Narrative

11535-2

Reason for Visit Narrative

29299-5

Referral Note

57113-1

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 168
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 96: Clinical Note and External Document Reference Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

externalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:2016-07-01)
@classCode

1..1

SHALL

32561189

@moodCode

1..1

SHALL

32561178

templateId

1..1

SHALL

32561176

@root

1..1

SHALL

32561180

2.16.840.1.113883.10.20.34.3.44

@extension

1..1

SHALL

32561181

2016-07-01

id

1..*

SHALL

32561182

code

0..1

MAY

32561179

text

0..1

MAY

32561185

@mediaType

1..1

SHALL

32561187

reference

0..1

MAY

32561186

@value

1..1

SHALL

32561188

setId

0..1

MAY

32561183

versionNumber

0..1

MAY

32561184

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

If referencing a CDA document use DOCCLIN, otherwise use DOC.
1. SHALL contain exactly one [1..1] @classCode (CONF:3256-1189).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:3256-1178).
3. SHALL contain exactly one [1..1] templateId (CONF:3256-1176) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.44"
(CONF:3256-1180).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1181).
4. SHALL contain at least one [1..*] id (CONF:3256-1182).
The code represents the type of document. Either a code and/or text description should be
used to describe the external document.
5. MAY contain zero or one [0..1] code (CONF:3256-1179).
6. MAY contain zero or one [0..1] text (CONF:3256-1185).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 169
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. The text, if present, SHALL contain exactly one [1..1] @mediaType (CONF:3256-1187).
b. The text, if present, MAY contain zero or one [0..1] reference (CONF:3256-1186).
i.

The reference, if present, SHALL contain exactly one [1..1] @value
(CONF:3256-1188).

7. MAY contain zero or one [0..1] setId (CONF:3256-1183).
8. MAY contain zero or one [0..1] versionNumber (CONF:3256-1184).
Figure 55: Clinical Note and External Document Reference - Non-CDA Example

Figure 56: Clinical Note and External Document Reference - CDA Document (Referral) Example

3.10 Co-morbid Condition Observation (RETIRED)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.4:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
This template represents a co-morbid condition.
Retired as per STU Comment:
http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=921

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 170
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Co-morbid conditions are now represented using the Problem/Diagnosis/Symptom/Condition
Observation.
Table 97: Co-morbid Condition Observation (RETIRED) Constraints Overview
X Card.
P
a
t
h

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.4:2016-07-01)

Figure 57: Co-morbid Condition Observation (V2) Example

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 171
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.11 Condition Control Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.21 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
This template represents the degree to which the manifestations of the condition are minimized
by therapeutic interventions. Care should be taken to ensure that the identified level of control
does not conflict with the SNOMED/ICD diagnosis code.
Table 98: Condition Control Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.21)
@classCode

1..1

SHALL

1106234

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106235

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106236

1..1

SHALL

1106237

id

1..*

SHALL

1106238

code

1..1

SHALL

1106239

1..1

SHALL

1106240

1..1

SHALL

1106241

1..1

SHALL

1106242

1..1

SHALL

1..1

SHALL

@root

@code
statusCode
@code
value
@code

CD

2.16.840.1.113883.10.20.34.3.21

urn:oid:2.16.840.1.113883.5.4
(ActCode) = ASSERTION

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1106243
1106389

urn:oid:2.16.840.1.114222.4.11.7
433 (Condition Control (NCHS))

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-234).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-235).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-236) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.21"
(CONF:1106-237).
4. SHALL contain at least one [1..*] id (CONF:1106-238).
5. SHALL contain exactly one [1..1] code (CONF:1106-239).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 172
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion
(CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1106-240).
6. SHALL contain exactly one [1..1] statusCode (CONF:1106-241).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-242).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1106-243).
a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from
ValueSet Condition Control (NCHS) urn:oid:2.16.840.1.114222.4.11.7433
DYNAMIC (CONF:1106-389).
Table 99: Condition Control (NCHS)
Value Set: Condition Control (NCHS) urn:oid:2.16.840.1.114222.4.11.7433
Descendants of Disease Condition Finding (371314008) in SNOMED CT
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7433
Code

Code System

Code System OID

Print Name

67106002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Condition determination,
moderately controlled

12650007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Condition determination,
fairly well controlled

39431006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Condition determination,
slightly controlled

28876000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Condition determination,
uncontrolled

1194003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Condition determination,
well controlled

2761002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Condition determination,
arrested

51231003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Condition determination,
cured

Figure 58: Condition Control Observation Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 173
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.12 Coverage Activity (V2)
[act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.60:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 100: Coverage Activity (V2) Contexts
Contained By:

Contains:

Payers Section (V2) (optional)

Policy Activity (V2)

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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 174
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 101: Coverage Activity (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.60:2014-06-09)
@classCode

1..1

SHALL

10988872

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

10988873

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10988897

@root

1..1

SHALL

109810492

2.16.840.1.113883.10.20.22.4.60

@extension

1..1

SHALL

109832596

2014-06-09

id

1..*

SHALL

10988874

code

1..1

SHALL

10988876

@code

1..1

SHALL

109819160

48768-6

@codeSystem

1..1

SHALL

109832156

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

10988875

1..1

SHALL

109819094

1..*

SHALL

10988878

@typeCode

1..1

SHALL

10988879

sequenceNumber

0..1

MAY

109817174

1..1

SHALL

109817175

1..1

SHALL

109815528

statusCode
@code
entryRelationship

@value
act

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

Policy Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.61:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8872).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8873).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-8897) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.60"
(CONF:1098-10492).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 175
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32596).
4. SHALL contain at least one [1..*] id (CONF:1098-8874).
5. SHALL contain exactly one [1..1] code (CONF:1098-8876).
a. This code SHALL contain exactly one [1..1] @code="48768-6" Payment sources
(CONF:1098-19160).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32156).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8875).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819094).
7. SHALL contain at least one [1..*] entryRelationship (CONF:1098-8878) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8879).
b. MAY contain zero or one [0..1] sequenceNumber (CONF:1098-17174).
i.

The sequenceNumber, if present, SHALL contain exactly one [1..1] @value
(CONF:1098-17175).

c. SHALL contain exactly one [1..1] Policy Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.61:2014-06-09) (CONF:109815528).
Figure 59: Coverage Activity (V2) Example

. . .

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 176
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.13 Cultural and Religious Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.111 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 102: Cultural and Religious Observation Contexts
Contained By:

Contains:

Social History Section (V2) (optional)

This template represents a patient’s spiritual, religious, and cultural belief practices, such as a
kosher diet or fasting ritual. religiousAffiliationCode in the document header captures only the
patient’s religious affiliation.
Table 103: Cultural and Religious Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.111)
@classCode

1..1

SHALL

109827924

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

109827925

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109827926

1..1

SHALL

109827927

id

1..*

SHALL

109827928

code

1..1

SHALL

109827929

@code

1..1

SHALL

109827930

75281-6

@codeSystem

1..1

SHALL

109827931

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

109827936

1..1

SHALL

109827937

1..1

SHALL

109828442

@root

statusCode
@code
value

2.16.840.1.113883.10.20.22.4.11
1

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-27924).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-27925).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-27926) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 177
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.111"
(CONF:1098-27927).
4. SHALL contain at least one [1..*] id (CONF:1098-27928).
5. SHALL contain exactly one [1..1] code (CONF:1098-27929).
a. This code SHALL contain exactly one [1..1] @code="75281-6" Personal belief
(CONF:1098-27930).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-27931).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-27936).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109827937).
7. SHALL contain exactly one [1..1] value (CONF:1098-28442).
a. If xsi:type is CD, SHALL contain exactly one 1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMEDCT urn:oid:2.16.840.1.113883.6.96 STATIC) (CONF:1098-32487).
Figure 60: Cultural and Religious Observation Example

Does not accept blood transfusions, or donates, or
stores blood for transfusion.

3.14 Discharge Status Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.28 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 104: Discharge Status Observation Contexts
Contained By:

Contains:

Hospital Admission Encounter (required)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 178
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

This template represents the patient's status at time of discharge. If the status is unknown use
nullFlavor="UNK".
Table 105: Discharge Status Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.28)
@classCode

1..1

SHALL

1106685

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106686

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106687

1..1

SHALL

1106688

id

1..*

SHALL

1106689

code

1..1

SHALL

1106690

@code

1..1

SHALL

1106691

75527-2

@codeSystem

1..1

SHALL

1106692

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

1106693

1..1

SHALL

1106694

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

1106695

urn:oid:2.16.840.1.114222.4.11.7
440 (Hospital Discharge Status
(NCHS))

0..1

MAY

1106696

UNK

@root

statusCode
@code
value

@nullFlavor

CD

2.16.840.1.113883.10.20.34.3.28

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-685).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-686).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-687) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.28"
(CONF:1106-688).
4. SHALL contain at least one [1..*] id (CONF:1106-689).
5. SHALL contain exactly one [1..1] code (CONF:1106-690).
a. This code SHALL contain exactly one [1..1] @code="75527-2" Vital status at
discharge (CONF:1106-691).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 179
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1106-692).
6. SHALL contain exactly one [1..1] statusCode (CONF:1106-693).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-694).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be
selected from ValueSet Hospital Discharge Status (NCHS)
urn:oid:2.16.840.1.114222.4.11.7440 DYNAMIC (CONF:1106-695).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" Unknown
(CONF:1106-696).
Table 106: Hospital Discharge Status (NCHS)
Value Set: Hospital Discharge Status (NCHS) urn:oid:2.16.840.1.114222.4.11.7440
This value set represents the patient's status at discharge.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7440
Code

Code System

Code System OID

Print Name

371827001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient discharged alive

371828006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient deceased during
stay (discharge status =
dead)

...

Figure 61: Discharge Status Observation Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 180
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.15 Drug Monitoring Act
[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.123 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 107: Drug Monitoring Act Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)

US Realm Patient Name (PTN.US.FIELDED)

This template represents the act of monitoring the patient's medication and includes a
participation to record the person responsible for monitoring the medication. The prescriber of
the medication is not necessarily the same person or persons monitoring the drug. The
effectiveTime indicates the time when the activity is intended to take place.
For example, a cardiologist may prescribe a patient Warfarin. The patient's primary care
provider may monitor the patient's INR and adjust the dosing of the Warfarin based on these
lab results. Here the person designated to monitor the drug is the primary care provider.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 181
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 108: Drug Monitoring Act Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.123)
@classCode

1..1

SHALL

109830823

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

109828656

INT

templateId

1..1

SHALL

109828657

1..1

SHALL

109828658

id

1..*

SHALL

109831920

code

1..1

SHALL

109828660

@code

1..1

SHALL

109830818

395170001

@codeSystem

1..1

SHALL

109830819

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) =
2.16.840.1.113883.6.96

1..1

SHALL

109831921

1..1

SHALL

109832358

effectiveTime

1..1

SHALL

109831922

participant

1..*

SHALL

109828661

@typeCode

1..1

SHALL

109828663

participantRole

1..1

SHALL

109828662

@classCode

1..1

SHALL

109828664

id

1..*

SHALL

109828665

playingEntity

1..1

SHALL

109828667

@classCode

1..1

SHALL

109828668

PSN

name

1..1

SHALL

109828669

US Realm Patient Name
(PTN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1

@root

statusCode
@code

2.16.840.1.113883.10.20.22.4.12
3

urn:oid:2.16.840.1.113883.1.11.1
59331 (ActStatus)

RESP

ASSIGNED

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 182
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] @classCode="ACT" act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1098-30823).
2. SHALL contain exactly one [1..1] @moodCode="INT" (CONF:1098-28656).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-28657) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.123"
(CONF:1098-28658).
4. SHALL contain at least one [1..*] id (CONF:1098-31920).
5. SHALL contain exactly one [1..1] code (CONF:1098-28660).
a. This code SHALL contain exactly one [1..1] @code="395170001" medication
monitoring (regime/therapy) (CONF:1098-30818).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT
urn:oid:2.16.840.1.113883.6.96) (CONF:1098-30819).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-31921).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC
(CONF:1098-32358).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31922).
8. SHALL contain at least one [1..*] participant (CONF:1098-28661) such that it
a. SHALL contain exactly one [1..1] @typeCode="RESP" (CONF:1098-28663).
b. SHALL contain exactly one [1..1] participantRole (CONF:1098-28662).
i.

This participantRole SHALL contain exactly one [1..1]
@classCode="ASSIGNED" (CONF:1098-28664).

ii. This participantRole SHALL contain at least one [1..*] id (CONF:1098-28665).
iii. This participantRole SHALL contain exactly one [1..1] playingEntity
(CONF:1098-28667).
1. This playingEntity SHALL contain exactly one [1..1]
@classCode="PSN" (CONF:1098-28668).
2. This playingEntity SHALL contain exactly one [1..1] US Realm
Patient Name (PTN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1) (CONF:1098-28669).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 183
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 109: ActStatus
Value Set: ActStatus urn:oid:2.16.840.1.113883.1.11.159331
Contains the names (codes) for each of the states in the state-machine of the RIM Act class.
Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=

2.16.840.1.113883.1.11.15933
Code

Code System

Code System OID

Print Name

normal

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

normal

aborted

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

aborted

active

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

active

cancelled

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

cancelled

completed

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

completed

held

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

held

new

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

new

suspended

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

suspended

nullified

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

nullified

obsolete

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

obsolete

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 184
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 62: Drug Monitoring Act Example

Listener
Larry
DR

3.16 Drug Vehicle
[participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.24 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 110: Drug Vehicle Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Immunization Activity (V2) (optional)

This template represents the vehicle (e.g., saline, dextrose) for administering a medication.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 185
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 111: 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

817490

templateId

1..1

SHALL

817495

1..1

SHALL

8110493

1..1

SHALL

8119137

@code

1..1

SHALL

8119138

412307009

@codeSystem

1..1

SHALL

8126502

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) =
2.16.840.1.113883.6.96

1..1

SHALL

817492

code

1..1

SHALL

817493

name

0..1

MAY

817494

@root
code

playingEntity

urn:oid:2.16.840.1.113883.5.110
(RoleClass) = MANU

2.16.840.1.113883.10.20.22.4.24

1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass
urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:81-7490).
2. SHALL contain exactly one [1..1] templateId (CONF:81-7495) such that it
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]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT
urn:oid:2.16.840.1.113883.6.96) (CONF:81-26502).
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).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 186
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 63: Drug Vehicle Example

Aerosol

3.17 Encounter Activity (V2)
[encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 112: Encounter Activity (V2) Contexts
Contained By:

Contains:

Encounters Section (entries optional) (V2) (optional)

Encounter Diagnosis (V2)
Indication (V2)
Service Delivery Location

This clinical statement describes an interaction between a patient and clinician. Interactions
may include in-person encounters, telephone conversations, and email exchanges.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 187
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 113: Encounter Activity (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09)
@classCode

1..1

SHALL

10988710

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

10988711

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10988712

@root

1..1

SHALL

109826353

2.16.840.1.113883.10.20.22.4.49

@extension

1..1

SHALL

109832546

2014-06-09

id

1..*

SHALL

10988713

code

1..1

SHALL

10988714

originalText

0..1

SHOUL
D

10988719

reference

0..1

SHOUL
D

109815970

@value

0..1

SHOUL
D

109815971

translation

0..1

MAY

109832323

effectiveTime

1..1

SHALL

10988715

sdtc:dischargeDispositionCode

0..1

MAY

109832176

performer

0..*

MAY

10988725

1..1

SHALL

10988726

code

0..1

MAY

10988727

participant

0..*

SHOUL
D

10988738

@typeCode

1..1

SHALL

10988740

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
LOC

participantRole

1..1

SHALL

109814903

Service Delivery Location
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.32

entryRelationship

0..*

MAY

1098-

assignedEntity

urn:oid:2.16.840.1.113883.3.88.1
2.80.32 (EncounterTypeCode)

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 188
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8722
@typeCode

1..1

SHALL

10988723

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109814899

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..*

MAY

109815492

1..1

SHALL

109815973

entryRelationship
act

Encounter Diagnosis (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.80:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8710).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8711).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-8712) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.49"
(CONF:1098-26353).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32546).
4. SHALL contain at least one [1..*] id (CONF:1098-8713).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet
EncounterTypeCode urn:oid:2.16.840.1.113883.3.88.12.80.32 DYNAMIC
(CONF:1098-8714).
a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-8719).
i.

The originalText, if present, SHOULD contain zero or one [0..1] reference
(CONF:1098-15970).
1. The reference, if present, SHOULD contain zero or one [0..1] @value
(CONF:1098-15971).
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:109815972).

The translation may exist to map the code of EncounterTypeCode
(2.16.840.1.113883.3.88.12.80.32) valueset to the code of Encounter Planned
(2.16.840.1.113883.11.20.9.52) valueset.
b. This code MAY contain zero or one [0..1] translation (CONF:1098-32323).
6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-8715).
7. MAY contain zero or one [0..1] sdtc:dischargeDispositionCode (CONF:1098-32176).
Note: 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
dischargeDispositionCode element

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 189
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This sdtc:dischargeDispositionCode SHOULD contain exactly [1..1] @code, which
SHOULD be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04
FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) DYNAMIC or, if
access to NUBC is unavailable, from CodeSystem 2.16.840.1.113883.12.112 HL7
Discharge Disposition (CONF:1098-32177).
b. This sdtc:dischargeDispositionCode SHOULD contain exactly [1..1] @codeSystem,
which SHOULD be either CodeSystem: NUBC 2.16.840.1.113883.6.301.5 OR
CodeSystem: HL7 Discharge Disposition 2.16.840.1.113883.12.112 (CONF:109832377).
8. MAY contain zero or more [0..*] performer (CONF:1098-8725).
a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-8726).
i.

This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-8727).

9. SHOULD contain zero or more [0..*] participant (CONF:1098-8738) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8740).
b. SHALL contain exactly one [1..1] Service Delivery Location (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-14903).
10. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8722) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8723).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109814899).
11. MAY contain zero or more [0..*] entryRelationship (CONF:1098-15492) such that it
a. SHALL contain exactly one [1..1] Encounter Diagnosis (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2014-06-09) (CONF:109815973).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 190
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 114: EncounterTypeCode
Value Set: EncounterTypeCode urn:oid:2.16.840.1.113883.3.88.12.80.32
This value set includes only the codes of the Current Procedure and Terminology designated for Evaluation and
Management (99200 – 99607) (subscription to AMA Required)
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

99201

CPT4

urn:oid:2.16.840.1.11388
3.6.12

Office or other outpatient
visit (problem focused)

99202

CPT4

urn:oid:2.16.840.1.11388
3.6.12

Office or other outpatient
visit (expanded problem
(expanded)

99203

CPT4

urn:oid:2.16.840.1.11388
3.6.12

Office or other outpatient
visit (detailed)

99204

CPT4

urn:oid:2.16.840.1.11388
3.6.12

Office or other outpatient
visit (comprehensive,
(comprehensive moderate)

99205

CPT4

urn:oid:2.16.840.1.11388
3.6.12

Office or other outpatient
visit (comprehensive,
comprehensive-high)

19681004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Nursing evaluation of
patient and report
(procedure)

207195004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

History and physical
examination with
evaluation and
management of nursing
facility patient
(procedure)

209099002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

History and physical
examination with
management of
domiciliary or rest home
patient (procedure)

210098006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Domiciliary or rest home
patient evaluation and
management (procedure)

225929007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Joint home visit
(procedure)

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 191
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 64: Encounter Activity (V2) Example

. . .

. . .

. . .

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 192
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.17.1 Current Emergency Department Visit (V2)
[encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.40:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 115: Current Emergency Department Visit (V2) Contexts
Contained By:

Contains:

Emergency Department Encounters Section (V2)
(required)

Clinical Note and External Document Reference
Episode of Care Observation (V2)
Major Reason for Visit
Patient Seen in this ED in last 72 Hours and
Discharged
Point of Origin Observation
Transport Mode to Hospital Observation

This template represents the patient's current emergency department visit. The major reason
for this visit is represented by the Major Reason for this Visit template. To indicate whether this
is an initial or follow-up visit use the Episode of Care template. The method of transport to the
hospital is recorded in the Transport Mode to Hospital Observation. The point of origin of the
patient is entered in the Point of Origin Observation template. The Clinical Note and External
Document Reference template is used to record clinician notes (e.g., physicians', nurses',
P.A.s', N.P.s' and C.N.M.s' notes) such as Triage, Intake, History of Present Illness, Clinical
Impression and Discharge.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 193
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 116: Current Emergency Department Visit (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.40:2016-07-01)
@classCode

1..1

SHALL

32561036

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

32561037

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

3256997

@root

1..1

SHALL

32561010

2.16.840.1.113883.10.20.34.3.40

@extension

1..1

SHALL

32561011

2016-07-01

1..1

SHALL

32561006

@code

1..1

SHALL

32561038

EMER

@codeSystem

1..1

SHALL

32561039

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

entryRelationship

0..1

MAY

3256999

@typeCode

1..1

SHALL

32561016

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

32561015

Major Reason for Visit (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.7

0..1

MAY

32561001

@typeCode

1..1

SHALL

32561021

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

32561115

Episode of Care Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.32:2015-04-01

0..1

MAY

32561002

@typeCode

1..1

SHALL

32561024

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

32561025

Transport Mode to Hospital
Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.24

0..1

MAY

3256-

code

entryRelationship

entryRelationship

entryRelationship

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 194
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1003
@typeCode

1..1

SHALL

32561027

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

32561028

Patient Seen in this ED in last 72
Hours and Discharged (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.31

0..1

MAY

32561005

@typeCode

1..1

SHALL

32561033

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

32561034

Point of Origin Observation
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.36:2015-04-01

0..*

MAY

32561155

@typeCode

1..1

SHALL

32561156

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

externalDocument

1..1

SHALL

32561157

Clinical Note and External
Document Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.44:2016-07-01

entryRelationship

reference

1. Conforms to Encounter Activity (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:3256-1036).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:3256-1037).
4. SHALL contain exactly one [1..1] templateId (CONF:3256-997) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.40"
(CONF:3256-1010).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1011).
5. SHALL contain exactly one [1..1] code (CONF:3256-1006).
a. This code SHALL contain exactly one [1..1] @code="EMER" Emergency (CONF:32561038).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1039).
6. MAY contain zero or one [0..1] entryRelationship (CONF:3256-999) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561016).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 195
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. SHALL contain exactly one [1..1] Major Reason for Visit (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.7) (CONF:3256-1015).
Note: Major Reason for This Visit
7. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1001) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561021).
b. SHALL contain exactly one [1..1] Episode of Care Observation (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01)
(CONF:3256-1115).
8. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1002) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561024).
b. SHALL contain exactly one [1..1] Transport Mode to Hospital Observation
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.24) (CONF:32561025).
Note: Mode of arrival
9. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1003) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561027).
b. SHALL contain exactly one [1..1] Patient Seen in this ED in last 72 Hours
and Discharged (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.31)
(CONF:3256-1028).
Note: Was this patient seen in this ED and discharged in the prior 72 hours?
10. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1005) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561033).
b. SHALL contain exactly one [1..1] Point of Origin Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01) (CONF:32561034).
Note: Point of Origin
11. MAY contain zero or more [0..*] reference (CONF:3256-1155).
a. The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers
to (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002) (CONF:3256-1156).
b. The reference, if present, SHALL contain exactly one [1..1] Clinical Note and
External Document Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:2016-07-01) (CONF:32561157).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 196
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 65: Current Emergency Department Visit (V2) Example

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 197
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

...

...

3.17.2 Current Inpatient Visit
[encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.39:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 117: Current Inpatient Visit Contexts
Contained By:

Contains:

Inpatient Encounters Section (V2) (optional)

Admission Priority Observation
Point of Origin Observation

This template represents the patient's current inpatient visit to the facility. The priority level of
the admission is indicated using the Admission Priority Observation template and the point of
origin of the patient is entered in the Point of Origin Observation template.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 198
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 118: Current Inpatient Visit Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.39:2015-04-01)
@classCode

1..1

SHALL

1184983

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

1184984

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184949

@root

1..1

SHALL

1184961

2.16.840.1.113883.10.20.34.3.39

@extension

1..1

SHALL

1184989

2015-04-01

1..1

SHALL

1184988

@code

1..1

SHALL

1184990

IMP

@codeSystem

1..1

SHALL

1184991

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

entryRelationship

0..1

MAY

1184956

@typeCode

1..1

SHALL

1184980

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

1184981

Admission Priority Observation
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.35:2015-04-01

0..1

MAY

1184957

@typeCode

1..1

SHALL

1184985

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

1184986

Point of Origin Observation
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.36:2015-04-01

code

entryRelationship

1. Conforms to Encounter Activity (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1184-983).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-984).
4. SHALL contain exactly one [1..1] templateId (CONF:1184-949) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 199
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.39"
(CONF:1184-961).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-989).
5. SHALL contain exactly one [1..1] code (CONF:1184-988).
a. This code SHALL contain exactly one [1..1] @code="IMP" Inpatient (CONF:1184-990).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:1184-991).
6. MAY contain zero or one [0..1] entryRelationship (CONF:1184-956) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184980).
b. SHALL contain exactly one [1..1] Admission Priority Observation
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.35:2015-04-01)
(CONF:1184-981).
Note: Admission priority
7. MAY contain zero or one [0..1] entryRelationship (CONF:1184-957) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184985).
b. SHALL contain exactly one [1..1] Point of Origin Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01) (CONF:1184-986).
Note: Point of Origin

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 200
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 66: Current Inpatient Visit Example

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 201
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.17.3 Current Outpatient Visit (V3)
[encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.10:2016-07-01
(open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 119: Current Outpatient Visit (V3) Contexts
Contained By:

Contains:

Outpatient Encounters Section (V3) (required)

Clinical Note and External Document Reference
Episode of Care Observation (V2)
Major Reason for Visit
New Patient Act
Number of Visits in the Last 12 Months
Procedure Follow-Up Attempt Observation

This template represents the patient's current outpatient visit to the facility. If the current visit
is the result of a referral, the referral document is referenced through the Clinical Note and
External Document Reference template. If the patient is an established patient, then a count of
all visits in the last 12 months (excluding this visit) is entered in the Number of Visits in the
Last 12 Months template. If the patient is a new patient, this is indicated using the New Patient
Act template. The major reason for this visit is represented by the Major Reason for this Visit
template. To indicate whether this is an initial or follow-up visit use the Episode of Care
template. Information about follow-up after surgery is contained in the Procedure Follow-up
Attempt Observation template.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 202
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 120: Current Outpatient Visit (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.10:2016-07-01)
@classCode

1..1

SHALL

3256463

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

3256464

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

3256465

@root

1..1

SHALL

3256466

2.16.840.1.113883.10.20.34.3.10

@extension

1..1

SHALL

3256993

2016-07-01

1..1

SHALL

3256992

@code

1..1

SHALL

3256994

AMB

@codeSystem

1..1

SHALL

3256995

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

entryRelationship

0..1

MAY

3256469

@typeCode

1..1

SHALL

3256474

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

3256470

Number of Visits in the Last 12
Months (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.26

0..1

MAY

3256471

@typeCode

1..1

SHALL

3256475

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

3256472

Major Reason for Visit (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.7

0..1

MAY

3256484

@typeCode

1..1

SHALL

3256485

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

act

1..1

SHALL

3256486

New Patient Act (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.9

0..1

MAY

3256747

code

entryRelationship

entryRelationship

entryRelationship

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 203
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@typeCode

1..1

SHALL

3256748

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

32561063

Episode of Care Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.32:2015-04-01

0..1

MAY

32561152

@typeCode

1..1

SHALL

32561153

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

32561154

Procedure Follow-Up Attempt
Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.42:2015-04-01

0..*

MAY

32561158

@typeCode

1..1

SHALL

32561159

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

externalDocument

1..1

SHALL

32561160

Clinical Note and External
Document Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.44:2016-07-01

entryRelationship

reference

1. Conforms to Encounter Activity (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:3256-463).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:3256-464).
4. SHALL contain exactly one [1..1] templateId (CONF:3256-465) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.10"
(CONF:3256-466).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-993).
5. SHALL contain exactly one [1..1] code (CONF:3256-992).
a. This code SHALL contain exactly one [1..1] @code="AMB" Ambulatory (outpatient)
(CONF:3256-994).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-995).
6. MAY contain zero or one [0..1] entryRelationship (CONF:3256-469) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256474).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 204
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. SHALL contain exactly one [1..1] Number of Visits in the Last 12 Months
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.26) (CONF:3256-470).
Note: Number of Past Visits in the Last 12 Months
7. MAY contain zero or one [0..1] entryRelationship (CONF:3256-471) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256475).
b. SHALL contain exactly one [1..1] Major Reason for Visit (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.7) (CONF:3256-472).
Note: Major Reason for This Visit
8. MAY contain zero or one [0..1] entryRelationship (CONF:3256-484) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256485).
b. SHALL contain exactly one [1..1] New Patient Act (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.9) (CONF:3256-486).
Note: Has patient been seen in clinic/location before
9. MAY contain zero or one [0..1] entryRelationship (CONF:3256-747) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256748).
b. SHALL contain exactly one [1..1] Episode of Care Observation (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01)
(CONF:3256-1063).
Note: Initial or follow-up visit
10. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1152) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561153).
b. SHALL contain exactly one [1..1] Procedure Follow-Up Attempt Observation
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.42:2015-04-01)
(CONF:3256-1154).
11. MAY contain zero or more [0..*] reference (CONF:3256-1158).
a. The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers
to (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002) (CONF:3256-1159).
b. The reference, if present, SHALL contain exactly one [1..1] Clinical Note and
External Document Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:2016-07-01) (CONF:32561160).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 205
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 67: Current Outpatient Visit (V3) Example

...

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 206
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

...

3.17.4 Hospital Admission Encounter
[encounter: identifier urn:oid:2.16.840.1.113883.10.20.34.3.18 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 121: Hospital Admission Encounter Contexts
Contained By:

Contains:

Emergency Department Encounters Section (V2)
(optional)

Discharge Status Observation
Hospital Discharge Diagnosis (V2)
Listed for Admission to Hospital Act
Service Delivery Location

This template represents the encounter when the patient was admitted to hospital this ED
visit.
If efforts have been exhausted to collect the data, set the appropriate nullFlavor to "UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 207
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 122: Hospital Admission Encounter Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

encounter (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.18)
@classCode

1..1

SHALL

1106540

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

1106541

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106532

1..1

SHALL

1106542

1..1

SHALL

1106533

@code

1..1

SHALL

1106543

32485007

@codeSystem

1..1

SHALL

1106544

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) =
2.16.840.1.113883.6.96

1..1

SHALL

1106534

low

1..1

SHALL

1106545

high

1..1

SHALL

1106546

sdtc:dischargeDispositionCode

0..1

SHOUL
D

1106548

participant

1..1

SHALL

1106531

@typeCode

1..1

SHALL

1106547

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
LOC

participantRole

1..1

SHALL

1106539

Service Delivery Location
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.32

1..1

SHALL

1106536

@typeCode

1..1

SHALL

1106551

participantRole

1..1

SHALL

1106537

@classCode

0..1

MAY

1106552

urn:oid:2.16.840.1.113883.5.110
(RoleClass) = ASSIGNED

code

1..1

SHALL

1106553

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

@root
code

effectiveTime

participant

2.16.840.1.113883.10.20.34.3.18

urn:oid:2.16.840.1.114222.4.11.7
436 (Disposition (NCHS))

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = ADM

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 208
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

entryRelationship

1..1

SHALL

1106535

@typeCode

1..1

SHALL

1106550

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

act

1..1

SHALL

1106549

Hospital Discharge Diagnosis (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.33:2014-06-09

1..1

SHALL

@typeCode

1..1

SHALL

1106698

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

observation

1..1

SHALL

1106699

Discharge Status Observation
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.28

1..1

SHALL

1106538

@typeCode

1..1

SHALL

1106554

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SAS

act

1..1

SHALL

1106555

Listed for Admission to Hospital
Act (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.15

entryRelationship

entryRelationship

EntryR
elation
ship

1106697

1. Conforms to Encounter Activity (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-540).
3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-541).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-532) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.18"
(CONF:1106-542).
5. SHALL contain exactly one [1..1] code (CONF:1106-533).
a. This code SHALL contain exactly one [1..1] @code="32485007" Hospital admission
(CONF:1106-543).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT
urn:oid:2.16.840.1.113883.6.96) (CONF:1106-544).
6. SHALL contain exactly one [1..1] effectiveTime (CONF:1106-534).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1106-545).
Note: Form Element: Date and time patient actually left the ED or observation unit

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 209
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:1106-546).
Note: Form Element: Hospital Discharge Date
7. SHOULD contain zero or one [0..1] sdtc:dischargeDispositionCode, which SHALL be
selected from ValueSet Disposition (NCHS) urn:oid:2.16.840.1.114222.4.11.7436
DYNAMIC (CONF:1106-548).
Note: Form Element: Hospital discharge disposition
8. SHALL contain exactly one [1..1] participant (CONF:1106-531) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106547).
b. SHALL contain exactly one [1..1] Service Delivery Location (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1106-539).
Note: Form Element: Admitted To
9. SHALL contain exactly one [1..1] participant (CONF:1106-536) such that it
a. SHALL contain exactly one [1..1] @typeCode="ADM" Admitter (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1106-551).
b. SHALL contain exactly one [1..1] participantRole (CONF:1106-537).
Note: Form Element: Admitting Physician
i.

This participantRole MAY contain zero or one [0..1] @classCode="ASSIGNED"
(CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110)
(CONF:1106-552).

ii. This participantRole SHALL contain exactly one [1..1] code, which SHALL be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1106-553).
10. SHALL contain exactly one [1..1] entryRelationship (CONF:1106-535) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106550).
b. SHALL contain exactly one [1..1] Hospital Discharge Diagnosis (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2014-06-09)
(CONF:1106-549).
Note: Form Element: Principal Hospital Discharge Diagnosis
11. SHALL contain exactly one [1..1] entryRelationship (CONF:1106-697) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106698).
b. SHALL contain exactly one [1..1] Discharge Status Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.28) (CONF:1106-699).
Note: Form Element: Discharge Status
12. SHALL contain exactly one [1..1] entryRelationship (CONF:1106-538) such that it
a. SHALL contain exactly one [1..1] @typeCode="SAS" Starts after start (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106554).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 210
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. SHALL contain exactly one [1..1] Listed for Admission to Hospital Act
(identifier: urn:oid:2.16.840.1.113883.10.20.34.3.15) (CONF:1106-555).
Note: Form Element: Date and time bed requested for hospital admission
Table 123: Disposition (NCHS)
Value Set: Disposition (NCHS) urn:oid:2.16.840.1.114222.4.11.7436
This value set describes visit disposition concepts.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7436
Code

Code System

Code System OID

Print Name

PHC1270

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Refer to other physician

PHC1271

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return at specified time

PHC1272

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Refer to ER/Admit to
hospital

PHC1273

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Other

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 211
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 68: Hospital Admission Encounter Example

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 212
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

...

...

3.17.5 Observation Unit Stay Encounter
[encounter: identifier urn:oid:2.16.840.1.113883.10.20.34.3.33 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 124: Observation Unit Stay Encounter Contexts
Contained By:

Contains:

Emergency Department Encounters Section (V2)
(optional)

This template represents the encounter when the patient stayed in the observation unit.
If this information is not available at time of abstraction, then complete the Hospital Admission
Log.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 213
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 125: Observation Unit Stay Encounter Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

encounter (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.33)
@classCode

1..1

SHALL

1106797

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

1106798

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106775

1..1

SHALL

1106785

1..1

SHALL

1106776

@code

1..1

SHALL

1106868

75912-6

@codeSystem

1..1

SHALL

1106869

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

1106777

1..1

SHALL

1106788

@nullFlavor

0..1

MAY

1106799

@value

0..1

SHOUL
D

1106800

1..1

SHALL

1106789

@nullFlavor

0..1

MAY

1106801

@value

0..1

SHOUL
D

1106802

@root
code

effectiveTime
low

high

2.16.840.1.113883.10.20.34.3.33

UNK

UNK

1. Conforms to Encounter Activity (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-797).
3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-798).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-775) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.33"
(CONF:1106-785).
5. SHALL contain exactly one [1..1] code (CONF:1106-776).
a. This code SHALL contain exactly one [1..1] @code="75912-6" Observation unit stay
discharge (CONF:1106-868).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 214
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1106-869).
If either the admission or discharge date and time is unknown, use @nullFlavor="UNK"
6. SHALL contain exactly one [1..1] effectiveTime (CONF:1106-777).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1106-788).
Note: Form Element: Date and time of observation unit admission
i.

This low MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106799).

ii. This low SHOULD contain zero or one [0..1] @value (CONF:1106-800).
b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:1106-789).
Note: Form Element: Date and time of observation unit discharge
i.

This high MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106801).

ii. This high SHOULD contain zero or one [0..1] @value (CONF:1106-802).
Figure 69: Observation Unit Stay Encounter Example

3.17.6 Specialty Unit Stay Encounter
[encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.38:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 126: Specialty Unit Stay Encounter Contexts
Contained By:

Contains:

Inpatient Encounters Section (V2) (optional)

This template represents a specialty unit (such as ICU, NICU or CCU) stay.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 215
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 127: Specialty Unit Stay Encounter Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.38:2015-04-01)
@classCode

1..1

SHALL

1184945

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

1184946

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184923

@root

1..1

SHALL

1184933

2.16.840.1.113883.10.20.34.3.38

@extension

1..1

SHALL

1184947

2015-04-01

code

1..1

SHALL

1184924

urn:oid:2.16.840.1.114222.4.11.7
363 (Specialty Unit Type (NCHS))

effectiveTime

1..1

SHALL

1184925

low

1..1

SHALL

1184936

high

1..1

SHALL

1184937

1. Conforms to Encounter Activity (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1184-945).
3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-946).
4. SHALL contain exactly one [1..1] templateId (CONF:1184-923) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.38"
(CONF:1184-933).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-947).
5. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Specialty
Unit Type (NCHS) urn:oid:2.16.840.1.114222.4.11.7363 DYNAMIC (CONF:1184-924).
6. SHALL contain exactly one [1..1] effectiveTime (CONF:1184-925).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1184-936).
Note: Date patient entered the unit.
b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:1184-937).
Note: Date patient left the unit.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 216
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 128: Specialty Unit Type (NCHS)
Value Set: Specialty Unit Type (NCHS) urn:oid:2.16.840.1.114222.4.11.7363
The kind of hospital unit having any necessary specialized equipment and/or personnel for handling critically
ill or injured patients.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7363
Code

Code System

Code System OID

Print Name

1026-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Burn critical care unit

1028-0

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Medical cardiac critical
care unit

1027-2

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Medical critical care unit

1029-8

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Medical/Surgical critical
care unit

1039-7

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Neonatal critical care unit
[Level II/III]

1040-5

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Neonatal critical care unit
[Level III]

1035-5

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Neurology critical care
and stroke unit

1031-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Neurosurgical critical
care unit

1042-1

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Pediatric burn critical
care unit

1044-7

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Pediatric medical critical
care unit

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 217
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 70: Special Unit Stay Encounter Example

3.18 Encounter Diagnosis (V2)
[act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 129: Encounter Diagnosis (V2) Contexts
Contained By:

Contains:

Encounter Activity (V2) (optional)

Problem Observation (V2)

This template wraps relevant problems or diagnoses at the close of a visit or that need to be
followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital
Discharge Diagnosis must be used. This entry requires at least one Problem Observation entry.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 218
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 130: Encounter Diagnosis (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2014-06-09)
@classCode

1..1

SHALL

109814889

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

109814890

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109814895

@root

1..1

SHALL

109814896

2.16.840.1.113883.10.20.22.4.80

@extension

1..1

SHALL

109832542

2014-06-09

1..1

SHALL

109819182

@code

1..1

SHALL

109819183

29308-4

@codeSystem

1..1

SHALL

109832160

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

entryRelationship

1..*

SHALL

109814892

@typeCode

1..1

SHALL

109814893

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

observation

1..1

SHALL

109814898

Problem Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.4:2014-06-09

code

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-14889).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-14890).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-14895) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.80"
(CONF:1098-14896).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32542).
4. SHALL contain exactly one [1..1] code (CONF:1098-19182).
a. This code SHALL contain exactly one [1..1] @code="29308-4" Diagnosis
(CONF:1098-19183).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32160).
5. SHALL contain at least one [1..*] entryRelationship (CONF:1098-14892) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 219
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-14893).
b. SHALL contain exactly one [1..1] Problem Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09) (CONF:109814898).
Figure 71: Encounter Diagnosis (V2) Example

...

3.19 Episode of Care Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 131: Episode of Care Observation (V2) Contexts
Contained By:

Contains:

Current Outpatient Visit (V3) (optional)
Current Emergency Department Visit (V2) (optional)

This template represents whether this is a follow-up visit to this facility for this problem or if it
is the initial visit to this facility for this problem. If it is unknown whether or not this is a
follow-up visit use nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 220
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 132: Episode of Care Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01)
@classCode

1..1

SHALL

1184846

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184847

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184842

1..1

SHALL

1184844

id

1..*

SHALL

1184848

code

1..1

SHALL

1184849

@code

1..1

SHALL

1184851

78030-4

@codeSystem

1..1

SHALL

1184852

2.16.840.1.113883.6.1

1..1

SHALL

1184843

1..1

SHALL

1184845

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

1184850

urn:oid:2.16.840.1.114222.4.11.7
439 (Episode of Care (NCHS))

0..1

MAY

1184853

UNK

@root

statusCode
@code
value
@nullFlavor

CD

2.16.840.1.113883.10.20.34.3.32

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1184-846).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-847).
3. SHALL contain exactly one [1..1] templateId (CONF:1184-842) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.32"
(CONF:1184-844).
4. SHALL contain at least one [1..*] id (CONF:1184-848).
5. SHALL contain exactly one [1..1] code (CONF:1184-849).
a. This code SHALL contain exactly one [1..1] @code="78030-4" Episode of Care
(CONF:1184-851).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1184-852).
6. SHALL contain exactly one [1..1] statusCode (CONF:1184-843).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-845).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 221
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be
selected from ValueSet Episode of Care (NCHS)
urn:oid:2.16.840.1.114222.4.11.7439 DYNAMIC (CONF:1184-850).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-853).
Table 133: Episode of Care (NCHS)
Value Set: Episode of Care (NCHS) urn:oid:2.16.840.1.114222.4.11.7439
These values specify the type of visit.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7439
Code

Code System

Code System OID

Print Name

315639002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Initial patient assessment

185389009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Follow-up visit

...

Figure 72: Episode of Care Observation (V2) Example

3.20 Estimated Date of Delivery
[observation: identifier urn:oid:2.16.840.1.113883.10.20.15.3.1 (closed)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 134: Estimated Date of Delivery Contexts
Contained By:

Contains:

Pregnancy Observation (optional)

This clinical statement represents the anticipated date when a woman will give birth.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 222
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 135: 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

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

81-445

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

8116762

1..1

SHALL

8116763

1..1

SHALL

8119139

@code

1..1

SHALL

8119140

11778-8

@codeSystem

1..1

SHALL

8126503

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

81-448

1..1

SHALL

8119096

1..1

SHALL

@root
code

statusCode
@code
value

TS

2.16.840.1.113883.10.20.15.3.1

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

81-450

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-444).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-445).
3. SHALL contain exactly one [1..1] templateId (CONF:81-16762) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.1"
(CONF:81-16763).
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
urn:oid:2.16.840.1.113883.6.1) (CONF:81-26503).
5. SHALL contain exactly one [1..1] statusCode (CONF:81-448).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119096).
6. SHALL contain exactly one [1..1] value with @xsi:type="TS" (CONF:81-450).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 223
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 73: Estimated Date of Delivery Example

3.21 Follow-up Attempt Outcome Observation
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.43:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 136: Follow-up Attempt Outcome Observation Contexts
Contained By:

Contains:

Procedure Follow-Up Attempt Observation (optional)

This template represents the outcome of a follow-up attempt made within 24 hours of surgery.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 224
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 137: Follow-up Attempt Outcome Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.43:2015-04-01)
@classCode

1..1

SHALL

11841145

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

11841146

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

11841135

@root

1..1

SHALL

11841139

2.16.840.1.113883.10.20.34.3.43

@extension

1..1

SHALL

11841140

2015-04-01

id

1..*

SHALL

11841147

code

1..1

SHALL

11841136

@code

1..1

SHALL

11841141

78028-8

@codeSystem

1..1

SHALL

11841142

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

11841138

1..1

SHALL

11841144

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

11841137

urn:oid:2.16.840.1.114222.4.11.7
362 (Follow-up Attempt Outcome
(NCHS))

0..1

MAY

11841143

urn:oid:2.16.840.1.113883.10.20.
5.9.1 (NullValues_UNK_OTH)

statusCode
@code
value

@nullFlavor

CD

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1184-1145).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1184-1146).
3. SHALL contain exactly one [1..1] templateId (CONF:1184-1135) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.43"
(CONF:1184-1139).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1140).
4. SHALL contain at least one [1..*] id (CONF:1184-1147).
5. SHALL contain exactly one [1..1] code (CONF:1184-1136).
a. This code SHALL contain exactly one [1..1] @code="78028-8" Follow-up attempt
outcome (CONF:1184-1141).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 225
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1184-1142).
6. SHALL contain exactly one [1..1] statusCode (CONF:1184-1138).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-1144).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Follow-up Attempt Outcome (NCHS)
urn:oid:2.16.840.1.114222.4.11.7362 DYNAMIC (CONF:1184-1137).
a. This value MAY contain zero or one [0..1] @nullFlavor, which SHALL be selected
from ValueSet NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1
(CONF:1184-1143).
Table 138: Follow-up Attempt Outcome (NCHS)
Value Set: Follow-up Attempt Outcome (NCHS) urn:oid:2.16.840.1.114222.4.11.7362
The finding(s) or result(s) of contact made by healthcare staff with a patient after an outpatient surgical
procedure.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7362
Code

Code System

Code System OID

Print Name

398090008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Unable to reach Patient

160245001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient reported no
problems

PHC1392

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Patient reported problems
and sought medical care

PHC1393

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Patient reported problems
and was advised by
ambulatory surgical staff
to seek medical care

PHC1394

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Patient reported
problems, but no followup medical care was
needed

...

Table 139: NullValues_UNK_OTH
Value Set: NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1
Null values of unknown and other.
Code

Code System

Code System OID

Print Name

UNK

HL7NullFlavor

urn:oid:2.16.840.1.11388
3.5.1008

Unknown

OTH

HL7NullFlavor

urn:oid:2.16.840.1.11388
3.5.1008

Other

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 226
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 74: Follow-up Attempt Outcome Observation

3.22 Hospital Discharge Diagnosis (V2)
[act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 140: Hospital Discharge Diagnosis (V2) Contexts
Contained By:

Contains:

Hospital Admission Encounter (required)

Problem Observation (V2)

This template represents problems or diagnoses present at the time of discharge which
occurred during the hospitalization or need to be monitored after hospitalization. It requires at
least one Problem Observation entry.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 227
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 141: Hospital Discharge Diagnosis (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2014-06-09)
@classCode

1..1

SHALL

10987663

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

10987664

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109816764

@root

1..1

SHALL

109816765

2.16.840.1.113883.10.20.22.4.33

@extension

1..1

SHALL

109832534

2014-06-09

1..1

SHALL

109819147

@code

1..1

SHALL

109819148

11535-2

@codeSystem

1..1

SHALL

109832163

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

entryRelationship

1..*

SHALL

10987666

@typeCode

1..1

SHALL

10987667

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

observation

1..1

SHALL

109815536

Problem Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.4:2014-06-09

code

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7663).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7664).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-16764) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.33"
(CONF:1098-16765).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32534).
4. SHALL contain exactly one [1..1] code (CONF:1098-19147).
a. This code SHALL contain exactly one [1..1] @code="11535-2" Hospital discharge
diagnosis (CONF:1098-19148).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32163).
5. SHALL contain at least one [1..*] entryRelationship (CONF:1098-7666) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 228
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7667).
b. SHALL contain exactly one [1..1] Problem Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09) (CONF:109815536).
Figure 75: Hospital Discharge Diagnosis (V2) Example

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 229
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.23 Immunization Activity (V2)
[substanceAdministration: identifier
urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 142: Immunization Activity (V2) Contexts
Contained By:

Contains:

Immunizations Section (optional)

Author Participation
Drug Vehicle
Immunization Medication Information (V2)
Immunization Refusal Reason
Indication (V2)
Instruction (V2)
Medication Dispense (V2)
Medication Supply Order (V2)
Precondition for Substance Administration (V2)
Reaction Observation (V2)
Substance Administered Act

An Immunization Activity describes immunization substance administrations that have
actually occurred or are intended to occur. Immunization Activities in "INT" mood are
reflections of immunizations a clinician intends a patient to receive. Immunization Activities in
"EVN" mood reflect immunizations actually received.
An Immunization Activity is very similar to a Medication Activity with some key differentiators.
The drug code system is constrained to CVX codes. Administration timing is less complex.
Patient refusal reasons should be captured. All vaccines administered should be fully
documented in the patient's permanent medical record. Healthcare providers who administer
vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the
permanent medical record of the recipient indicates:
1) Date of administration
2) Vaccine manufacturer
3) Vaccine lot number
4) Name and title of the person who administered the vaccine and the address of the clinic or
facility where the permanent record will reside
5) Vaccine information statement (VIS)
a. Date printed on the VIS
b. Date VIS given to patient or parent/guardian.
This information should be included in an Immunization Activity when available. (Reference:
http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/vacc_admin.p
df)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 230
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 143: Immunization Activity (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2014-06-09)
@classCode

1..1

SHALL

10988826

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = SBADM

@moodCode

1..1

SHALL

10988827

urn:oid:2.16.840.1.113883.11.20.
9.18 (MoodCodeEvnInt)

@negationInd

0..1

MAY

10988985

templateId

1..1

SHALL

10988828

@root

1..1

SHALL

109810498

2.16.840.1.113883.10.20.22.4.52

@extension

1..1

SHALL

109832528

2014-06-09

id

1..*

SHALL

10988829

code

0..1

MAY

10988830

statusCode

1..1

SHALL

10988833

1..1

SHALL

109832359

effectiveTime

1..1

SHALL

10988834

repeatNumber

0..1

MAY

10988838

routeCode

0..1

MAY

10988839

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.7 (Medication Route
FDA)

approachSiteCode

0..1

MAY

10988840

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

doseQuantity

0..1

SHOUL
D

10988841

0..1

SHOUL
D

10988842

urn:oid:2.16.840.1.113883.1.11.1
2839
(UnitsOfMeasureCaseSensitive)

administrationUnitCode

0..1

MAY

10988846

urn:oid:2.16.840.1.113762.1.4.10
21.30
(AdministrationUnitDoseForm)

consumable

1..1

SHALL

10988847

1..1

SHALL

109815546

@code

@unit

manufacturedProduct

SET

urn:oid:2.16.840.1.113883.1.11.1
59331 (ActStatus)

Immunization Medication
Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.54:2014-06-09

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 231
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

performer

0..1

SHOUL
D

10988849

author

0..*

SHOUL
D

109831151

participant

0..*

MAY

10988850

@typeCode

1..1

SHALL

10988851

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = CSM

participantRole

1..1

SHALL

109815547

Drug Vehicle (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.24

entryRelationship

0..*

MAY

10988853

@typeCode

1..1

SHALL

10988854

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109815537

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..1

MAY

10988856

@typeCode

1..1

SHALL

10988857

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

10988858

true

act

1..1

SHALL

109831392

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

0..1

MAY

10988860

@typeCode

1..1

SHALL

10988861

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

supply

1..1

SHALL

109815539

Medication Supply Order (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.17:2014-06-09

0..1

MAY

10988863

@typeCode

1..1

SHALL

10988864

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

supply

1..1

SHALL

109815540

Medication Dispense (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.18:2014-06-09

0..1

MAY

1098-

entryRelationship

entryRelationship

entryRelationship

entryRelationship

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 232
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8866
@typeCode

1..1

SHALL

10988867

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
CAUS

observation

1..1

SHALL

109815541

Reaction Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.9:2014-06-09

0..1

MAY

10988988

@typeCode

1..1

SHALL

10988989

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109815542

Immunization Refusal Reason
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.53

0..*

SHOUL
D

109831510

@typeCode

1..1

SHALL

109831511

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

@inversionInd

1..1

SHALL

109831512

true

sequenceNumber

0..1

MAY

109831513

act

1..1

SHALL

109831514

precondition

0..*

MAY

10988869

@typeCode

1..1

SHALL

10988870

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
PRCN

criterion

1..1

SHALL

109815548

Precondition for Substance
Administration (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.25:2014-06-09

entryRelationship

entryRelationship

Substance Administered Act
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.118

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8826).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2014-09-01
(CONF:1098-8827).
3. MAY contain zero or one [0..1] @negationInd (CONF:1098-8985).
Note: Use negationInd="true" to indicate that the immunization was not given.
4. SHALL contain exactly one [1..1] templateId (CONF:1098-8828) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 233
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.52"
(CONF:1098-10498).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32528).
5. SHALL contain at least one [1..*] id (CONF:1098-8829).
6. MAY contain zero or one [0..1] code (CONF:1098-8830).
Note: SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee,
"this is intended to further specify the nature of the substance administration act. To date
the committee has made no use of this attribute". Because the type of substance
administration is generally implicit in the routeCode, in the consumable participant, etc.,
the field is generally not used and there is no defined value set.
7. SHALL contain exactly one [1..1] statusCode (CONF:1098-8833).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC
(CONF:1098-32359).
8. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-8834).
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.
9. MAY contain zero or one [0..1] repeatNumber (CONF:1098-8838).
10. MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet
Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC
(CONF:1098-8839).
11. MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from
ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC
(CONF:1098-8840).
12. SHOULD contain zero or one [0..1] doseQuantity (CONF:1098-8841).
a. The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL
be selected from ValueSet UnitsOfMeasureCaseSensitive
urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-8842).
13. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from
ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30
DYNAMIC (CONF:1098-8846).
14. SHALL contain exactly one [1..1] consumable (CONF:1098-8847).
a. This consumable SHALL contain exactly one [1..1] Immunization Medication
Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09) (CONF:109815546).
15. SHOULD contain zero or one [0..1] performer (CONF:1098-8849).
16. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31151).
17. MAY contain zero or more [0..*] participant (CONF:1098-8850) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 234
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988851).
b. SHALL contain exactly one [1..1] Drug Vehicle (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.24) (CONF:1098-15547).
18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8853) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8854).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815537).
19. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8856) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8857).
b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-8858).
c. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831392).
20. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8860) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8861).
b. SHALL contain exactly one [1..1] Medication Supply Order (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09) (CONF:109815539).
21. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8863) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8864).
b. SHALL contain exactly one [1..1] Medication Dispense (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09) (CONF:109815540).
22. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8866) such that it
a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8867).
b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109815541).
23. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8988) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8989).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 235
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. SHALL contain exactly one [1..1] Immunization Refusal Reason (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.53) (CONF:1098-15542).
The following entryRelationship is used to indicate a given immunization's order in a series.
The nested Substance Administered Act identifies an administration in the series. The
entryRelationship/sequenceNumber shows the order of this particular administration in that
series.
24. SHOULD contain zero or more [0..*] entryRelationship (CONF:1098-31510) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831511).
b. SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1098-31512).
c. MAY contain zero or one [0..1] sequenceNumber (CONF:1098-31513).
d. SHALL contain exactly one [1..1] Substance Administered Act (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.118) (CONF:1098-31514).
25. MAY contain zero or more [0..*] precondition (CONF:1098-8869) such that it
a. SHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8870).
b. SHALL contain exactly one [1..1] Precondition for Substance Administration
(V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-0609) (CONF:1098-15548).
Table 144: MoodCodeEvnInt
Value Set: MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18
Contains moodCode EVN and INT
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

EVN

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Event

INT

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Intent

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 236
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 145: Medication Route FDA
Value Set: Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7
Route of Administration value set is based upon FDA Drug Registration and Listing Database (FDA Orange
Book) which are used in FDA Structured Product Labeling (SPL).
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.3.88.12.32
21.8.7
Code

Code System

Code System OID

Print Name

C38192

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

AURICULAR (OTIC)

C38193

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

BUCCAL

C38194

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

CONJUNCTIVAL

C38675

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

CUTANEOUS

C38197

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

DENTAL

C38633

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

ELECTRO-OSMOSIS

C38205

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

ENDOCERVICAL

C38206

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

ENDOSINUSIAL

C38208

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

ENDOTRACHEAL

C38209

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

ENTERAL

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 237
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 146: Body Site
Value Set: Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9
Contains 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.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

362783006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

entire medial surface of
lower extremity (body
structure)

302539009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

entire hand (body
structure)

287679003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

left hip region structure
(body structure)

3341006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

right lung structure (body
structure)

87878005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

left ventricular structure
(body structure)

49848007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

structure of myocardium
of left ventricle (body
structure)

38033009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

amputation stump (body
structure)

305005006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

6/7 interchondral joint
(body structure)

28726007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

corneal structure (body
structure)

75324005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

70 to 79 percent of body
surface (body structure)

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 238
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 147: UnitsOfMeasureCaseSensitive
Value Set: UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839
The 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.html
Code

Code System

Code System OID

Print Name

min

UCUM

urn:oid:2.16.840.1.11388
3.6.8

minute

hour

UCUM

urn:oid:2.16.840.1.11388
3.6.8

hr

%

UCUM

urn:oid:2.16.840.1.11388
3.6.8

percent

cm

UCUM

urn:oid:2.16.840.1.11388
3.6.8

centimeter

g

UCUM

urn:oid:2.16.840.1.11388
3.6.8

gram

g/(12.h)

UCUM

urn:oid:2.16.840.1.11388
3.6.8

gram per 12 hour

g/L

UCUM

urn:oid:2.16.840.1.11388
3.6.8

gram per liter

mol

UCUM

urn:oid:2.16.840.1.11388
3.6.8

mole

[IU]

UCUM

urn:oid:2.16.840.1.11388
3.6.8

international unit

Hz

UCUM

urn:oid:2.16.840.1.11388
3.6.8

Hertz

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 239
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 148: AdministrationUnitDoseForm
Value Set: AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30
Codes that are similar to a drug "form" but limited to those used as units when describing drug administration
when the drug item is a physical form that is continuous and therefore not administered as an "each" of the
physical form, or is not using standard measurement units (inch, ounce, gram, etc.) This set does not include
unit concepts that mimic "physical form" concepts that can be counted using "each", such as tablet, bar,
lozenge, packet, etc.
Code

Code System

Code System OID

Print Name

C122629

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Actuation Dosing Unit

C25397

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Application Unit

C102405

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Capful Dosing Unit

C122631

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Dropperful Dosing Unit

C48501

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Inhalation Dosing Unit

C48491

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Metric Drop

C71204

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Nebule Dosing Unit

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Puff Dosing Unit

C48536

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Scoopful Dosing Unit

C48537

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.11388
3.3.26.1.1

Spray Dosing Unit

C65060

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 240
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 76: Immunization Activity (V2) Example

1

Health LS - Immuno Inc.

1007 Health Drive
Portland
OR
99123
US

Harold
Hippocrates

Good Health Clinic

1007 Health Drive
Portland
OR
99123
US

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 241
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.24 Immunization Medication Information (V2)
[manufacturedProduct: identifier
urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 149: Immunization Medication Information (V2) Contexts
Contained By:

Contains:

Immunization Activity (V2) (required)
Medication Supply Order (V2) (optional)
Medication Dispense (V2) (optional)
Planned Immunization Activity (required)

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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 242
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 150: Immunization Medication Information (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

manufacturedProduct (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09)
@classCode

1..1

SHALL

10989002

templateId

1..1

SHALL

10989004

@root

1..1

SHALL

109810499

2.16.840.1.113883.10.20.22.4.54

@extension

1..1

SHALL

109832602

2014-06-09

id

0..*

MAY

10989005

manufacturedMaterial

1..1

SHALL

10989006

1..1

SHALL

10989007

urn:oid:2.16.840.1.113762.1.4.10
10.6 (CVX Vaccines Administered
- Vaccine Set )

translation

0..*

MAY

109831543

urn:oid:2.16.840.1.113762.1.4.10
10.8 (Vaccine Clinical Drug)

translation

0..*

MAY

109831881

urn:oid:2.16.840.1.113762.1.4.10
10.10 (Specific Vaccine Clinical
Drug)

lotNumberText

1..1

SHALL

10989014

0..1

SHOUL
D

10989012

code

manufacturerOrganization

urn:oid:2.16.840.1.113883.5.110
(RoleClass) = MANU

1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass
urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:1098-9002).
2. SHALL contain exactly one [1..1] templateId (CONF:1098-9004) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.54"
(CONF:1098-10499).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32602).
3. MAY contain zero or more [0..*] id (CONF:1098-9005).
4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:1098-9006).
a. This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be
selected from ValueSet CVX Vaccines Administered - Vaccine Set
urn:oid:2.16.840.1.113762.1.4.1010.6 DYNAMIC (CONF:1098-9007).
i.

This code MAY contain zero or more [0..*] translation, which MAY be
selected from ValueSet Vaccine Clinical Drug
urn:oid:2.16.840.1.113762.1.4.1010.8 DYNAMIC (CONF:1098-31543).

ii. This code MAY contain zero or more [0..*] translation, which MAY be
selected from ValueSet Specific Vaccine Clinical Drug
urn:oid:2.16.840.1.113762.1.4.1010.10 DYNAMIC (CONF:1098-31881).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 243
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This manufacturedMaterial SHALL contain exactly one [1..1] lotNumberText
(CONF:1098-9014).
5. SHOULD contain zero or one [0..1] manufacturerOrganization (CONF:1098-9012).
Table 151: CVX Vaccines Administered - Vaccine Set
Value Set: CVX Vaccines Administered - Vaccine Set urn:oid:2.16.840.1.113762.1.4.1010.6
CVX vaccine concepts that represent actual vaccines types. This does not include the identifiers for CVX codes
that do not represent vaccines.
Value set intensionally defined from CVX (OID: 2.16.840.1.113883.12.292)
FilterOnProperty(nonvaccine,FALSE).
Value Set Source: http://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=cvx
Code

Code System

Code System OID

Print Name

19

CDC Vaccine Code (CVX)

urn:oid:2.16.840.1.11388
3.12.292

BCG

26

CDC Vaccine Code (CVX)

urn:oid:2.16.840.1.11388
3.12.292

Cholera

24

CDC Vaccine Code (CVX)

urn:oid:2.16.840.1.11388
3.12.292

Anthrax

27

CDC Vaccine Code (CVX)

urn:oid:2.16.840.1.11388
3.12.292

Botulinum antitoxin

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 244
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 152: Vaccine Clinical Drug
Value Set: Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.8
Administrable vaccine medication formulations represented using either a "generic" or "brand-specific"
concept.
Value set intensionally defined from RXNORM (OID: 2.16.840.1.113883.6.88), comprised of those codes whose
ingredients map to NDC codes that the CDC associates with CVX codes.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

898572

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

0.17 ML Rho(D) Immune
Globulin 0.3 MG/ML
Prefilled Syringe
[HyperRHO]

807276

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

0.5 ML diphtheria toxoid
vaccine, inactivated 4
UNT/ML / tetanus toxoid
vaccine, inactivated 10
UNT/ML Prefilled Syringe
[Decavac]

798482

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

0.5 ML Hepatitis A
Vaccine (Inactivated)
Strain HM175 1440
UNT/ML Prefilled Syringe
[Havrix]

836636

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

0.5 ML Hepatitis A
Vaccine, Inactivated 50
UNT/ML Prefilled Syringe
[Vaqta]

...

Table 153: Specific Vaccine Clinical Drug
Value Set: Specific Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.10
This value set contains extensionally identified RxNorm vaccine codes. It should be used to supplement the
Vaccine Clinical Drug Value Set (Value Set OID 2.16.840.1.113762.1.4.1010.8). Intensional rules for the latter
value set are being refined, but at this time lack complete sensitivity, and as a result can miss including
relevant codes. This Specific Vaccine Clinical Drug Value Set is used to manually provide for these other
RxNorm codes.
(At the time of Consolidated CDA R2 publication, the value set has no members)
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

NA

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

At the time of
Consolidated CDA R2
publication, the value set
has no members

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 245
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 77: Immunization Medication Information (V2) Example

1

Health LS - Immuno Inc.

3.25 Immunization Refusal Reason
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.53 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 154: Immunization Refusal Reason Contexts
Contained By:

Contains:

Immunization Activity (V2) (optional)

The Immunization Refusal Reason documents the rationale for the patient declining an
immunization.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 246
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 155: Immunization Refusal Reason Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.53)
@classCode

1..1

SHALL

818991

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

818992

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

818993

1..1

SHALL

8110500

id

1..*

SHALL

818994

code

1..1

SHALL

818995

statusCode

1..1

SHALL

818996

1..1

SHALL

8119104

@root

@code

2.16.840.1.113883.10.20.22.4.53

urn:oid:2.16.840.1.113883.1.11.1
9717 (No Immunization Reason
Value Set)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-8991).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-8992).
3. SHALL contain exactly one [1..1] templateId (CONF:81-8993) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.53"
(CONF:81-10500).
4. SHALL contain at least one [1..*] id (CONF:81-8994).
5. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet No
Immunization Reason Value Set urn:oid:2.16.840.1.113883.1.11.19717 DYNAMIC
(CONF:81-8995).
6. SHALL contain exactly one [1..1] statusCode (CONF:81-8996).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119104).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 247
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 156: No Immunization Reason Value Set
Value Set: No Immunization Reason Value Set urn:oid:2.16.840.1.113883.1.11.19717
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

IMMUNE

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Immunity

MEDPREC

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Medical precaution

OSTOCK

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Out of stock

PATOBJ

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Patient objection

PHILISOP

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Philosophical objection

RELIG

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Religious objection

VACEFF

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Vaccine efficacy concerns

VACSAF

ActReason

urn:oid:2.16.840.1.11388
3.5.8

Vaccine safety concerns

Figure 78: Immunization Refusal Reason Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 248
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.26 Indication (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 157: Indication (V2) Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Procedure Activity Act (V2) (optional)
Procedure Activity Procedure (V2) (optional)
Procedure Activity Observation (V2) (optional)
Immunization Activity (V2) (optional)
Encounter Activity (V2) (optional)
Planned Act (V2) (optional)
Planned Procedure (V2) (optional)
Planned Observation (V2) (optional)
Planned Medication Activity (V2) (optional)
Planned Immunization Activity (optional)

This template represents the rationale for an action such as an encounter, a medication
administration, or a procedure. The id element can be used to reference a problem recorded
elsewhere in the document, or can be used with a code and value to record the problem.
Indications for treatment are not laboratory results; rather the problem associated with the
laboratory result should be sited (e.g., hypokalemia instead of a laboratory result of Potassium
2.0 mEq/L). Use the Drug Monitoring Act [templateId 2.16.840.1.113883.10.20.22.4.123] to
indicate if a particular drug needs special monitoring (e.g., anticoagulant therapy). Use
Precondition for Substance Administration (V2) [templateId
2.16.840.1.113883.10.20.22.4.25.2] to represent that a medication is to be administered only
when the associated criteria are met.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 249
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 158: Indication (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09)
@classCode

1..1

SHALL

10987480

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10987481

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987482

@root

1..1

SHALL

109810502

2.16.840.1.113883.10.20.22.4.19

@extension

1..1

SHALL

109832570

2014-06-09

id

1..*

SHALL

10987483

code

1..1

SHALL

109831229

statusCode

1..1

SHALL

10987487

1..1

SHALL

109819105

effectiveTime

0..1

SHOUL
D

10987488

value

0..1

MAY

@code

CD

10987489

urn:oid:2.16.840.1.113883.3.88.1
2.3221.7.2 (Problem Type)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

urn:oid:2.16.840.1.113883.3.88.1
2.3221.7.4 (Problem)

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7480).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7481).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7482) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.19"
(CONF:1098-10502).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32570).
4. SHALL contain at least one [1..*] id (CONF:1098-7483).
Note: If the id element is used to reference a problem recorded else where in the document
then this id must equal another entry/id in the same document instance. Application
Software must be responsible for resolving the identifier back to its original object and then
rendering the information in the correct place in the containing section's narrative text. Its
purpose is to obviate the need to repeat the complete XML representation of the referred to
entry when relating one entry to another.
5. SHALL contain exactly one [1..1] code, which MAY be selected from ValueSet Problem Type
urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:109831229).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 250
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7487).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819105).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7488).
8. MAY contain zero or one [0..1] value with @xsi:type="CD", where the code SHOULD be
selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4
DYNAMIC (CONF:1098-7489).
Table 159: Problem
Value Set: Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4
A 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:

http://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.3.88.12.322
1.7.4
Code

Code System

Code System OID

Print Name

46635009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

diabetes mellitus type 1

234422006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

acute intermittent
porphyria

31712002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

primary biliary cirrhosis

302002000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

difficulty moving

15188001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

hearing loss

129851009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

alteration in bowel
elimination

247472004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

hives

39579001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

anaphylaxis

274945004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

AA amyloidosis (disorder)

129851009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

alteration in comfort:
pain

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 251
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 160: Problem Type
Value Set: Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2
This 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 Name

75326-9

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Problem HL7.CCDAR2

75325-1

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Symptom HL7.CCDAR2

75324-4

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Diagnosis

75321-0

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Clinical finding
HL7.CCDAR2

75323-6

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Condition HL7.CCDAR2

29308-4

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Complaint HL7.CCDAR2

75322-8

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Functional performance
HL7.CCDAR2

75275-8

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Cognitive Function
HL7.CCDAR2

75318-6

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Problem family member
HL7.CCDAR2

75319-4

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Symptom family member
HL7.CCDAR2

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 252
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 79: Indication (V2) Example

0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN
wheezing

...

...

3.26.1 Major Reason for Visit
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.7 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 161: Major Reason for Visit Contexts
Contained By:

Contains:

Current Outpatient Visit (V3) (optional)
Current Emergency Department Visit (V2) (optional)

This template represents the major reason for this visit.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 253
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 162: Major Reason for Visit Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.7)
@classCode

1..1

SHALL

1106405

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106406

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106407

1..1

SHALL

1106408

1..1

SHALL

1106409

@code

1..1

SHALL

1106410

ASSERTION

@codeSystem

1..1

SHALL

1106411

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

1106412

urn:oid:2.16.840.1.114222.4.11.7
404 (Major Reason for Visit
(NCHS))

@root
code

value

CD

2.16.840.1.113883.10.20.34.3.7

1. Conforms to Indication (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-405).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-406).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-407) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.7"
(CONF:1106-408).
5. SHALL contain exactly one [1..1] code (CONF:1106-409).
a. This code SHALL contain exactly one [1..1] @code="ASSERTION" (CONF:1106-410).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:1106-411).
6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Major Reason for Visit (NCHS)
urn:oid:2.16.840.1.114222.4.11.7404 DYNAMIC (CONF:1106-412).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 254
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 163: Major Reason for Visit (NCHS)
Value Set: Major Reason for Visit (NCHS) urn:oid:2.16.840.1.114222.4.11.7404
These codes describe the major reason for the visit.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7404
Code

Code System

Code System OID

Print Name

PHC1268

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Chronic problem, flare-up

PHC1267

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Chronic problem, routine

PHC1265

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

New problem (<3 mos.
onset)

PHC1269

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Pre/Post surgery

PHC1266

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Preventive care (e.g.,
routine prenatal, wellbaby, screening,
insurance, general
exams)

...

Figure 80: Major Reason for Visit Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 255
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.27 Instruction (V2)
[act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 164: Instruction (V2) Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Procedure Activity Act (V2) (optional)
Procedure Activity Procedure (V2) (optional)
Procedure Activity Observation (V2) (optional)
Immunization Activity (V2) (optional)
Planned Act (V2) (optional)
Planned Procedure (V2) (optional)
Planned Observation (V2) (optional)
Planned Medication Activity (V2) (optional)
Medication Supply Order (V2) (optional)
Planned Immunization Activity (optional)

The Instruction 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 template's
moodCode can only be INT. If an instruction was already be given, the Procedure Activity Act
template (instead of this template) should be used to represent the already occurred
instruction. 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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 256
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 165: Instruction (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09)
@classCode

1..1

SHALL

10987391

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

10987392

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = INT

templateId

1..1

SHALL

10987393

@root

1..1

SHALL

109810503

2.16.840.1.113883.10.20.22.4.20

@extension

1..1

SHALL

109832598

2014-06-09

code

1..1

SHALL

109816884

urn:oid:2.16.840.1.113883.11.20.
9.34 (Patient Education)

statusCode

1..1

SHALL

10987396

1..1

SHALL

109819106

@code

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7391).
2. SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7392).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7393) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.20"
(CONF:1098-10503).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32598).
4. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Patient
Education urn:oid:2.16.840.1.113883.11.20.9.34 DYNAMIC (CONF:1098-16884).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7396).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819106).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 257
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 166: Patient Education
Value Set: Patient Education urn:oid:2.16.840.1.113883.11.20.9.34
Limited to terms descending from the Education (409073007) hierarchy.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

311401005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient Education

171044003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Immunization Education

243072006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Cancer Education

...

Figure 81: Instruction (V2) Example

Possible flu-like symptoms for three days.

3.28 Listed for Admission to Hospital Act
[act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.15 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 167: Listed for Admission to Hospital Act Contexts
Contained By:

Contains:

Hospital Admission Encounter (required)

This template represents the time that a bed was requested for the patient for hospital
admission.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 258
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 168: Listed for Admission to Hospital Act Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.15)
@classCode

1..1

SHALL

1106700

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

1106701

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106560

1..1

SHALL

1106564

id

1..*

SHALL

1106565

code

1..1

SHALL

1106561

@code

1..1

SHALL

1106566

183767005

@codeSystem

1..1

SHALL

1106567

2.16.840.1.113883.6.96

1..1

SHALL

1106563

1..1

SHALL

1106569

1..1

SHALL

1106562

1..1

SHALL

1106568

@root

statusCode
@code
effectiveTime
low

2.16.840.1.113883.10.20.34.3.15

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-700).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-701).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-560) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.15"
(CONF:1106-564).
4. SHALL contain at least one [1..*] id (CONF:1106-565).
5. SHALL contain exactly one [1..1] code (CONF:1106-561).
a. This code SHALL contain exactly one [1..1] @code="183767005" Listed for admission
to hospital (CONF:1106-566).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" SNOMED (CONF:1106-567).
6. SHALL contain exactly one [1..1] statusCode (CONF:1106-563).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-569).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 259
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

7. SHALL contain exactly one [1..1] effectiveTime (CONF:1106-562).
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1106-568).
Note: Form Element: Date and time bed was requested for hospital admission
Figure 82: Listed for Admission to Hospital Act Example

3.29 Medication Activity (V2)
[substanceAdministration: identifier
urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 169: Medication Activity (V2) Contexts
Contained By:

Contains:

Medications Section (entries optional) (V2) (optional)
Reaction Observation (V2) (optional)
Procedure Activity Act (V2) (optional)
Procedure Activity Procedure (V2) (optional)
Procedure Activity Observation (V2) (optional)
Medications Section (optional)

Author Participation
Drug Monitoring Act
Drug Vehicle
Indication (V2)
Instruction (V2)
Medication Dispense (V2)
Medication Free Text Sig
Medication Information (V2)
Medication Supply Order (V2)
Precondition for Substance Administration (V2)
Reaction Observation (V2)
Substance Administered Act

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. For example, a clinician may intend that a patient to be
administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered
was Lisinopril 10 mg., then the Medication activities in the "EVN" mood would reflect actual
use.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 260
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

A moodCode of INT is allowed, but it is recommended that the Planned Medication Activity (V2)
template be used for moodCodes other than EVN if the document type contains a section that
includes Planned Medication Activity (V2) (for example a Care Plan document with Plan of
Treatment, Intervention, or Goal sections).
At a minimum, a Medication Activity shall include an effectiveTime indicating the duration of
the administration (or single-administration timestamp). Ambulatory medication lists generally
provide a summary of use for a given medication over time - a medication activity in event
mood with the duration reflecting when the medication started and stopped. Ongoing
medications will not have a stop date (or will have a stop date with a suitable NULL value).
Ambulatory medication lists will generally also have a frequency (e.g., a medication is being
taken twice a day). Inpatient medications generally record each administration as a separate
act.
The dose (doseQuantity) represents how many of the consumables are to be administered at
each administration event. As a result, the dose is always relative to the consumable and the
interval of administration. Thus, a patient consuming a single "metoprolol 25mg tablet" per
administration will have a doseQuantity of "1", whereas a patient consuming "metoprolol" will
have a dose of "25 mg".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 261
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 170: Medication Activity (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09)
@classCode

1..1

SHALL

10987496

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = SBADM

@moodCode

1..1

SHALL

10987497

urn:oid:2.16.840.1.113883.11.20.
9.18 (MoodCodeEvnInt)

templateId

1..1

SHALL

10987499

@root

1..1

SHALL

109810504

2.16.840.1.113883.10.20.22.4.16

@extension

1..1

SHALL

109832498

2014-06-09

id

1..*

SHALL

10987500

code

0..1

MAY

10987506

statusCode

1..1

SHALL

10987507

1..1

SHALL

109832360

1..1

SHALL

@value

0..1

SHOUL
D

109832775

low

0..1

SHOUL
D

109832776

high

0..1

MAY

109832777

effectiveTime

0..1

SHOUL
D

10987513

@operator

1..1

SHALL

10989106

repeatNumber

0..1

MAY

10987555

routeCode

0..1

SHOUL
D

10987514

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.7 (Medication Route
FDA)

approachSiteCode

0..1

MAY

10987515

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

doseQuantity

1..1

SHALL

10987516

0..1

SHOUL
D

10987526

0..1

MAY

1098-

@code
effectiveTime

@unit

rateQuantity

IVL_TS

SET

urn:oid:2.16.840.1.113883.1.11.1
59331 (ActStatus)

10987508

A

urn:oid:2.16.840.1.113883.1.11.1
2839
(UnitsOfMeasureCaseSensitive)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 262
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

7517
@unit

1..1

SHALL

maxDoseQuantity

0..1

MAY

administrationUnitCode

0..1

MAY

10987519

consumable

1..1

SHALL

10987520

1..1

SHALL

109816085

performer

0..1

MAY

10987522

author

0..*

SHOUL
D

109831150

participant

0..*

MAY

10987523

@typeCode

1..1

SHALL

10987524

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = CSM

participantRole

1..1

SHALL

109816086

Drug Vehicle (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.24

entryRelationship

0..*

MAY

10987536

@typeCode

1..1

SHALL

10987537

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109816087

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..1

MAY

10987539

@typeCode

1..1

SHALL

10987540

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

10987542

true

act

1..1

SHALL

109831387

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

0..1

MAY

10987543

1..1

SHALL

10987547

manufacturedProduct

entryRelationship

entryRelationship
@typeCode

10987525
RTO

urn:oid:2.16.840.1.113883.1.11.1
2839
(UnitsOfMeasureCaseSensitive)

10987518
urn:oid:2.16.840.1.113762.1.4.10
21.30
(AdministrationUnitDoseForm)

Medication Information (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.23:2014-06-09

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 263
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

REFR
supply

1..1

SHALL

109816089

0..*

MAY

10987549

@typeCode

1..1

SHALL

10987553

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

supply

1..1

SHALL

109816090

Medication Dispense (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.18:2014-06-09

0..*

MAY

10987552

@typeCode

1..1

SHALL

10987544

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
CAUS

observation

1..1

SHALL

109816091

Reaction Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.9:2014-06-09

0..1

MAY

109830820

@typeCode

1..1

SHALL

109830821

COMP

act

1..1

SHALL

109830822

Drug Monitoring Act (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.123

0..*

MAY

109831515

@typeCode

1..1

SHALL

109831516

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

@inversionInd

1..1

SHALL

109831517

true

sequenceNumber

0..1

MAY

109831518

act

1..1

SHALL

109831519

0..*

MAY

109832907

@typeCode

1..1

SHALL

109832908

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

substanceAdministration

1..1

SHALL

1098-

Medication Free Text Sig
(identifier:

entryRelationship

entryRelationship

entryRelationship

entryRelationship

entryRelationship

Medication Supply Order (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.17:2014-06-09

Substance Administered Act
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.118

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 264
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

32909

urn:oid:2.16.840.1.113883.10.20.
22.4.147

precondition

0..*

MAY

109831520

@typeCode

1..1

SHALL

109831882

PRCN

criterion

1..1

SHALL

109831883

Precondition for Substance
Administration (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.25:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7496).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03
(CONF:1098-7497).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7499) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16"
(CONF:1098-10504).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32498).
4. SHALL contain at least one [1..*] id (CONF:1098-7500).
5. MAY contain zero or one [0..1] code (CONF:1098-7506).
Note: SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee,
"this is intended to further specify the nature of the substance administration act. To date
the committee has made no use of this attribute". Because the type of substance
administration is generally implicit in the routeCode, in the consumable participant, etc.,
the field is generally not used, and there is no defined value set.
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7507).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC
(CONF:1098-32360).
The substance administration effectiveTime field can repeat, in order to represent varying levels
of complex dosing. effectiveTime can be used to represent the duration of administration (e.g.,
"10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require
that there SHALL be an effectiveTime documentation of the duration (or single-administration
timestamp), and that there SHOULD be an effectiveTime documentation of the frequency.
Other timing nuances, supported by the base CDA R2 standard, may also be included.
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-7508) such that it
Note: This effectiveTime represents either the medication duration (i.e., the time the
medication was started and stopped) or the single-administration timestamp.
a. SHOULD contain zero or one [0..1] @value (CONF:1098-32775).
Note: indicates a single-administration timestamp
b. SHOULD contain zero or one [0..1] low (CONF:1098-32776).
Note: indicates when medication started

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 265
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

c. MAY contain zero or one [0..1] high (CONF:1098-32777).
Note: indicates when medication stopped
d. This effectiveTime SHALL contain either a low or a @value but not both
(CONF:1098-32890).
8. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it
Note: This effectiveTime represents the medication frequency (e.g., administration times per
day).
a. SHALL contain exactly one [1..1] @operator="A" (CONF:1098-9106).
b. SHALL contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:109828499).
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.
9. MAY contain zero or one [0..1] repeatNumber (CONF:1098-7555).
10. SHOULD contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet
Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC
(CONF:1098-7514).
11. MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from
ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC
(CONF:1098-7515).
12. SHALL contain exactly one [1..1] doseQuantity (CONF:1098-7516).
a. This doseQuantity SHOULD contain zero or one [0..1] @unit, which SHALL be selected
from ValueSet UnitsOfMeasureCaseSensitive
urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-7526).
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" per administration) (CONF:1098-16878).
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:1098-16879).
13. MAY contain zero or one [0..1] rateQuantity (CONF:1098-7517).
a. The rateQuantity, if present, SHALL contain exactly one [1..1] @unit, which SHALL be
selected from ValueSet UnitsOfMeasureCaseSensitive
urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-7525).
14. MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-7518).
administrationUnitCode@code describes the units of medication administration for an item
using a code that is pre-coordinated to include a physical unit form (ointment, powder,
solution, etc.) which differs from the units used in administering the consumable (capful,
spray, drop, etc.). For example when recording medication administrations, “metric drop

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 266
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

(C48491)” would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25%
Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value.
15. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from
ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30
DYNAMIC (CONF:1098-7519).
16. SHALL contain exactly one [1..1] consumable (CONF:1098-7520).
a. This consumable SHALL contain exactly one [1..1] Medication Information (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09)
(CONF:1098-16085).
17. MAY contain zero or one [0..1] performer (CONF:1098-7522).
18. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31150).
19. MAY contain zero or more [0..*] participant (CONF:1098-7523) such that it
a. SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10987524).
b. SHALL contain exactly one [1..1] Drug Vehicle (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.24) (CONF:1098-16086).
20. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7536) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7537).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109816087).
21. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7539) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7540).
b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7542).
c. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831387).
22. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7543) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7547).
b. SHALL contain exactly one [1..1] Medication Supply Order (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09) (CONF:109816089).
23. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7549) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7553).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 267
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. SHALL contain exactly one [1..1] Medication Dispense (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09) (CONF:109816090).
24. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7552) such that it
a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7544).
b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109816091).
25. MAY contain zero or one [0..1] entryRelationship (CONF:1098-30820) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:109830821).
b. SHALL contain exactly one [1..1] Drug Monitoring Act (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.123) (CONF:1098-30822).
The following entryRelationship is used to indicate a given medication's order in a series. The
nested Substance Administered Act identifies an administration in the series. The
entryRelationship/sequenceNumber shows the order of this particular administration in that
series.
26. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31515) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831516).
b. SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1098-31517).
c. MAY contain zero or one [0..1] sequenceNumber (CONF:1098-31518).
d. SHALL contain exactly one [1..1] Substance Administered Act (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.118) (CONF:1098-31519).
27. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32907) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832908).
b. SHALL contain exactly one [1..1] Medication Free Text Sig (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.147) (CONF:1098-32909).
28. MAY contain zero or more [0..*] precondition (CONF:1098-31520).
a. The precondition, if present, SHALL contain exactly one [1..1] @typeCode="PRCN"
(CONF:1098-31882).
b. The precondition, if present, SHALL contain exactly one [1..1] Precondition for
Substance Administration (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09) (CONF:109831883).
29. Medication Activity SHOULD include doseQuantity OR rateQuantity (CONF:1098-30800).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 268
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 83: Medication Activity (V2) Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 269
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 84: No Known Medications Example

3.30 Medication Dispense (V2)
[supply: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 171: Medication Dispense (V2) Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Immunization Activity (V2) (optional)

Immunization Medication Information (V2)
Medication Information (V2)
Medication Supply Order (V2)
US Realm Address (AD.US.FIELDED)

This template records the act of supplying medications (i.e., dispensing).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 270
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 172: Medication Dispense (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

supply (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09)
@classCode

1..1

SHALL

10987451

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = SPLY

@moodCode

1..1

SHALL

10987452

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987453

@root

1..1

SHALL

109810505

2.16.840.1.113883.10.20.22.4.18

@extension

1..1

SHALL

109832580

2014-06-09

id

1..*

SHALL

10987454

statusCode

1..1

SHALL

10987455

1..1

SHALL

109832361

effectiveTime

0..1

SHOUL
D

10987456

repeatNumber

0..1

SHOUL
D

10987457

quantity

0..1

SHOUL
D

10987458

product

0..1

MAY

10987459

1..1

SHALL

109815607

0..1

MAY

10989331

1..1

SHALL

109831696

0..1

MAY

10987461

1..1

SHALL

10987467

0..1

SHOUL
D

10987468

0..1

MAY

10987473

@code

manufacturedProduct

product
manufacturedProduct

performer
assignedEntity
addr

entryRelationship

urn:oid:2.16.840.1.113883.3.88.1
2.80.64 (Medication Fill Status)

Medication Information (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.23:2014-06-09

Immunization Medication
Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.54:2014-06-09

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 271
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@typeCode

1..1

SHALL

10987474

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

supply

1..1

SHALL

109815606

Medication Supply Order (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.17:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7451).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7452).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7453) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.18"
(CONF:1098-10505).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32580).
4. SHALL contain at least one [1..*] id (CONF:1098-7454).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7455).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet Medication Fill Status
urn:oid:2.16.840.1.113883.3.88.12.80.64 STATIC 2014-04-23 (CONF:109832361).
6. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7456).
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.
7. SHOULD contain zero or one [0..1] repeatNumber (CONF:1098-7457).
8. SHOULD contain zero or one [0..1] quantity (CONF:1098-7458).
9. MAY contain zero or one [0..1] product (CONF:1098-7459) such that it
a. SHALL contain exactly one [1..1] Medication Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) (CONF:109815607).
10. MAY contain zero or one [0..1] product (CONF:1098-9331) such that it
a. SHALL contain exactly one [1..1] Immunization Medication Information (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09)
(CONF:1098-31696).
11. MAY contain zero or one [0..1] performer (CONF:1098-7461).
a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-7467).
i.

This assignedEntity SHOULD contain zero or one [0..1] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-7468).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 272
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

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:109810565).
12. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7473) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7474).
b. SHALL contain exactly one [1..1] Medication Supply Order (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09) (CONF:109815606).
13. A supply act SHALL contain one product/Medication Information OR one
product/Immunization Medication Information template (CONF:1098-9333).
Table 173: Medication Fill Status
Value Set: Medication Fill Status urn:oid:2.16.840.1.113883.3.88.12.80.64
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

aborted

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

Aborted

completed

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

Completed

Figure 85: Medication Dispense (V2) Example

. . .

. . .

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 273
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.31 Medication Free Text Sig
[substanceAdministration: identifier urn:oid:2.16.840.1.113883.10.20.22.4.147
(closed)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2.1
Table 174: Medication Free Text Sig Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)

The template is available to explicitly identify the free text Sig within each medication.
An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 274
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 175: Medication Free Text Sig Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

substanceAdministration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.147)
@classCode

1..1

SHALL

119832770

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = SBADM

@moodCode

1..1

SHALL

119832771

urn:oid:2.16.840.1.113883.11.20.
9.18 (MoodCodeEvnInt)

templateId

1..1

SHALL

119832753

1..1

SHALL

119832772

2.16.840.1.113883.10.20.22.4.14
7

1..1

SHALL

119832775

urn:oid:2.16.840.1.113883.6.1
(LOINC)

@code

1..1

SHALL

119832780

76662-6

@codeSystem

1..1

SHALL

119832781

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

119832754

reference

1..1

SHALL

119832755

@value

0..1

SHOUL
D

119832756

1..1

SHALL

119832776

1..1

SHALL

119832777

1..1

SHALL

119832778

1..1

SHALL

119832779

@root
code

text

consumable
manufacturedProduct
manufacturedLabeledDrug
@nullFlavor

NA

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-32770).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03
(CONF:1198-32771).
Note: moodCode must match the parent substanceAdministration EVN or INT
3. SHALL contain exactly one [1..1] templateId (CONF:1198-32753) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.147"
(CONF:1198-32772).
4. SHALL contain exactly one [1..1] code (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32775).
a. This code SHALL contain exactly one [1..1] @code="76662-6" Instructions
Medication (CONF:1198-32780).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 275
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:1198-32781).
5. SHALL contain exactly one [1..1] text (CONF:1198-32754).
Reference into the section/text to a tag that only contains free text sig.
a. This text SHALL contain exactly one [1..1] reference (CONF:1198-32755).
i.

This reference SHOULD contain zero or one [0..1] @value (CONF:1198-32756).
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:1198-32774).

6. SHALL contain exactly one [1..1] consumable (CONF:1198-32776).
a. This consumable SHALL contain exactly one [1..1] manufacturedProduct
(CONF:1198-32777).
i.

This manufacturedProduct SHALL contain exactly one [1..1]
manufacturedLabeledDrug (CONF:1198-32778).
1. This manufacturedLabeledDrug SHALL contain exactly one [1..1]
@nullFlavor="NA" Not Applicable (CONF:1198-32779).
Figure 86: Medication Free Text Sig Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 276
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.32 Medication Information (V2)
[manufacturedProduct: identifier
urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 176: Medication Information (V2) Contexts
Contained By:

Contains:

Medication Activity (V2) (required)
Planned Medication Activity (V2) (required)
Medication Supply Order (V2) (optional)
Medication Dispense (V2) (optional)

A medication should be recorded as a pre-coordinated ingredient + strength + dose form (e.g.,
“metoprolol 25mg tablet”, “amoxicillin 400mg/5mL suspension”) where possible. This includes
RxNorm codes whose Term Type is SCD (semantic clinical drug), SBD (semantic brand drug),
GPCK (generic pack), BPCK (brand pack).
The dose (doseQuantity) represents how many of the consumables are to be administered at
each administration event. As a result, the dose is always relative to the consumable. Thus, a
patient consuming a single "metoprolol 25mg tablet" per administration will have a
doseQuantity of "1", whereas a patient consuming "metoprolol" will have a dose of "25 mg".
Table 177: Medication Information (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

manufacturedProduct (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09)
@classCode

1..1

SHALL

10987408

templateId

1..1

SHALL

10987409

@root

1..1

SHALL

109810506

2.16.840.1.113883.10.20.22.4.23

@extension

1..1

SHALL

109832579

2014-06-09

id

0..*

MAY

10987410

manufacturedMaterial

1..1

SHALL

10987411

1..1

SHALL

10987412

urn:oid:2.16.840.1.113762.1.4.10
10.4 (Medication Clinical Drug)

0..*

MAY

109831884

urn:oid:2.16.840.1.113762.1.4.10
10.2 (Clinical Substance)

0..1

MAY

10987416

code
translation
manufacturerOrganization

urn:oid:2.16.840.1.113883.5.110
(RoleClass) = MANU

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 277
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass
urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:1098-7408).
2. SHALL contain exactly one [1..1] templateId (CONF:1098-7409) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.23"
(CONF:1098-10506).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32579).
3. MAY contain zero or more [0..*] id (CONF:1098-7410).
4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:1098-7411).
Note: A medication should be recorded as a pre-coordinated ingredient + strength + dose
form (e.g., “metoprolol 25mg tablet”, “amoxicillin 400mg/5mL suspension”) where possible.
This includes RxNorm codes whose Term Type is SCD (semantic clinical drug), SBD
(semantic brand drug), GPCK (generic pack), BPCK (brand pack).
a. This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be
selected from ValueSet Medication Clinical Drug
urn:oid:2.16.840.1.113762.1.4.1010.4 DYNAMIC (CONF:1098-7412).
i.

This code MAY contain zero or more [0..*] translation, which MAY be
selected from ValueSet Clinical Substance
urn:oid:2.16.840.1.113762.1.4.1010.2 DYNAMIC (CONF:1098-31884).

5. MAY contain zero or one [0..1] manufacturerOrganization (CONF:1098-7416).
Table 178: Medication Clinical Drug
Value Set: Medication Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.4
All prescribable medication formulations represented using either a "generic" or "brand-specific" concept. This
includes RxNorm codes whose Term Type is SCD (semantic clinical drug), SBD (semantic brand drug), GPCK
(generic pack), BPCK (brand pack), SCDG (semantic clinical drug group), SBDG (semantic brand drug group),
SCDF (semantic clinical drug form), or SBDF (semantic brand drug form).
Value set intensionally defined as a GROUPING made up of: Value Set: Medication Clinical General Drug
(2.16.840.1.113883.3.88.12.80.17) (RxNorm Generic Drugs); Value Set: Medication Clinical Brand-specific
Drug (2.16.840.1.113762.1.4.1010.5) (RxNorm Branded Drugs).
Value Set Source: http://phinvads.cdc.gov/vads/ViewValueSet.action?id=239BEF3E-971C-

DF11-B334-0015173D1785
Code

Code System

Code System OID

Print Name

978727

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

0.2 ML Dalteparin
Sodium 12500 UNT/ML
Prefilled Syringe
[Fragmin]

827318

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

Acetaminophen 250 MG /
Aspirin 250 MG /
Caffeine 65 MG Oral
Capsule

199274

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

Aspirin 300 MG Oral
Capsule

362867

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

Cefotetan Injectable
Solution [Cefotan]

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 278
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 179: Clinical Substance
Value Set: Clinical Substance urn:oid:2.16.840.1.113762.1.4.1010.2
All substances that may need to be represented in the context of health care related activities. This value set is
quite broad in coverage and includes concepts that may never be needed in a health care activity event,
particularly the included SNOMED CT concepts. The code system-specific value sets in this grouping value set
are intended to provide broad coverage of all kinds of agents, but the expectation for use is that the chosen
concept identifier for a substance should be appropriately specific and drawn from the appropriate code system
as noted: prescribable medications should use RXNORM concepts, more specific drugs and chemicals should
be represented using UNII concepts, and any substances not found in either of those two code systems, should
use the appropriate SNOMED CT concept. This overarching grouping value set is intended to support
identification of prescribable medications, foods, general substances and environmental entities.
Value set intensionally defined as a GROUPING made up of: Value Set: Medication Clinical Drug
(2.16.840.1.113762.1.4.1010.4) (RxNorm generic and brand codes); Value Set: Unique Ingredient Identifier Complete Set (2.16.840.1.113883.3.88.12.80.20) (UNII codes); Value Set: Substance Other Than Clinical Drug
(2.16.840.1.113762.1.4.1010.9) (SNOMED CT codes).
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

369436

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

6-Aminocaproic Acid Oral
Tablet [Amicar]

1116447

RxNorm

urn:oid:2.16.840.1.11388
3.6.88

Acepromazine Oral Tablet

9042592173

Unique Ingredient
Identifier (UNII)

urn:oid:2.16.840.1.11388
3.4.9

ATROMEPINE

7673326042

Unique Ingredient
Identifier (UNII)

urn:oid:2.16.840.1.11388
3.4.9

IRINOTECAN

413480003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Almond product
(substance)

256915001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Aluminum hydroxide
absorbed plasma
(substance)

10020007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Biperiden hydrochloride
(substance)

10133003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Cyclizine lactate
(substance)

10174003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Procarbazine
hydrochloride (substance)

102259006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Citrus fruit (substance)

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 279
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 87: Medication Information (V2) Example

Medication Factory Inc.

3.33 Medication Supply Order (V2)
[supply: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 180: Medication Supply Order (V2) Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Immunization Activity (V2) (optional)
Medication Dispense (V2) (optional)

Immunization Medication Information (V2)
Instruction (V2)
Medication Information (V2)

This template records the intent to supply a patient with medications.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 280
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 181: Medication Supply Order (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

supply (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09)
@classCode

1..1

SHALL

10987427

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = SPLY

@moodCode

1..1

SHALL

10987428

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = INT

templateId

1..1

SHALL

10987429

@root

1..1

SHALL

109810507

2.16.840.1.113883.10.20.22.4.17

@extension

1..1

SHALL

109832578

2014-06-09

id

1..*

SHALL

10987430

statusCode

1..1

SHALL

10987432

1..1

SHALL

109832362

0..1

SHOUL
D

1..1

SHALL

109815144

repeatNumber

0..1

SHOUL
D

10987434

quantity

0..1

SHOUL
D

10987436

product

0..1

MAY

10987439

1..1

SHALL

109816093

0..1

MAY

10989334

1..1

SHALL

109831695

author

0..1

MAY

10987438

entryRelationship

0..1

MAY

10987442

1..1

SHALL

10987444

@code
effectiveTime
high

manufacturedProduct

product
manufacturedProduct

@typeCode

IVL_TS

urn:oid:2.16.840.1.113883.1.11.1
59331 (ActStatus)

109815143

Medication Information (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.23:2014-06-09

Immunization Medication
Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.54:2014-06-09

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 281
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@inversionInd

1..1

SHALL

10987445

true

act

1..1

SHALL

109831391

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7427).
2. SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7428).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7429) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.17"
(CONF:1098-10507).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32578).
4. SHALL contain at least one [1..*] id (CONF:1098-7430).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7432).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC
(CONF:1098-32362).
6. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-15143) such that it
a. SHALL contain exactly one [1..1] high (CONF:1098-15144).
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.
7. SHOULD contain zero or one [0..1] repeatNumber (CONF:1098-7434).
8. SHOULD contain zero or one [0..1] quantity (CONF:1098-7436).
9. MAY contain zero or one [0..1] product (CONF:1098-7439) such that it
a. SHALL contain exactly one [1..1] Medication Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) (CONF:109816093).
10. MAY contain zero or one [0..1] product (CONF:1098-9334) such that it
a. SHALL contain exactly one [1..1] Immunization Medication Information (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09)
(CONF:1098-31695).
i.

A supply act SHALL contain one product/Medication Information OR one
product/Immunization Medication Information template (CONF:109816870).

11. MAY contain zero or one [0..1] author (CONF:1098-7438).
12. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7442).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7444).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 282
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. The entryRelationship, if present, SHALL contain exactly one [1..1]
@inversionInd="true" True (CONF:1098-7445).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] Instruction
(V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-0609) (CONF:1098-31391).
Figure 88: Medication Supply Order (V2) Example

. . .

. . .

. . .

3.34 New Patient Act
[act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.9 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 182: New Patient Act Contexts
Contained By:

Contains:

Current Outpatient Visit (V3) (optional)

This template represents the fact that this patient is a new patient at this practice.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 283
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 183: New Patient Act Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.9)
@classCode

1..1

SHALL

1106476

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

1106477

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106478

1..1

SHALL

1106479

id

1..*

SHALL

1106480

code

1..1

SHALL

1106481

@code

1..1

SHALL

1106482

108220007

@codeSystem

1..1

SHALL

1106483

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) =
2.16.840.1.113883.6.96

1..1

SHALL

1106741

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

@root

statusCode

2.16.840.1.113883.10.20.34.3.9

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-476).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-477).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-478) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.9"
(CONF:1106-479).
4. SHALL contain at least one [1..*] id (CONF:1106-480).
5. SHALL contain exactly one [1..1] code (CONF:1106-481).
a. This code SHALL contain exactly one [1..1] @code="108220007" Evaluation and/or
management - new patient (CONF:1106-482).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT
urn:oid:2.16.840.1.113883.6.96) (CONF:1106-483).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem:
ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-741).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 284
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 89: New Patient Act Example

3.35 Number of Visits in the Last 12 Months
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.26 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 184: Number of Visits in the Last 12 Months Contexts
Contained By:

Contains:

Current Outpatient Visit (V3) (optional)

This template represents the number of visits in the last 12 months, excluding the current
visit.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 285
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 185: Number of Visits in the Last 12 Months Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.26)
@classCode

1..1

SHALL

1106521

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106522

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106523

1..1

SHALL

1106524

id

1..*

SHALL

1106525

code

1..1

SHALL

1106526

@code

0..1

MAY

1106527

75612-2

@codeSystem

0..1

MAY

1106528

2.16.840.1.113883.6.1

statusCode

1..1

SHALL

1106529

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

value

1..1

SHALL

@root

INT

2.16.840.1.113883.10.20.34.3.26

1106530

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-521).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-522).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-523) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.26"
(CONF:1106-524).
4. SHALL contain at least one [1..*] id (CONF:1106-525).
5. SHALL contain exactly one [1..1] code (CONF:1106-526).
a. This code MAY contain zero or one [0..1] @code="75612-2" Number of visits to this
healthcare entity in the last 12MO (CONF:1106-527).
b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1"
(CONF:1106-528).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem:
ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-529).
7. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1106-530).
Note: Form Element: Number of Visits in the Last 12 Months

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 286
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 90: Number of Visits in the Last 12 Months Example

3.36 On Oxygen on Arrival Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.29 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 186: On Oxygen on Arrival Observation Contexts
Contained By:

Contains:

Triage Section (required)

This template represents whether or not the patient was on oxygen on arrival. If it is unknown
whether the patient was on oxygen on arrival use nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 287
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 187: On Oxygen on Arrival Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.29)
@classCode

1..1

SHALL

1106704

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106705

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106706

1..1

SHALL

1106707

id

1..*

SHALL

1106708

code

1..1

SHALL

1106709

@code

1..1

SHALL

1106713

75610-6

@codeSystem

0..1

MAY

1106714

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

1106710

1..1

SHALL

1106711

1..1

SHALL

@nullFlavor

0..1

MAY

1106715

@value

0..1

SHOUL
D

1106856

@root

statusCode
@code
value

BL

2.16.840.1.113883.10.20.34.3.29

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1106712
UNK

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-704).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-705).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-706) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.29"
(CONF:1106-707).
4. SHALL contain at least one [1..*] id (CONF:1106-708).
5. SHALL contain exactly one [1..1] code (CONF:1106-709).
a. This code SHALL contain exactly one [1..1] @code="75610-6" Oxygen therapy at
arrival (CONF:1106-713).
b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1"
(CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1106-714).
6. SHALL contain exactly one [1..1] statusCode (CONF:1106-710).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 288
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-711).
7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1106-712).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106-715).
b. This value SHOULD contain zero or one [0..1] @value (CONF:1106-856).
Figure 91: On Oxygen on Arrival Observation Example

3.37 Patient Residence Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.25 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 188: Patient Residence Observation Contexts
Contained By:

Contains:

Patient Information Section (V3) (optional)

This template represents the patient residence type. If the type of residence is other use
nullFlavor="OTH". If the type of residence is unknown use nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 289
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 189: Patient Residence Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.25)
@classCode

1..1

SHALL

1106606

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106607

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106601

1..1

SHALL

1106603

id

1..*

SHALL

1106679

code

1..1

SHALL

1106602

@code

1..1

SHALL

1106604

75617-1

@codeSystem

1..1

SHALL

1106605

2.16.840.1.113883.6.1

1..1

SHALL

1106680

0..1

MAY

1106681

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

1106608

urn:oid:2.16.840.1.114222.4.11.7
402 (Patient Residence (NCHS))

0..1

MAY

1106675

urn:oid:2.16.840.1.113883.10.20.
5.9.1 (NullValues_UNK_OTH)

@root

statusCode
@code
value
@nullFlavor

CD

2.16.840.1.113883.10.20.34.3.25

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-606).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-607).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-601) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.25"
(CONF:1106-603).
4. SHALL contain at least one [1..*] id (CONF:1106-679).
5. SHALL contain exactly one [1..1] code (CONF:1106-602).
a. This code SHALL contain exactly one [1..1] @code="75617-1" Residence
(CONF:1106-604).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1106-605).
6. SHALL contain exactly one [1..1] statusCode (CONF:1106-680).
a. This statusCode MAY contain zero or one [0..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-681).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 290
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be
selected from ValueSet Patient Residence (NCHS)
urn:oid:2.16.840.1.114222.4.11.7402 DYNAMIC (CONF:1106-608).
a. This value MAY contain zero or one [0..1] @nullFlavor, which SHALL be selected
from ValueSet NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1
STATIC 2014-01-01 (CONF:1106-675).
Table 190: Patient Residence (NCHS)
Value Set: Patient Residence (NCHS) urn:oid:2.16.840.1.114222.4.11.7402
These codes describe the patient's residence type.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7402
Code

Code System

Code System OID

Print Name

394778007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Client's or patient's home

42665001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Nursing home

32911000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Homeless

...

Figure 92: Patient Residence Example

3.38 Patient Seen in this ED in last 72 Hours and Discharged
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.31 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 191: Patient Seen in this ED in last 72 Hours and Discharged Contexts
Contained By:

Contains:

Current Emergency Department Visit (V2) (optional)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 291
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

This template represents whether or not the patient has been seen in this ED within the last 72
hours and discharged. If this fact is unknown use nullFlavor="UNK".
Table 192: Patient Seen in this ED in last 72 Hours and Discharged Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.31)
@classCode

1..1

SHALL

1106722

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106723

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106718

1..1

SHALL

1106720

id

1..*

SHALL

1106724

code

1..1

SHALL

1106725

@code

0..1

MAY

1106727

75611-4

@codeSystem

0..1

MAY

1106728

2.16.840.1.113883.6.1

1..1

SHALL

1106719

1..1

SHALL

1106721

1..1

SHALL

@nullFlavor

0..1

MAY

1106729

@value

0..1

SHOUL
D

1106862

@root

statusCode
@code
value

BL

2.16.840.1.113883.10.20.34.3.31

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1106726
UNK

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-722).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-723).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-718) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.31"
(CONF:1106-720).
4. SHALL contain at least one [1..*] id (CONF:1106-724).
5. SHALL contain exactly one [1..1] code (CONF:1106-725).
a. This code MAY contain zero or one [0..1] @code="75611-4" Patient seen in this ED
in last 72H and discharged (CONF:1106-727).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 292
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1"
(CONF:1106-728).
6. SHALL contain exactly one [1..1] statusCode (CONF:1106-719).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-721).
Use @value="true" for "yes", @value="false" for "no" and @nullFlavor="UNK" for "unknown".
7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1106-726).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106-729).
b. This value SHOULD contain zero or one [0..1] @value (CONF:1106-862).
Figure 93: Patient Seen in this ED in last 72 Hours and Discharged Example

3.39 Planned Act (V2)
[act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.39:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 193: Planned Act (V2) Contexts
Contained By:

Contains:
Author Participation
Indication (V2)
Instruction (V2)
Priority Preference

This template represents planned acts that are not classified as an observation or a procedure
according to the HL7 RIM. Examples of these acts are a dressing change, the teaching or
feeding of a patient or the providing of comfort measures.
The priority of the activity to the patient and provider is communicated through Priority
Preference. The effectiveTime indicates the time when the activity is intended to take place.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 293
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 194: Planned Act (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.39:2014-06-09)
@classCode

1..1

SHALL

10988538

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

10988539

urn:oid:2.16.840.1.113883.11.20.
9.23 (Planned moodCode
(Act/Encounter/Procedure))

templateId

1..1

SHALL

109830430

@root

1..1

SHALL

109830431

2.16.840.1.113883.10.20.22.4.39

@extension

1..1

SHALL

109832552

2014-06-09

id

1..*

SHALL

10988546

code

1..1

SHALL

109831687

statusCode

1..1

SHALL

109830432

1..1

SHALL

109832019

effectiveTime

0..1

SHOUL
D

109830433

performer

0..*

MAY

109830435

author

0..1

SHOUL
D

109832020

entryRelationship

0..*

MAY

109831067

@typeCode

1..1

SHALL

109831068

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

109831069

Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.143

0..*

MAY

109832021

@typeCode

1..1

SHALL

109832022

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109832023

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..*

MAY

109832024

@code

entryRelationship

entryRelationship

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = active

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 294
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@typeCode

1..1

SHALL

109832025

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

act

1..1

SHALL

109832026

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8538).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
Planned moodCode (Act/Encounter/Procedure)
urn:oid:2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:1098-8539).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-30430) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.39"
(CONF:1098-30431).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32552).
4. SHALL contain at least one [1..*] id (CONF:1098-8546).
5. SHALL contain exactly one [1..1] code (CONF:1098-31687).
a. This code in a Planned 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:1098-32030).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-30432).
a. This statusCode SHALL contain exactly one [1..1] @code="active" Active
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832019).
The effectiveTime in a planned act represents the time that the act should occur.
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30433).
The clinician who is expected to carry out the act could be identified using act/performer.
8. MAY contain zero or more [0..*] performer (CONF:1098-30435).
The author in a planned act represents the clinician who is requesting or planning the act.
9. SHOULD contain zero or one [0..1] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32020).
The following entryRelationship represents the priority that a patient or a provider places on
the activity.
10. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31067) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831068).
b. SHALL contain exactly one [1..1] Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31069).
The following entryRelationship represents the indication for the act.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 295
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

11. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32021) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832022).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832023).
The following entryRelationship captures any instructions associated with the planned act.
12. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32024) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832025).
b. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832026).
Table 195: Planned moodCode (Act/Encounter/Procedure)
Value Set: Planned moodCode (Act/Encounter/Procedure) urn:oid:2.16.840.1.113883.11.20.9.23
This value set is used to restrict the moodCode on an act, an encounter or a procedure to future moods
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

INT

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Intent

ARQ

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Appointment Request

PRMS

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Promise

PRP

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Proposal

RQO

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Request

APT

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Appointment

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 296
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 94: Planned Act (V2) Example

...

...

...

...

...

3.39.1 Ordered Service Act
[act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.19 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 196: Ordered Service Act Contexts
Contained By:

Contains:

Services and Procedures Section (optional)

This template represents service activities ordered, but not yet provided. Examples of service
acts include non-medication treatments, such as physical therapy or home health care, other

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 297
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

tests and procedures (except excision of tissue), as well as health education or counseling. To
represent the ordered service act, the moodCode value is constrained to "RQO".
Table 197: Ordered Service Act Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.19)
@classCode

1..1

SHALL

1106221

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

1106222

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = RQO

templateId

1..1

SHALL

1106223

1..1

SHALL

1106224

1..1

SHALL

1106225

@code

0..1

SHOUL
D

1106362

translation

0..*

MAY

1106363

1..1

SHALL

1106378

@root
code

@code

2.16.840.1.113883.10.20.34.3.19

urn:oid:2.16.840.1.113883.6.12
(CPT4)

1. Conforms to Planned Act (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.39:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-221).
3. SHALL contain exactly one [1..1] @moodCode="RQO" Request (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-222).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-223) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.19"
(CONF:1106-224).
5. SHALL contain exactly one [1..1] code (CONF:1106-225).
a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-362).
Note: Inclusion of both SNOMED CT/LOINC and a local code is permitted. When
both codes are available, include the local code within the translation element.
When only a local code is available, include the local code within the translation
element and use @nullFlavor="OTH" in the code element.
i.

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) (CONF:1106-767).

b. This code MAY contain zero or more [0..*] translation (CONF:1106-363).
i.

The translation, if present, SHALL contain exactly one [1..1] @code
(CodeSystem: CPT4 urn:oid:2.16.840.1.113883.6.12) (CONF:1106-378).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 298
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 95: Ordered Service Act Example

3.40 Planned Coverage
[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 198: Planned Coverage Contexts
Contained By:

Contains:

Planned Procedure (V2) (optional)
Planned Observation (V2) (optional)
Payment Sources Section (optional)

Author Participation

This template represents the insurance coverage intended to cover an act or procedure.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 299
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 199: Planned Coverage Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.129)
@classCode

1..1

SHALL

109831945

urn:oid:2.16.840.1.113883.5.4
(ActCode) = ACT

@moodCode

1..1

SHALL

109831946

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = INT

templateId

1..1

SHALL

109831947

1..1

SHALL

109831948

id

1..*

SHALL

109831950

code

1..1

SHALL

109831951

@code

1..1

SHALL

109831952

48768-6

@codeSystem

1..1

SHALL

109831953

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

109831954

1..1

SHALL

109831955

urn:oid:2.16.840.1.113883.5.4
(ActCode) = active

author

0..*

MAY

109832178

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

entryRelationship

1..1

SHALL

109831967

@typeCode

1..1

SHALL

109831968

act

1..1

SHALL

109831969

@classCode

1..1

SHALL

109831970

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

109831971

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = INT

id

1..*

SHALL

109831972

code

1..1

SHALL

109831973

statusCode

1..1

SHALL

109831974

1..1

SHALL

109831975

@root

statusCode
@code

@code

2.16.840.1.113883.10.20.22.4.12
9

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

urn:oid:2.16.840.1.114222.4.11.3
591 (Payer)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = active

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 300
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] @classCode="ACT" act (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:1098-31945).
2. SHALL contain exactly one [1..1] @moodCode="INT" Intent (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-31946).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-31947) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.129"
(CONF:1098-31948).
4. SHALL contain at least one [1..*] id (CONF:1098-31950).
5. SHALL contain exactly one [1..1] code (CONF:1098-31951).
a. This code SHALL contain exactly one [1..1] @code="48768-6" Payment Sources
(CONF:1098-31952).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31953).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-31954).
a. This statusCode SHALL contain exactly one [1..1] @code="active" Active
(CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1098-31955).
7. MAY contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32178).
8. SHALL contain exactly one [1..1] entryRelationship (CONF:1098-31967) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831968).
b. SHALL contain exactly one [1..1] act (CONF:1098-31969).
i.

This act SHALL contain exactly one [1..1] @classCode="ACT" ACT
(CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6)
(CONF:1098-31970).

ii. This act SHALL contain exactly one [1..1] @moodCode="INT" intent
(CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001)
(CONF:1098-31971).
These act/identifiers are unique identifiers for the policy or program providing the coverage.
iii. This act SHALL contain at least one [1..*] id (CONF:1098-31972).
iv. This act SHALL contain exactly one [1..1] code, which SHALL be selected from
ValueSet Payer urn:oid:2.16.840.1.114222.4.11.3591 DYNAMIC
(CONF:1098-31973).
v. This act SHALL contain exactly one [1..1] statusCode (CONF:1098-31974).
1. This statusCode SHALL contain exactly one [1..1] @code="active"
Active (CodeSystem: ActStatus
urn:oid:2.16.840.1.113883.5.14) (CONF:1098-31975).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 301
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 200: Payer
Value Set: Payer urn:oid:2.16.840.1.114222.4.11.3591
A value set of Public Health Data Standards Consortium Source of Payment Typology Version 3.0 Codes
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

Medicare

2

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

Medicaid

311

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

Tricare (CHAMPUS)

33

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

Indian Health Service or
Tribe

62

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

BC Indemnity

61

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

BC Managed Care

611

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

BC Managed Care - HMO

619

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

BC Managed Care - Other

613

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

BC Managed Care - POS

612

Source of Payment
Typology (PHDSC)

urn:oid:2.16.840.1.11388
3.3.221.5

BC Managed Care - PPO

...

Figure 96: Planned Coverage Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 302
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.41 Planned Immunization Activity
[substanceAdministration: identifier urn:oid:2.16.840.1.113883.10.20.22.4.120
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 201: Planned Immunization Activity Contexts
Contained By:

Contains:

Immunizations Section (optional)

Author Participation
Immunization Medication Information (V2)
Indication (V2)
Instruction (V2)
Precondition for Substance Administration (V2)
Priority Preference

This template represents planned immunizations. Planned Immunization Activity is very
similar to Planned Medication Activity with some key differences, for example, the drug code
system is constrained to CVX codes.
The priority of the immunization activity to the patient and provider is communicated through
Priority Preference. The effectiveTime indicates the time when the immunization activity is
intended to take place and authorTime indicates when the documentation of the plan occurred.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 303
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 202: Planned Immunization Activity Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

substanceAdministration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.120)
@classCode

1..1

SHALL

109832091

SBADM

@moodCode

1..1

SHALL

109832097

urn:oid:2.16.840.1.113883.11.20.
9.24 (Planned moodCode
(SubstanceAdministration/Suppl
y))

templateId

1..1

SHALL

109832098

1..1

SHALL

109832099

id

1..*

SHALL

109832100

statusCode

1..1

SHALL

109832101

1..1

SHALL

109832102

effectiveTime

1..1

SHALL

109832103

repeatNumber

0..1

MAY

109832126

routeCode

0..1

MAY

109832127

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.7 (Medication Route
FDA)

approachSiteCode

0..*

MAY

109832128

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

doseQuantity

0..1

MAY

109832129

0..1

SHOUL
D

109832130

1..1

SHALL

109832131

1..1

SHALL

109832132

performer

0..*

MAY

109832104

author

0..*

MAY

109832105

entryRelationship

0..*

MAY

109832108

1..1

SHALL

1098-

@root

@code

@unit

consumable
manufacturedProduct

@typeCode

2.16.840.1.113883.10.20.22.4.12
0

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = active

urn:oid:2.16.840.1.113883.1.11.1
2839
(UnitsOfMeasureCaseSensitive)

Immunization Medication
Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.54:2014-06-09

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

urn:oid:2.16.840.1.113883.5.100

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 304
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

observation

32109

2 (HL7ActRelationshipType) =
REFR
Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.143

1..1

SHALL

109832110

0..*

MAY

109832114

@typeCode

1..1

SHALL

109832115

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109832116

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..*

MAY

109832117

@typeCode

1..1

SHALL

109832118

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

act

1..1

SHALL

109832119

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

precondition

0..*

MAY

109832123

@typeCode

1..1

SHALL

109832124

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
PRCN

criterion

1..1

SHALL

109832125

Precondition for Substance
Administration (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.25:2014-06-09

entryRelationship

entryRelationship

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CONF:1098-32091).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
Planned moodCode (SubstanceAdministration/Supply)
urn:oid:2.16.840.1.113883.11.20.9.24 STATIC 2014-09-01 (CONF:1098-32097).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-32098) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.120"
(CONF:1098-32099).
4. SHALL contain at least one [1..*] id (CONF:1098-32100).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-32101).
a. This statusCode SHALL contain exactly one [1..1] @code="active" Active
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832102).
The effectiveTime in a planned immunization activity represents the time that the
immunization activity should occur.
6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-32103).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 305
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

In a Planned Immunization Activity, repeatNumber defines the number of allowed
administrations. For example, a repeatNumber of "3" means that the substance can be
administered up to 3 times.
7. MAY contain zero or one [0..1] repeatNumber (CONF:1098-32126).
8. MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet
Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC
(CONF:1098-32127).
9. MAY contain zero or more [0..*] approachSiteCode, which SHALL be selected from ValueSet
Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109832128).
10. MAY contain zero or one [0..1] doseQuantity (CONF:1098-32129).
a. The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL
be selected from ValueSet UnitsOfMeasureCaseSensitive
urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32130).
11. SHALL contain exactly one [1..1] consumable (CONF:1098-32131).
a. This consumable SHALL contain exactly one [1..1] Immunization Medication
Information (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09) (CONF:109832132).
The clinician who is expected to perform the planned immunization activity could be identified
using substanceAdministration/performer.
12. MAY contain zero or more [0..*] performer (CONF:1098-32104).
The author in a planned immunization activity represents the clinician who is requesting or
planning the immunization activity.
13. MAY contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32105).
The following entryRelationship represents the priority that a patient or a provider places on
the immunization activity.
14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32108) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832109).
b. SHALL contain exactly one [1..1] Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-32110).
The following entryRelationship represents the indication for the immunization activity.
15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32114) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832115).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832116).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 306
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

The following entryRelationship captures any instructions associated with the planned
immunization activity.
16. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32117) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832118).
b. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832119).
17. MAY contain zero or more [0..*] precondition (CONF:1098-32123) such that it
a. SHALL contain exactly one [1..1] @typeCode="PRCN" Precondition (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832124).
b. SHALL contain exactly one [1..1] Precondition for Substance Administration
(V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-0609) (CONF:1098-32125).
Table 203: Planned moodCode (SubstanceAdministration/Supply)
Value Set: Planned moodCode (SubstanceAdministration/Supply) urn:oid:2.16.840.1.113883.11.20.9.24
This value set is used to restrict the moodCode on a substance administration or a supply to future moods.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

INT

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Intent

PRMS

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Promise

PRP

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Proposal

RQO

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Request

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 307
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 97: Planned Immunization Activity

...

...

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 308
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.42 Planned Medication Activity (V2)
[substanceAdministration: identifier
urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 204: Planned Medication Activity (V2) Contexts
Contained By:

Contains:

Medications Section (optional)

Author Participation
Indication (V2)
Instruction (V2)
Medication Information (V2)
Precondition for Substance Administration (V2)
Priority Preference

This template represents planned medication activities. The priority of the medication activity
to the patient and provider is communicated through Priority Preference. The effectiveTime
indicates the time when the medication activity is intended to take place. The authorTime
indicates when the documentation of the plan occurred.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 309
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 205: Planned Medication Activity (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09)
@classCode

1..1

SHALL

10988572

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = SBADM

@moodCode

1..1

SHALL

10988573

urn:oid:2.16.840.1.113883.11.20.
9.24 (Planned moodCode
(SubstanceAdministration/Suppl
y))

templateId

1..1

SHALL

109830465

@root

1..1

SHALL

109830466

2.16.840.1.113883.10.20.22.4.42

@extension

1..1

SHALL

109832557

2014-06-09

id

1..*

SHALL

10988575

statusCode

1..1

SHALL

109832087

1..1

SHALL

109832088

effectiveTime

1..1

SHALL

109830468

repeatNumber

0..1

MAY

109832066

routeCode

0..1

MAY

109832067

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.7 (Medication Route
FDA)

approachSiteCode

0..*

MAY

109832078

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

doseQuantity

0..1

MAY

109832068

0..1

SHOUL
D

109832133

0..1

MAY

109832079

0..1

SHOUL
D

109832134

maxDoseQuantity

0..1

MAY

109832080

administrationUnitCode

0..1

MAY

109832081

consumable

1..1

SHALL

109832082

@code

@unit

rateQuantity
@unit

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = active

urn:oid:2.16.840.1.113883.1.11.1
2839
(UnitsOfMeasureCaseSensitive)

urn:oid:2.16.840.1.113883.1.11.1
2839
(UnitsOfMeasureCaseSensitive)

urn:oid:2.16.840.1.113762.1.4.10
21.30
(AdministrationUnitDoseForm)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 310
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

manufacturedProduct

1..1

SHALL

109832083

performer

0..*

MAY

109830470

author

0..1

SHOUL
D

109832046

entryRelationship

0..*

MAY

109831104

@typeCode

1..1

SHALL

109831105

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

109831106

Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.143

0..*

MAY

109832069

@typeCode

1..1

SHALL

109832070

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109832071

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..*

MAY

109832072

@typeCode

1..1

SHALL

109832073

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

act

1..1

SHALL

109832074

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

precondition

0..*

MAY

109832084

@typeCode

1..1

SHALL

109832085

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
PRCN

criterion

1..1

SHALL

109832086

Precondition for Substance
Administration (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.25:2014-06-09

entryRelationship

entryRelationship

Medication Information (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.23:2014-06-09

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8572).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
Planned moodCode (SubstanceAdministration/Supply)
urn:oid:2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:1098-8573).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-30465) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 311
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.42"
(CONF:1098-30466).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32557).
4. SHALL contain at least one [1..*] id (CONF:1098-8575).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-32087).
a. This statusCode SHALL contain exactly one [1..1] @code="active" Active
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832088).
The effectiveTime in a planned medication activity represents the time that the medication
activity should occur.
6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-30468).
In a Planned Medication Activity, repeatNumber defines the number of allowed
administrations. For example, a repeatNumber of "3" means that the substance can be
administered up to 3 times.
7. MAY contain zero or one [0..1] repeatNumber (CONF:1098-32066).
8. MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet
Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC
(CONF:1098-32067).
9. MAY contain zero or more [0..*] approachSiteCode, which SHALL be selected from ValueSet
Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109832078).
10. MAY contain zero or one [0..1] doseQuantity (CONF:1098-32068).
a. The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL
be selected from ValueSet UnitsOfMeasureCaseSensitive
urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32133).
11. MAY contain zero or one [0..1] rateQuantity (CONF:1098-32079).
a. The rateQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL
be selected from ValueSet UnitsOfMeasureCaseSensitive
urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32134).
12. MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-32080).
13. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from
ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30
DYNAMIC (CONF:1098-32081).
14. SHALL contain exactly one [1..1] consumable (CONF:1098-32082).
a. This consumable SHALL contain exactly one [1..1] Medication Information (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09)
(CONF:1098-32083).
The clinician who is expected to perform the medication activity could be identified using
substanceAdministration/performer.
15. MAY contain zero or more [0..*] performer (CONF:1098-30470).
The author in a planned medication activity represents the clinician who is requesting or
planning the medication activity.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 312
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

16. SHOULD contain zero or one [0..1] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32046).
The following entryRelationship represents the priority that a patient or a provider places on
the planned medication activity.
17. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31104) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831105).
b. SHALL contain exactly one [1..1] Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31106).
The following entryRelationship represents the indication for the planned medication activity.
18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32069) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832070).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832071).
The following entryRelationship captures any instructions associated with the planned
medication activity.
19. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32072) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832073).
b. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832074).
20. MAY contain zero or more [0..*] precondition (CONF:1098-32084).
a. The precondition, if present, SHALL contain exactly one [1..1] @typeCode="PRCN"
Precondition (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32085).
b. The precondition, if present, SHALL contain exactly one [1..1] Precondition for
Substance Administration (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09) (CONF:109832086).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 313
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 98: Planned Medication Activity (V2) Example

Heparin 0.25 ml Prefilled Syringe

...

...

...

...

...

3.43 Planned Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 206: Planned Observation (V2) Contexts
Contained By:

Contains:
Author Participation
Indication (V2)
Instruction (V2)
Planned Coverage

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 314
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Contained By:

Contains:
Priority Preference

This template represents planned observations that result in new information about the patient
which cannot be classified as a procedure according to the HL7 RIM, i.e., procedures alter the
patient's body. Examples of these observations are laboratory tests, diagnostic imaging tests,
EEGs, and EKGs.
The importance of the planned observation to the patient and provider is communicated
through Priority Preference. The effectiveTime indicates the time when the observation is
intended to take place and authorTime indicates when the documentation of the plan occurred.
The Planned Observation template may also indicate the potential insurance coverage for the
observation.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 315
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 207: Planned Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09)
@classCode

1..1

SHALL

10988581

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10988582

urn:oid:2.16.840.1.113883.11.20.
9.25 (Planned moodCode
(Observation))

templateId

1..1

SHALL

109830451

@root

1..1

SHALL

109830452

2.16.840.1.113883.10.20.22.4.44

@extension

1..1

SHALL

109832555

2014-06-09

id

1..*

SHALL

10988584

code

1..1

SHALL

109831030

statusCode

1..1

SHALL

109830453

1..1

SHALL

109832032

effectiveTime

0..1

SHOUL
D

109830454

value

0..1

MAY

109831031

methodCode

0..1

MAY

109832043

targetSiteCode

0..*

SHOUL
D

109832044

performer

0..*

MAY

109830456

author

0..*

SHOUL
D

109832033

entryRelationship

0..*

MAY

109831073

@typeCode

1..1

SHALL

109831074

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

109831075

Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.143

0..*

MAY

109832034

1..1

SHALL

1098-

@code

entryRelationship
@typeCode

urn:oid:2.16.840.1.113883.6.1
(LOINC)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = active

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

urn:oid:2.16.840.1.113883.5.100

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 316
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

observation

32035

2 (HL7ActRelationshipType) =
RSON
Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

1..1

SHALL

109832036

0..*

MAY

109832037

@typeCode

1..1

SHALL

109832038

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

act

1..1

SHALL

109832039

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

0..*

MAY

109832040

@typeCode

1..1

SHALL

109832041

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

act

1..1

SHALL

109832042

Planned Coverage (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.129

entryRelationship

entryRelationship

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8581).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
Planned moodCode (Observation) urn:oid:2.16.840.1.113883.11.20.9.25 STATIC
2011-09-30 (CONF:1098-8582).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-30451) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.44"
(CONF:1098-30452).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32555).
4. SHALL contain at least one [1..*] id (CONF:1098-8584).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC
(urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31030).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-30453).
a. This statusCode SHALL contain exactly one [1..1] @code="active" Active
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832032).
The effectiveTime in a planned observation represents the time that the observation should
occur.
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30454).
8. MAY contain zero or one [0..1] value (CONF:1098-31031).
In a planned observation the provider may suggest that an observation should be performed
using a particular method.
9. MAY contain zero or one [0..1] methodCode (CONF:1098-32043).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 317
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

The targetSiteCode is used to identify the part of the body of concern for the planned
observation.
10. SHOULD contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet
Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109832044).
The clinician who is expected to perform the observation could be identified using
procedure/performer.
11. MAY contain zero or more [0..*] performer (CONF:1098-30456).
The author in a planned observation represents the clinician who is requesting or planning the
observation.
12. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32033).
The following entryRelationship represents the priority that a patient or a provider places on
the observation.
13. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31073) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831074).
b. SHALL contain exactly one [1..1] Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31075).
The following entryRelationship represents the indication for the observation.
14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32034) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832035).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832036).
The following entryRelationship captures any instructions associated with the planned
observation.
15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32037) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832038).
b. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832039).
The following entryRelationship represents the insurance coverage the patient may have for the
observation.
16. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32040) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 318
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832041).
b. SHALL contain exactly one [1..1] Planned Coverage (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:1098-32042).
Table 208: Planned moodCode (Observation)
Value Set: Planned moodCode (Observation) urn:oid:2.16.840.1.113883.11.20.9.25
This value set is used to restrict the moodCode on an Observation to future moods.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

INT

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Intent

PRMS

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Promise

PRP

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Proposal

RQO

ActMood

urn:oid:2.16.840.1.11388
3.5.1001

Request

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 319
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 99: Planned Observation (V2) Example

...

...

...

...

3.43.1 Ordered Service Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.2 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 209: Ordered Service Observation Contexts
Contained By:

Contains:

Services and Procedures Section (optional)

This template represents service observations ordered, but not yet provided. Examples of
service observations include examinations, blood tests, and imaging. To represent the ordered
service observation, the moodCode value is constrained to "RQO".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 320
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 210: Ordered Service Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.2)
@classCode

1..1

SHALL

1106381

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106382

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = RQO

templateId

1..1

SHALL

1106383

1..1

SHALL

1106384

1..1

SHALL

1106385

@code

0..1

SHOUL
D

1106386

translation

0..*

MAY

1106387

1..1

SHALL

1106388

@root
code

@code

2.16.840.1.113883.10.20.34.3.2

1. Conforms to Planned Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-381).
3. SHALL contain exactly one [1..1] @moodCode="RQO" Request (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-382).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-383) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.2"
(CONF:1106-384).
5. SHALL contain exactly one [1..1] code (CONF:1106-385).
a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-386).
Note: Inclusion of both SNOMED CT/LOINC and a local code is permitted. When
both codes are available, include the local code within the translation element.
When only a local code is available, include the local code within the translation
element and use @nullFlavor="OTH" in the code element.
i.

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) (CONF:1106-769).

b. This code MAY contain zero or more [0..*] translation (CONF:1106-387).
i.

The translation, if present, SHALL contain exactly one [1..1] @code
(CONF:1106-388).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 321
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 100: Ordered Service Observation Example

3.44 Planned Procedure (V2)
[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 211: Planned Procedure (V2) Contexts
Contained By:

Contains:
Author Participation
Indication (V2)
Instruction (V2)
Planned Coverage
Priority Preference

This template represents planned alterations of the patient's physical condition. Examples of
such procedures are tracheostomy, knee replacement, and craniectomy. The priority of the
procedure to the patient and provider is communicated through Priority Preference. The
effectiveTime indicates the time when the procedure is intended to take place and authorTime
indicates when the documentation of the plan occurred. The Planned Procedure Template may
also indicate the potential insurance coverage for the procedure.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 322
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 212: Planned Procedure (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

procedure (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09)
@classCode

1..1

SHALL

10988568

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = PROC

@moodCode

1..1

SHALL

10988569

urn:oid:2.16.840.1.113883.11.20.
9.23 (Planned moodCode
(Act/Encounter/Procedure))

templateId

1..1

SHALL

109830444

@root

1..1

SHALL

109830445

2.16.840.1.113883.10.20.22.4.41

@extension

1..1

SHALL

109832554

2014-06-09

id

1..*

SHALL

10988571

code

1..1

SHALL

109831976

statusCode

1..1

SHALL

109830446

1..1

SHALL

109831978

effectiveTime

0..1

SHOUL
D

109830447

methodCode

0..*

MAY

109831980

targetSiteCode

0..*

MAY

109831981

performer

0..*

MAY

109830449

author

0..1

SHOUL
D

109831979

entryRelationship

0..*

MAY

109831079

@typeCode

1..1

SHALL

109831080

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

109831081

Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.143

0..*

MAY

109831982

1..1

SHALL

109831983

@code

entryRelationship
@typeCode

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = active

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 323
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

observation

1..1

SHALL

109831984

0..*

MAY

109831985

@typeCode

1..1

SHALL

109831986

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

109831987

true

act

1..1

SHALL

109831989

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

0..*

MAY

109831990

@typeCode

1..1

SHALL

109831991

COMP

act

1..1

SHALL

109831992

Planned Coverage (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.129

entryRelationship

entryRelationship

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8568).
2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet
Planned moodCode (Act/Encounter/Procedure)
urn:oid:2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:1098-8569).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-30444) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.41"
(CONF:1098-30445).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32554).
4. SHALL contain at least one [1..*] id (CONF:1098-8571).
5. SHALL contain exactly one [1..1] code (CONF:1098-31976).
a. The procedure/code in a planned procedure 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:1098-31977).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-30446).
a. This statusCode SHALL contain exactly one [1..1] @code="active" Active
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109831978).
The effectiveTime in a planned procedure represents the time that the procedure should occur.
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30447).
In a planned procedure the provider may suggest that a procedure should be performed using
a particular method.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 324
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

MethodCode SHALL NOT conflict with the method inherent in Procedure / code.
8. MAY contain zero or more [0..*] methodCode (CONF:1098-31980).
The targetSiteCode is used to identify the part of the body of concern for the planned
procedure.
9. MAY contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet
Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109831981).
The clinician who is expected to perform the procedure could be identified using
procedure/performer.
10. MAY contain zero or more [0..*] performer (CONF:1098-30449).
The author in a planned procedure represents the clinician who is requesting or planning the
procedure.
11. SHOULD contain zero or one [0..1] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31979).
The following entryRelationship represents the priority that a patient or a provider places on
the procedure.
12. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31079) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831080).
b. SHALL contain exactly one [1..1] Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31081).
The following entryRelationship represents the indication for the procedure.
13. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31982) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831983).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109831984).
The following entryRelationship captures any instructions associated with the planned
procedure.
14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31985) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831986).
b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-31987).
c. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831989).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 325
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

The following entryRelationship represents the insurance coverage the patient may have for the
procedure.
15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31990) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:109831991).
b. SHALL contain exactly one [1..1] Planned Coverage (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:1098-31992).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 326
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 101: Planned Procedure (V2) Example

...

...

...

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 327
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.44.1 Ordered Service Procedure
[procedure: identifier urn:oid:2.16.840.1.113883.10.20.34.3.11 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 213: Ordered Service Procedure Contexts
Contained By:

Contains:

Services and Procedures Section (optional)

This template represents procedure services ordered, but not yet provided. Examples of
procedure services include excisions of tissue. To represent the ordered procedure service, the
moodCode value is constrained to "RQO".
Table 214: Ordered Service Procedure Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

procedure (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.11)
@classCode

1..1

SHALL

1106138

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = PROC

@moodCode

1..1

SHALL

1106139

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = RQO

templateId

1..1

SHALL

1106140

1..1

SHALL

1106141

1..1

SHALL

1106142

@code

0..1

SHOUL
D

translation

0..*

MAY

1106379

1..1

SHALL

1106380

@root
code

@code

CS

2.16.840.1.113883.10.20.34.3.11

1106143

1. Conforms to Planned Procedure (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-138).
3. SHALL contain exactly one [1..1] @moodCode="RQO" Request (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-139).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-140) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.11"
(CONF:1106-141).
5. SHALL contain exactly one [1..1] code (CONF:1106-142).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 328
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-143).
Note: Inclusion of both SNOMED CT/LOINC and a local code is permitted. When
both codes are available, include the local code within the translation element.
When only a local code is available, include the local code within the translation
element and use @nullFlavor="OTH" in the code element.
i.

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) (CONF:1106-768).

b. This code MAY contain zero or more [0..*] translation (CONF:1106-379).
i.

The translation, if present, SHALL contain exactly one [1..1] @code
(CONF:1106-380).
Figure 102: Ordered Service Procedure Example

3.45 Point of Origin Observation
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 215: Point of Origin Observation Contexts
Contained By:

Contains:

Current Inpatient Visit (optional)
Current Emergency Department Visit (V2) (optional)

This template represents the patient's point of origin before arrival for this visit.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 329
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 216: Point of Origin Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01)
@classCode

1..1

SHALL

1184614

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184615

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184609

@root

1..1

SHALL

1184611

2.16.840.1.113883.10.20.34.3.36

@extension

1..1

SHALL

1184894

2015-04-01

id

1..*

SHALL

1184682

code

1..1

SHALL

1184610

@code

1..1

SHALL

1184612

78029-6

@codeSystem

1..1

SHALL

1184613

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

1184683

1..1

SHALL

1184684

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

1184616

urn:oid:2.16.840.1.114222.4.11.7
359 (Point of Origin (NCHS))

0..1

MAY

1184892

urn:oid:2.16.840.1.113883.10.20.
5.9.1 (NullValues_UNK_OTH)

statusCode
@code
value
@nullFlavor

CD

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1184-614).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1184-615).
3. SHALL contain exactly one [1..1] templateId (CONF:1184-609) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.36"
(CONF:1184-611).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-894).
4. SHALL contain at least one [1..*] id (CONF:1184-682).
5. SHALL contain exactly one [1..1] code (CONF:1184-610).
a. This code SHALL contain exactly one [1..1] @code="78029-6" Point of Origin
(CONF:1184-612).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 330
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1184-613).
6. SHALL contain exactly one [1..1] statusCode (CONF:1184-683).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-684).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Point of Origin (NCHS)
urn:oid:2.16.840.1.114222.4.11.7359 DYNAMIC (CONF:1184-616).
a. This value MAY contain zero or one [0..1] @nullFlavor, which SHALL be selected
from ValueSet NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1
STATIC 2015-04-01 (CONF:1184-892).
Table 217: Point of Origin (NCHS)
Value Set: Point of Origin (NCHS) urn:oid:2.16.840.1.114222.4.11.7359
Where the patient came from immediately before arriving at the healthcare facility.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7359
Code

Code System

Code System OID

Print Name

4563007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Transfer from a different
hospital

448441000124103

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Transfer from
Intermediate Care Facility

448421000124105

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Transfer from physician's
office, NOS

1971000124109

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Transfer from a Hospice
Facility

107724000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient transfer from one
unit to another

448431000124108

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Transfer from Assisted
Living Facility

25986004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Transfer from jail or court

285202004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Non-Healthcare facility
point of origin NOS

442311008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Newborn born inside this
hospital

445585003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Newborn born outside
this hospital

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 331
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 103: Point of Origin Observation Example

3.46 Policy Activity (V2)
[act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.61:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 218: Policy Activity (V2) Contexts
Contained By:

Contains:

Coverage Activity (V2) (required)

US Realm Address (AD.US.FIELDED)

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 of the coverage. The payer is
represented as the performer of the policy activity.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 332
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 219: Policy Activity (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.61:2014-06-09)
@classCode

1..1

SHALL

10988898

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

10988899

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10988900

@root

1..1

SHALL

109810516

2.16.840.1.113883.10.20.22.4.61

@extension

1..1

SHALL

109832595

2014-06-09

id

1..*

SHALL

10988901

code

1..1

SHALL

10988903

statusCode

1..1

SHALL

10988902

@code

1..1

SHALL

109819109

performer

1..1

SHALL

10988906

@typeCode

1..1

SHALL

10988907

templateId

1..1

SHALL

109816808

1..1

SHALL

109816809

1..1

SHALL

10988908

id

1..*

SHALL

10988909

code

0..1

SHOUL
D

10988914

1..1

SHALL

109815992

urn:oid:2.16.840.1.113883.1.11.1
0416
(HL7FinanciallyResponsibleParty
Type)

addr

0..1

MAY

10988910

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

0..*

MAY

10988911

representedOrganization

0..1

SHOUL

1098-

@root
assignedEntity

@code

urn:oid:2.16.840.1.114222.4.11.3
591 (Payer)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = PRF

2.16.840.1.113883.10.20.22.4.87

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 333
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

D

8912

0..1

SHOUL
D

10988913

0..1

SHOUL
D

10988961

1..1

SHALL

109816810

1..1

SHALL

109816811

time

0..1

SHOUL
D

10988963

assignedEntity

1..1

SHALL

10988962

1..1

SHALL

10988968

@code

1..1

SHALL

109816096

GUAR

@codeSystem

1..1

SHALL

109832165

2.16.840.1.113883.5.110

addr

0..1

SHOUL
D

10988964

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

0..*

SHOUL
D

10988965

participant

1..1

SHALL

10988916

@typeCode

1..1

SHALL

10988917

templateId

1..1

SHALL

109816812

1..1

SHALL

109816814

0..1

SHOUL
D

10988918

low

0..1

SHOUL
D

10988919

high

0..1

SHOUL
D

10988920

1..1

SHALL

10988921

id

1..*

SHALL

10988922

code

1..1

SHALL

10988923

0..1

SHOUL
D

109816078

name
performer
templateId
@root

code

@root
time

participantRole

@code

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = PRF

2.16.840.1.113883.10.20.22.4.88

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = COV

2.16.840.1.113883.10.20.22.4.89

urn:oid:2.16.840.1.113883.1.11.1
8877 (Coverage Role Type)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 334
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

addr

0..1

SHOUL
D

10988956

playingEntity

0..1

SHOUL
D

10988932

name

1..*

SHALL

10988930

sdtc:birthTime

1..1

SHALL

109831344

0..1

SHOUL
D

10988934

@typeCode

1..1

SHALL

10988935

templateId

1..1

SHALL

109816813

1..1

SHALL

109816815

time

0..1

MAY

10988938

participantRole

1..1

SHALL

10988936

id

1..*

SHALL

10988937

addr

0..1

SHOUL
D

10988925

1..*

SHALL

10988939

1..1

SHALL

10988940

participant

@root

entryRelationship
@typeCode

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = HLD

2.16.840.1.113883.10.20.22.4.90

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8898).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8899).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-8900) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.61"
(CONF:1098-10516).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32595).
This id is a unique identifier for the policy or program providing the coverage
4. SHALL contain at least one [1..*] id (CONF:1098-8901).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Payer
urn:oid:2.16.840.1.114222.4.11.3591 DYNAMIC (CONF:1098-8903).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8902).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 335
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819109).
This performer represents the Payer.
7. SHALL contain exactly one [1..1] performer (CONF:1098-8906) such that it
a. SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988907).
b. SHALL contain exactly one [1..1] templateId (CONF:1098-16808).
i.

This templateId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.87" Payer Performer
(CONF:1098-16809).

c. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8908).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-8909).

ii. This assignedEntity SHOULD contain zero or one [0..1] code (CONF:10988914).
1. The code, if present, SHALL contain exactly one [1..1] @code, which
SHOULD be selected from ValueSet
HL7FinanciallyResponsiblePartyType
urn:oid:2.16.840.1.113883.1.11.10416 DYNAMIC (CONF:109815992).
iii. This assignedEntity MAY contain zero or one [0..1] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-8910).
iv. This assignedEntity MAY contain zero or more [0..*] telecom (CONF:10988911).
v. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:1098-8912).
1. The representedOrganization, if present, SHOULD contain zero or one
[0..1] name (CONF:1098-8913).
This performer represents the Guarantor.
8. SHOULD contain zero or one [0..1] performer="PRF" Performer (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-8961)
such that it
a. SHALL contain exactly one [1..1] templateId (CONF:1098-16810).
i.

This templateId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.88" Guarantor Performer
(CONF:1098-16811).

b. SHOULD contain zero or one [0..1] time (CONF:1098-8963).
c. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8962).
i.

This assignedEntity SHALL contain exactly one [1..1] code (CONF:10988968).
1. This code SHALL contain exactly one [1..1] @code="GUAR" Guarantor
(CONF:1098-16096).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 336
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.110" (CONF:1098-32165).
ii. This assignedEntity SHOULD contain zero or one [0..1] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-8964).
iii. This assignedEntity SHOULD contain zero or more [0..*] telecom
(CONF:1098-8965).
iv. SHOULD include assignedEntity/assignedPerson/name AND/OR
assignedEntity/representedOrganization/name (CONF:1098-8967).
9. SHALL contain exactly one [1..1] participant (CONF:1098-8916) such that it
a. SHALL contain exactly one [1..1] @typeCode="COV" Coverage target (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988917).
b. SHALL contain exactly one [1..1] templateId (CONF:1098-16812).
i.

This templateId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.89" Covered Party Participant
(CONF:1098-16814).

c. SHOULD contain zero or one [0..1] time (CONF:1098-8918).
i.

The time, if present, SHOULD contain zero or one [0..1] low (CONF:10988919).

ii. The time, if present, SHOULD contain zero or one [0..1] high (CONF:10988920).
d. SHALL contain exactly one [1..1] participantRole (CONF:1098-8921).
i.

This participantRole SHALL contain at least one [1..*] id (CONF:1098-8922).
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:1098-8984).

ii. This participantRole SHALL contain exactly one [1..1] code (CONF:10988923).
1. This code SHOULD contain zero or one [0..1] @code, which SHOULD be
selected from ValueSet Coverage Role Type
urn:oid:2.16.840.1.113883.1.11.18877 DYNAMIC (CONF:109816078).
iii. This participantRole SHOULD contain zero or one [0..1] addr (CONF:10988956).
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:109810484).
iv. This participantRole SHOULD contain zero or one [0..1] playingEntity
(CONF:1098-8932).
If the covered party’s name is recorded differently in the health plan and in the
registration/pharmacy benefit summary (due to marriage or for other reasons), use the name
as it is recorded in the health plan.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 337
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. The playingEntity, if present, SHALL contain at least one [1..*] name
(CONF:1098-8930).
If the covered party’s date of birth is recorded differently in the health plan and in the
registration/pharmacy benefit summary, use the date of birth as it is recorded in the health
plan.
2. The playingEntity, if present, SHALL contain exactly one [1..1]
sdtc:birthTime (CONF:1098-31344).
a. The prefix sdtc: SHALL be bound to the namespace “urn:hl7org:sdtc”. The use of the namespace provides a necessary
extension to CDA R2 for the use of the birthTime element
(CONF:1098-31345).
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.
10. SHOULD contain zero or one [0..1] participant (CONF:1098-8934) such that it
a. SHALL contain exactly one [1..1] @typeCode="HLD" Holder (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988935).
b. SHALL contain exactly one [1..1] templateId (CONF:1098-16813).
i.

This templateId SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.90" Policy Holder Participant
(CONF:1098-16815).

c. MAY contain zero or one [0..1] time (CONF:1098-8938).
d. SHALL contain exactly one [1..1] participantRole (CONF:1098-8936).
i.

This participantRole SHALL contain at least one [1..*] id (CONF:1098-8937).
1. This id is a unique identifier for the subscriber of the coverage
(CONF:1098-10120).

ii. This participantRole SHOULD contain zero or one [0..1] addr (CONF:10988925).
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:109810483).
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:1098-17139).
11. SHALL contain at least one [1..*] entryRelationship (CONF:1098-8939) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8940).
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:1098-8942).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 338
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

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:1098-8943).
Table 220: HL7FinanciallyResponsiblePartyType
Value Set: HL7FinanciallyResponsiblePartyType urn:oid:2.16.840.1.113883.1.11.10416
RoleClass 2.16.840.1.113883.5.110
http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

GUAR

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

Guarantor

EMP

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

Employee

INVSBJ

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

Investigation Subject

Table 221: Coverage Role Type
Value Set: Coverage Role Type urn:oid:2.16.840.1.113883.1.11.18877
A 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: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

FAMDEP

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

Family dependent

FSTUD

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

Full-time student

SELF

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

Self

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 339
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 104: Policy Activity (V2) Example

123 Insurance Road
Blue Bell
MA
02368
US

Good Health Insurance

123 Insurance Road
Blue Bell
MA
02368
US

17 Daws Rd.
Blue Bell
MA

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 340
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

02368
US

Mr.
Adam
Frankie
Everyman

17 Daws Rd.
Blue Bell
MA
02368
US

Mr.
Frank
A.
Everyman

17 Daws Rd.
Blue Bell
MA
02368
US

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 341
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

. . .

3.47 Precondition for Substance Administration (V2)
[criterion: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 222: Precondition for Substance Administration (V2) Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Immunization Activity (V2) (optional)
Planned Medication Activity (V2) (optional)
Planned Immunization 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 223: Precondition for Substance Administration (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

criterion (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09)
templateId

1..1

SHALL

10987372

@root

1..1

SHALL

109810517

2.16.840.1.113883.10.20.22.4.25

@extension

1..1

SHALL

109832603

2014-06-09

1..1

SHALL

@code

1..1

SHALL

109832397

ASSERTION

@codeSystem

1..1

SHALL

109832398

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

10987369

urn:oid:2.16.840.1.113883.3.88.1
2.3221.7.4 (Problem)

code

value

CD

CD

109832396

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 342
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] templateId (CONF:1098-7372) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.25"
(CONF:1098-10517).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32603).
2. SHALL contain exactly one [1..1] code with @xsi:type="CD" (CONF:1098-32396).
a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion
(CONF:1098-32397).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:1098-32398).
3. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4
DYNAMIC (CONF:1098-7369).
Figure 105: Precondition for Substance Administration (V2) Example

3.48 Pregnancy Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.15.3.8 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 224: Pregnancy Observation Contexts
Contained By:

Contains:

Social History Section (V2) (optional)
Patient Information Section (V3) (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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 343
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 225: 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

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

81-452

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

8116768

1..1

SHALL

8116868

1..1

SHALL

8119153

@code

1..1

SHALL

8119154

ASSERTION

@codeSystem

1..1

SHALL

8126505

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

81-455

1..1

SHALL

8119110

effectiveTime

0..1

SHOUL
D

812018

value

1..1

SHALL

1..1

SHALL

8126460

0..1

MAY

81-458

@typeCode

1..1

SHALL

81-459

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

8115584

Estimated Date of Delivery
(identifier:
urn:oid:2.16.840.1.113883.10.20.
15.3.1

@root
code

statusCode
@code

@code
entryRelationship

CD

2.16.840.1.113883.10.20.15.3.8

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

81-457
urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) = 77386006

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-451).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-452).
3. SHALL contain exactly one [1..1] templateId (CONF:81-16768) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.8"
(CONF:81-16868).
4. SHALL contain exactly one [1..1] code (CONF:81-19153).
a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:8119154).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 344
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:81-26505).
5. SHALL contain exactly one [1..1] statusCode (CONF:81-455).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119110).
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 urn:oid:2.16.840.1.113883.6.96) (CONF:81-26460).
8. MAY contain zero or one [0..1] entryRelationship (CONF:81-458) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid: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 106: Pregnancy Observation Example

. . .

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 345
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.49 Present on Admission Observation
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 226: Present on Admission Observation Contexts
Contained By:

Contains:

Injury or Poisoning Observation (V2) (optional)
Primary Diagnosis Observation (V2) (optional)
Problem/Diagnosis/Symptom/Condition Observation
(V2) (optional)

This template represents whether or not the containing diagnosis was present on admission
(POA). If this fact is unknown use nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 346
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 227: Present on Admission Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01)
@classCode

1..1

SHALL

1184905

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184906

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184899

@root

1..1

SHALL

1184903

2.16.840.1.113883.10.20.34.3.37

@extension

1..1

SHALL

1184912

2015-04-01

id

1..*

SHALL

1184907

code

1..1

SHALL

1184901

@code

0..1

MAY

1184908

78026-2

@codeSystem

0..1

MAY

1184909

2.16.840.1.113883.6.1

1..1

SHALL

1184900

1..1

SHALL

1184904

1..1

SHALL

@nullFlavor

0..1

MAY

1184910

@value

0..1

SHOUL
D

1184911

statusCode
@code
value

BL

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1184902
UNK

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1184-905).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-906).
3. SHALL contain exactly one [1..1] templateId (CONF:1184-899) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.37"
(CONF:1184-903).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-912).
4. SHALL contain at least one [1..*] id (CONF:1184-907).
5. SHALL contain exactly one [1..1] code (CONF:1184-901).
a. This code MAY contain zero or one [0..1] @code="78026-2" Present on admission
(CONF:1184-908).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 347
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1"
(CONF:1184-909).
6. SHALL contain exactly one [1..1] statusCode (CONF:1184-900).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-904).
Use @value="true" for "yes", @value="false" for "no" and @nullFlavor="UNK" for "unknown".
7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1184-902).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-910).
b. This value SHOULD contain zero or one [0..1] @value (CONF:1184-911).
Figure 107: Present on Admission Observation Example

3.50 Priority Preference
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.143 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 228: Priority Preference Contexts
Contained By:

Contains:

Problem Observation (V2) (optional)
Planned Act (V2) (optional)
Planned Procedure (V2) (optional)
Planned Observation (V2) (optional)
Planned Medication Activity (V2) (optional)
Planned Immunization Activity (optional)

Author Participation

This template represents priority preferences chosen by a patient or a care provider. Priority
preferences are choices made by care providers or patients or both relative to options for care
or treatment (including scheduling, care experience, and meeting of personal health goals), the
sharing and disclosure of health information, and the prioritization of concerns and problems.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 348
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 229: Priority Preference Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143)
@classCode

1..1

SHALL

109830949

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

109830950

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109830951

1..1

SHALL

109830952

id

1..*

SHALL

109830953

code

1..1

SHALL

109830954

@code

1..1

SHALL

109830955

225773000

@codeSystem

1..1

SHALL

109830956

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) =
2.16.840.1.113883.6.96

effectiveTime

0..1

SHOUL
D

109832327

value

1..1

SHALL

author

0..*

SHOUL
D

@root

CD

2.16.840.1.113883.10.20.22.4.14
3

109830957

urn:oid:2.16.840.1.113883.11.20.
9.60 (Priority Level)

109830958

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1098-30949).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-30950).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-30951) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.143"
(CONF:1098-30952).
4. SHALL contain at least one [1..*] id (CONF:1098-30953).
5. SHALL contain exactly one [1..1] code (CONF:1098-30954).
a. This code SHALL contain exactly one [1..1] @code="225773000" Preference
(CONF:1098-30955).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT
urn:oid:2.16.840.1.113883.6.96) (CONF:1098-30956).
6. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-32327).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 349
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Priority Level urn:oid:2.16.840.1.113883.11.20.9.60
STATIC 2014-06-11 (CONF:1098-30957).
8. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-30958).
Table 230: Priority Level
Value Set: Priority Level urn:oid:2.16.840.1.113883.11.20.9.60
A value set of SNOMED-CT that contains concepts representing priority.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

394849002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

High priority

394848005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Normal priority

441808003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Delayed priority

Figure 108: Priority Preference Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 350
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.51 Problem Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 231: Problem Observation (V2) Contexts
Contained By:

Contains:

Hospital Discharge Diagnosis (V2) (required)
Encounter Diagnosis (V2) (required)

Age Observation
Author Participation
Priority Preference
Problem Status (DEPRECATED)
Prognosis Observation

This template reflects a discrete observation about a patient's problem. Because it is a discrete
observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the
“biologically relevant time” is the time at which the observation holds for the patient. For a
provider seeing a patient in the clinic today, observing a history of heart attack that occurred
five years ago, the effectiveTime is five years ago.
The effectiveTime of the Problem Observation is the definitive indication of whether or not the
underlying condition is resolved. If the problem is known to be resolved, then an
effectiveTime/high would be present. If the date of resolution is not known, then
effectiveTime/high will be present with a nullFlavor of "UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 351
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 232: Problem Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09)
@classCode

1..1

SHALL

10989041

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10989042

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

@negationInd

0..1

MAY

109810139

templateId

1..1

SHALL

109814926

@root

1..1

SHALL

109814927

2.16.840.1.113883.10.20.22.4.4

@extension

1..1

SHALL

109832508

2014-06-09

id

1..*

SHALL

10989043

code

1..1

SHALL

10989045

statusCode

1..1

SHALL

10989049

1..1

SHALL

109819112

1..1

SHALL

10989050

low

1..1

SHALL

109815603

high

0..1

MAY

109815604

1..1

SHALL

qualifier

0..*

MAY

109831870

translation

0..*

MAY

109816749

0..1

MAY

109816750

0..1

MAY

109831871

author

0..*

SHOUL
D

109831147

entryRelationship

0..1

MAY

10989059

1..1

SHALL

10989060

@code
effectiveTime

value

@code
@code

@typeCode

CD

10989058

urn:oid:2.16.840.1.113883.3.88.1
2.3221.7.2 (Problem Type)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

urn:oid:2.16.840.1.113883.3.88.1
2.3221.7.4 (Problem)

urn:oid:2.16.840.1.113883.6.90
(ICD-10-CM)

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 352
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

SUBJ
@inversionInd

1..1

SHALL

10989069

true

observation

1..1

SHALL

109815590

Age Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.31

0..1

MAY

109829951

@typeCode

1..1

SHALL

109831531

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

109829952

Prognosis Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.113

0..*

MAY

109831063

@typeCode

1..1

SHALL

109831532

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

109831064

Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.143

0..1

MAY

10989063

@typeCode

1..1

SHALL

10989068

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

109815591

Problem Status (DEPRECATED)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.6:2014-06-09

entryRelationship

entryRelationship

entryRelationship

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-9041).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-9042).
The negationInd is used to indicate the absence of the condition in observation/value. A
negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease
(disorder)" indicates that the patient has no known conditions.
3. MAY contain zero or one [0..1] @negationInd (CONF:1098-10139).
4. SHALL contain exactly one [1..1] templateId (CONF:1098-14926) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4"
(CONF:1098-14927).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32508).
5. SHALL contain at least one [1..*] id (CONF:1098-9043).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 353
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

6. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem
Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:10989045).
7. SHALL contain exactly one [1..1] statusCode (CONF:1098-9049).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819112).
If the problem is known to be resolved, but the date of resolution is not known, then the high
element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the
existence of an high element within a problem does indicate that the problem has been
resolved.
8. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-9050).
The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically
active.
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1098-15603).
The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically
resolved.
b. This effectiveTime MAY contain zero or one [0..1] high (CONF:1098-15604).
9. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be
selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4
DYNAMIC (CONF:1098-9058).
The observation/value and all the qualifiers together (often referred to as a post-coordinated
expression) make up one concept. Qualifiers constrain the meaning of the primary code, and
cannot negate it or change its meaning. Qualifiers can only be used according to well-defined
rules of post-coordination and only if the underlying code system defines the use of such
qualifiers or if there is a third code system that specifies how other code systems may be
combined.
For example, SNOMED CT allows constructing concepts as a combination of multiple codes.
SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site"
(363698007) and another concept "left lower lobe of lung (body structure)" (41224006).
SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample
XML.
a. This value MAY contain zero or more [0..*] qualifier (CONF:1098-31870).
b. This value MAY contain zero or more [0..*] translation (CONF:1098-16749) such
that it
i.

contain zero or one [0..1] @code (CodeSystem: ICD-10-CM
urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1098-16750).
MAY

A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001
"Disease (disorder)" indicates that the patient has no known conditions.
c. This value MAY contain zero or one [0..1] @code (CONF:1098-31871).
10. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31147).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 354
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

11. MAY contain zero or one [0..1] entryRelationship (CONF:1098-9059) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-9060).
b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-9069).
c. SHALL contain exactly one [1..1] Age Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.31) (CONF:1098-15590).
12. MAY contain zero or one [0..1] entryRelationship (CONF:1098-29951) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831531).
b. SHALL contain exactly one [1..1] Prognosis Observation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.113) (CONF:1098-29952).
13. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31063) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831532).
b. SHALL contain exactly one [1..1] Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31064).
14. MAY contain zero or one [0..1] entryRelationship (CONF:1098-9063) such that it
a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:10989068).
b. SHALL contain exactly one [1..1] Problem Status (DEPRECATED) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.6:2014-06-09) (CONF:109815591).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 355
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 109: Problem Observation (V2) Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 356
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 110: No Known Problems Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 357
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 111: Resolved Problem and Resolved Concern Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 358
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 359
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 112: Problem with Qualifiers Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 360
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.51.1 Admission Diagnosis Observation
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.34:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 233: Admission Diagnosis Observation Contexts
Contained By:

Contains:

Problems Section (V3) (optional)

This template represents the admission diagnosis.
Table 234: Admission Diagnosis Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.34:2015-04-01)
@classCode

1..1

SHALL

1184869

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184870

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184867

@root

1..1

SHALL

1184871

2.16.840.1.113883.10.20.34.3.34

@extension

1..1

SHALL

1184874

2015-04-01

1..1

SHALL

1184868

@code

1..1

SHALL

1184872

8646-2

@codeSystem

1..1

SHALL

1184873

2.16.840.1.113883.6.1

code

1. Conforms to Problem Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-869).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-870).
4. SHALL contain exactly one [1..1] templateId (CONF:1184-867) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.34"
(CONF:1184-871).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-874).
5. SHALL contain exactly one [1..1] code (CONF:1184-868).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 361
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This code SHALL contain exactly one [1..1] @code="8646-2" Hospital Admission
Diagnosis (CONF:1184-872).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1184-873).
Figure 113: Admission Diagnosis Observation Example

3.51.2 Adverse Effect of Medical Treatment
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.14 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 235: Adverse Effect of Medical Treatment Contexts
Contained By:

Contains:

Problems Section (V3) (optional)

Cause of Injury, Poisoning, or Adverse Effect

This template represents that the visit is related to an adverse effect of medical treatment. If it
is unknown whether this visit is related to adverse effect of medical treatment use
nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 362
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 236: Adverse Effect of Medical Treatment Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.14)
@classCode

1..1

SHALL

1106487

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106488

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106489

1..1

SHALL

1106490

1..1

SHALL

1106491

@code

1..1

SHALL

1106492

ASSERTION

@codeSystem

1..1

SHALL

1106493

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

@nullFlavor

0..1

MAY

1106703

UNK

@code

0..1

SHOUL
D

1106495

269691005

@codeSystem

0..1

SHOUL
D

1106496

2.16.840.1.113883.6.96

entryRelationship

0..1

MAY

1106640

@typeCode

1..1

SHALL

1106641

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
CAUS

observation

1..1

SHALL

1106642

Cause of Injury, Poisoning, or
Adverse Effect (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.27

@root
code

value

CD

2.16.840.1.113883.10.20.34.3.14

1106494

1. Conforms to Problem Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-487).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-488).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-489) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.14"
(CONF:1106-490).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 363
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

5. SHALL contain exactly one [1..1] code (CONF:1106-491).
a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion
(CONF:1106-492).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:1106-493).
6. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1106-494).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106-703).
b. This value SHOULD contain zero or one [0..1] @code="269691005" Medical accidents
to patients during surgical and medical care (CONF:1106-495).
c. This value SHOULD contain zero or one [0..1]
@codeSystem="2.16.840.1.113883.6.96" (CONF:1106-496).
7. MAY contain zero or one [0..1] entryRelationship (CONF:1106-640).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="CAUS" (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002) (CONF:1106-641).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] Cause of
Injury, Poisoning, or Adverse Effect (identifier:
urn:oid:2.16.840.1.113883.10.20.34.3.27) (CONF:1106-642).
Figure 114: Adverse Effect of Medical Treatment Example

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 364
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.51.3 Injury or Poisoning Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.17:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 237: Injury or Poisoning Observation (V2) Contexts
Contained By:

Contains:

Problems Section (V3) (optional)

Cause of Injury, Poisoning, or Adverse Effect
Present on Admission Observation

This template represents whether this visit is related to an injury or poisoning. The code is
constrained to "Clinical Finding" and the value is constrained to the Injury or Poisoning value
set. If it is unknown whether this visit is related to an injury or poisoning use
nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 365
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 238: Injury or Poisoning Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.17:2015-04-01)
@classCode

1..1

SHALL

1184209

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184210

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184211

1..1

SHALL

1184212

1..1

SHALL

1184445

@code

1..1

SHALL

1184446

75321-0

@codeSystem

1..1

SHALL

1184447

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

1184218

urn:oid:2.16.840.1.114222.4.11.7
403 (Injury or Poisoning (NCHS))

0..1

MAY

1184702

UNK

0..1

MAY

1184637

@typeCode

1..1

SHALL

1184638

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
CAUS

observation

1..1

SHALL

1184639

Cause of Injury, Poisoning, or
Adverse Effect (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.3.27

0..1

MAY

11841096

@typeCode

1..1

SHALL

11841097

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

11841098

true

observation

1..1

SHALL

11841099

Present on Admission
Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.37:2015-04-01

@root
code

value
@nullFlavor
entryRelationship

entryRelationship

CD

2.16.840.1.113883.10.20.34.3.17

1. Conforms to Problem Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-209).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 366
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-210).
4. SHALL contain exactly one [1..1] templateId (CONF:1184-211) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.17"
(CONF:1184-212).
5. SHALL contain exactly one [1..1] code (CONF:1184-445).
a. This code SHALL contain exactly one [1..1] @code="75321-0" Clinical finding
(CONF:1184-446).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1184-447).
6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be
selected from ValueSet Injury or Poisoning (NCHS)
urn:oid:2.16.840.1.114222.4.11.7403 DYNAMIC (CONF:1184-218).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-702).
7. MAY contain zero or one [0..1] entryRelationship (CONF:1184-637) such that it
a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184638).
b. SHALL contain exactly one [1..1] Cause of Injury, Poisoning, or Adverse
Effect (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.27)
(CONF:1184-639).
8. MAY contain zero or one [0..1] entryRelationship (CONF:1184-1096) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:11841097).
b. SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1184-1098).
c. SHALL contain exactly one [1..1] Present on Admission Observation
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01)
(CONF:1184-1099).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 367
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 239: Injury or Poisoning (NCHS)
Value Set: Injury or Poisoning (NCHS) urn:oid:2.16.840.1.114222.4.11.7403
All SNOMED CT concepts that are children of the SNOMED CT concept 'traumatic AND/OR non-traumatic
injury', including the SNOMED CT concept 'traumatic AND/OR non-traumatic injury' plus all SNOMED CT
concepts that are children of the SNOMED CT concept 'poisoning', including the SNOMED CT concept
'poisoning'.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7403
Code

Code System

Code System OID

Print Name

72431002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Accidental Poisoning

410061008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Intentional Poisoning

269736006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Poisoning of
undetermined intent

242056005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Accidental injury

420025004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Non-accidental injury

269735005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Injury undetermined
whether accidental or
purposely inflicted

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 368
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 115: Injury or Poisoning Observation (V2) Example

...

3.51.4 Patient's Reason for Visit Observation
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.41:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 240: Patient's Reason for Visit Observation Contexts
Contained By:

Contains:

Reasons for Visit Section (V2) (optional)

This template represents the patient's reason for the visit.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 369
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 241: Patient's Reason for Visit Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.41:2015-04-01)
@classCode

1..1

SHALL

11841083

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

11841084

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

11841073

@root

1..1

SHALL

11841078

2.16.840.1.113883.10.20.34.3.41

@extension

1..1

SHALL

11841079

2015-04-01

1..1

SHALL

11841074

@code

1..1

SHALL

11841080

75322-8

@codeSystem

1..1

SHALL

11841081

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

code

1. Conforms to Problem Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1184-1083).
3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1184-1084).
4. SHALL contain exactly one [1..1] templateId (CONF:1184-1073) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.41"
(CONF:1184-1078).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1079).
5. SHALL contain exactly one [1..1] code (CONF:1184-1074).
a. This code SHALL contain exactly one [1..1] @code="75322-8" Complaint
(CONF:1184-1080).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1184-1081).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 370
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 116: Patient's Reason for Visit Observation Example

3.51.5 Primary Diagnosis Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.6:2015-04-01
(open)]
Draft as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm
Table 242: Primary Diagnosis Observation (V2) Contexts
Contained By:

Contains:

Problems Section (V3) (required)

Present on Admission Observation

This template represents the primary diagnosis. If no other means of determination is possible,
use first listed diagnosis as the primary diagnosis.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 371
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 243: Primary Diagnosis Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.6:2015-04-01)
@classCode

1..1

SHALL

1184339

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184340

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184341

1..1

SHALL

1184342

1..1

SHALL

1184518

@code

1..1

SHALL

1184519

52534-5

@codeSystem

1..1

SHALL

1184520

2.16.840.1.113883.6.1

entryRelationship

0..1

MAY

11841100

@typeCode

1..1

SHALL

11841101

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

0..1

MAY

11841102

true

observation

1..1

SHALL

11841103

Present on Admission
Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.37:2015-04-01

@root
code

2.16.840.1.113883.10.20.34.3.6

1. Conforms to Problem Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-339).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-340).
4. SHALL contain exactly one [1..1] templateId (CONF:1184-341) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.6"
(CONF:1184-342).
5. SHALL contain exactly one [1..1] code (CONF:1184-518).
a. This code SHALL contain exactly one [1..1] @code="52534-5" Principal Diagnosis
(CONF:1184-519).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1184-520).
6. MAY contain zero or one [0..1] entryRelationship (CONF:1184-1100).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 372
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002) (CONF:1184-1101).
b. The entryRelationship, if present, MAY contain zero or one [0..1]
@inversionInd="true" (CONF:1184-1102).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] Present on
Admission Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01) (CONF:11841103).
Figure 117: Primary Diagnosis Observation (V2) Example

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 373
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.51.6 Problem/Diagnosis/Symptom/Condition Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.1:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 244: Problem/Diagnosis/Symptom/Condition Observation (V2) Contexts
Contained By:

Contains:

Problems Section (V3) (optional)

Present on Admission Observation

This template represents a problem such as a diagnosis or a symptom or a condition. It is
based on the Problem Observation (V2) template.
Table 245: Problem/Diagnosis/Symptom/Condition Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.1:2015-04-01)
@classCode

1..1

SHALL

1184268

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1184269

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1184270

@root

1..1

SHALL

1184271

2.16.840.1.113883.10.20.34.3.1

@extension

1..1

SHALL

11841117

2015-04-01

0..1

MAY

11841116

@typeCode

1..1

SHALL

11841118

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

11841119

true

observation

1..1

SHALL

11841120

Present on Admission
Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.37:2015-04-01

entryRelationship

1. Conforms to Problem Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-268).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-269).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 374
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4. SHALL contain exactly one [1..1] templateId (CONF:1184-270) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.1"
(CONF:1184-271).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1117).
5. MAY contain zero or one [0..1] entryRelationship (CONF:1184-1116).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002) (CONF:1184-1118).
b. The entryRelationship, if present, SHALL contain exactly one [1..1]
@inversionInd="true" (CONF:1184-1119).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] Present on
Admission Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01) (CONF:11841120).
Figure 118: Problem/Diagnosis/Symptom/Condition Observation (V2) Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 375
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.52 Problem Status (DEPRECATED)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.6:2014-06-09
(open)]
Deprecated as part of Consolidated CDA Templates for Clinical Notes (US
Realm) DSTU R2
Table 246: Problem Status (DEPRECATED) Contexts
Contained By:

Contains:

Problem Observation (V2) (optional)

The Problem Status records whether the indicated problem is active, inactive, or resolved.
THIS TEMPLATE HAS BEEN DEPRECATED IN C-CDA R2 AND MAY BE DELETED FROM A
FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT
RECOMMENDED.
Reason for deprecation: Per the explanation in Volume 1, Section 3.2 "Determining a Clinical
Statement's Status", the status of a problem is determined based on attributes of the Problem
Observation.
Table 247: Problem Status (DEPRECATED) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.6:2014-06-09)
@classCode

1..1

SHALL

10987357

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10987358

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987359

1..1

SHALL

109810518

1..1

SHALL

109819162

1..1

SHALL

109819163

1..1

SHALL

10987364

1..1

SHALL

109819113

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

10987365

urn:oid:2.16.840.1.113883.3.88.1
2.80.68 (Problem Status)

@root
code
@code
statusCode
@code
value

CD

2.16.840.1.113883.10.20.22.4.6

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 33999-4

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7357).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 376
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7358).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7359) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.6"
(CONF:1098-10518).
4. SHALL contain exactly one [1..1] code (CONF:1098-19162).
a. This code SHALL contain exactly one [1..1] @code="33999-4" Status (CodeSystem:
LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:1098-19163).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7364).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819113).
6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Problem Status urn:oid:2.16.840.1.113883.3.88.12.80.68
DYNAMIC (CONF:1098-7365).
Table 248: Problem Status
Value Set: Problem Status urn:oid:2.16.840.1.113883.3.88.12.80.68
A value set of SNOMED-CT codes reflecting state of existence.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

55561003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Active

73425007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Inactive

413322009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Resolved

3.53 Procedure Activity Act (V2)
[act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.12:2014-06-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 249: Procedure Activity Act (V2) Contexts
Contained By:

Contains:
Author Participation
Indication (V2)
Instruction (V2)
Medication Activity (V2)
Service Delivery Location

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 377
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

This template represents any act that cannot be classified as an observation or procedure
according to the HL7 RIM. Examples of these acts are a dressing change, teaching or feeding a
patient, or providing comfort measures.
The common notion of "procedure" is broader than that specified by the HL7 Version 3
Reference Information Model (RIM). Procedure templates can be represented with various RIM
classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 378
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 250: Procedure Activity Act (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.12:2014-06-09)
@classCode

1..1

SHALL

10988289

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

10988290

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10988291

@root

1..1

SHALL

109810519

2.16.840.1.113883.10.20.22.4.12

@extension

1..1

SHALL

109832505

2014-06-09

id

1..*

SHALL

10988292

code

1..1

SHALL

10988293

originalText

0..1

SHOUL
D

109819186

reference

0..1

MAY

109819187

@value

0..1

MAY

109819188

1..1

SHALL

10988298

1..1

SHALL

109832364

effectiveTime

1..1

SHALL

10988299

priorityCode

0..1

MAY

10988300

performer

0..*

SHOUL
D

10988301

1..1

SHALL

10988302

id

1..*

SHALL

10988303

addr

1..*

SHALL

10988304

telecom

1..*

SHALL

10988305

representedOrganization

0..1

SHOUL
D

10988306

0..*

SHOUL
D

10988307

statusCode
@code

assignedEntity

id

urn:oid:2.16.840.1.113883.11.20.
9.22 (ProcedureAct statusCode)

urn:oid:2.16.840.1.113883.1.11.1
6866 (Act Priority)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 379
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

name

0..*

MAY

10988308

telecom

1..*

SHALL

10988310

addr

1..*

SHALL

10988309

author

1..*

SHOUL
D

109832477

participant

0..*

MAY

10988311

@typeCode

1..1

SHALL

10988312

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
LOC

participantRole

1..1

SHALL

109815599

Service Delivery Location
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.32

entryRelationship

0..*

MAY

10988314

@typeCode

1..1

SHALL

10988315

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

@inversionInd

1..1

SHALL

10988316

true

encounter

1..1

SHALL

10988317

@classCode

1..1

SHALL

10988318

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

10988319

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

id

1..1

SHALL

10988320

0..1

MAY

10988322

@typeCode

1..1

SHALL

10988323

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

10988324

true

act

1..1

SHALL

109831396

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

0..*

MAY

10988326

1..1

SHALL

10988327

entryRelationship

entryRelationship
@typeCode

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 380
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

observation

1..1

SHALL

109815601

0..*

MAY

10988329

@typeCode

1..1

SHALL

10988330

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

substanceAdministration

1..1

SHALL

109815602

Medication Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.16:2014-06-09

entryRelationship

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8289).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8290).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-8291) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.12"
(CONF:1098-10519).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32505).
4. SHALL contain at least one [1..*] id (CONF:1098-8292).
5. SHALL contain exactly one [1..1] code (CONF:1098-8293).
a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19186).
i.

The originalText, if present, MAY contain zero or one [0..1] reference
(CONF:1098-19187).
1. The reference, if present, MAY contain zero or one [0..1] @value
(CONF:1098-19188).
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:109819189).

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) or ICD10 PCS (CodeSystem:
2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13)
(CONF:1098-19190).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8298).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet ProcedureAct statusCode
urn:oid:2.16.840.1.113883.11.20.9.22 STATIC 2014-04-23 (CONF:109832364).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-8299).
8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act
Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-8300).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 381
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

9. SHOULD contain zero or more [0..*] performer (CONF:1098-8301).
a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-8302).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-8303).

ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:10988304).
iii. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10988305).
iv. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:1098-8306).
1. The representedOrganization, if present, SHOULD contain zero or
more [0..*] id (CONF:1098-8307).
2. The representedOrganization, if present, MAY contain zero or more
[0..*] name (CONF:1098-8308).
3. The representedOrganization, if present, SHALL contain at least one
[1..*] telecom (CONF:1098-8310).
4. The representedOrganization, if present, SHALL contain at least one
[1..*] addr (CONF:1098-8309).
10. SHOULD contain at least one [1..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32477).
11. MAY contain zero or more [0..*] participant (CONF:1098-8311) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8312).
b. SHALL contain exactly one [1..1] Service Delivery Location (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-15599).
12. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8314) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8315).
b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8316).
c. SHALL contain exactly one [1..1] encounter (CONF:1098-8317).
i.

This encounter SHALL contain exactly one [1..1] @classCode="ENC"
Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6
STATIC) (CONF:1098-8318).

ii. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event
(CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC)
(CONF:1098-8319).
iii. This encounter SHALL contain exactly one [1..1] id (CONF:1098-8320).
1. Set the encounter ID to the ID of an encounter in another section to
signify they are the same encounter (CONF:1098-16849).
13. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8322) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 382
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8323).
b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8324).
c. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831396).
14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8326) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8327).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815601).
15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8329) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8330).
b. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815602).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 383
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 251: Act Priority
Value Set: Act Priority urn:oid:2.16.840.1.113883.1.11.16866
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

A

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

ASAP

CR

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Callback results

CS

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Callback for scheduling

CSP

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Callback placer for
scheduling

CSR

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Contact recipient for
scheduling

EL

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Elective

EM

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Emergency

P

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Preoperative

PRN

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

As needed

R

ActPriority

urn:oid:2.16.840.1.11388
3.5.7

Routine

...

Table 252: ProcedureAct statusCode
Value Set: ProcedureAct statusCode urn:oid:2.16.840.1.113883.11.20.9.22
A ValueSet of HL7 actStatus codes for use with a procedure activity
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

completed

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

Completed

active

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

Active

aborted

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

Aborted

cancelled

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

Cancelled

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 384
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 119: Procedure Activity Act Example

1001 Village Avenue
Portland
OR
99123
US

Community Health and Hospitals

1001 Village Avenue
Portland
OR
99123
US

. . .

. . .

. . .

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 385
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.53.1 Provided Service Act
[act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.20 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 253: Provided Service Act Contexts
Contained By:

Contains:

Services and Procedures Section (optional)

This template represents a service activity that has been provided. Examples of service acts
include non-medication treatments, such as physical therapy, home health care, feeding a
patient, medical nutrition therapy, other tests and procedures (except excision of tissue), as
well as health education or counseling (e.g., nutrition counseling). To represent the provided
service act, the moodCode value is constrained to "EVN" and the statusCode value is
constrained to "completed".
Table 254: Provided Service Act Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.20)
@classCode

1..1

SHALL

1106227

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

1106228

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106229

1..1

SHALL

1106230

1..1

SHALL

1106231

@code

0..1

SHOUL
D

1106358

translation

0..*

MAY

1106359

1..1

SHALL

1106375

1..1

SHALL

1106233

1..1

SHALL

1106364

@root
code

@code
statusCode
@code

2.16.840.1.113883.10.20.34.3.20

urn:oid:2.16.840.1.113883.6.12
(CPT4)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 386
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. Conforms to Procedure Activity Act (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.12:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-227).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-228).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-229) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.20"
(CONF:1106-230).
5. SHALL contain exactly one [1..1] code (CONF:1106-231).
a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-358).
Note: Inclusion of both SNOMED CT/LOINC and CPT/HCPCS codes is
recommended. When both codes are available, include the CPT code within the
translation element. When only the CPT code is available, include the CPT code
within the translation element and use @nullFlavor="OTH" in the code element.
i.

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) (CONF:1106-772).

b. This code MAY contain zero or more [0..*] translation (CONF:1106-359).
i.

The translation, if present, SHALL contain exactly one [1..1] @code, which
SHOULD be selected from CodeSystem CPT4
(urn:oid:2.16.840.1.113883.6.12) (CONF:1106-375).

6. SHALL contain exactly one [1..1] statusCode (CONF:1106-233).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-364).
Figure 120: Provided Service Act Example 1

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 387
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 121: Provided Service Act Example 2

3.54 Procedure Activity Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 255: Procedure Activity Observation (V2) Contexts
Contained By:

Contains:
Author Participation
Indication (V2)
Instruction (V2)
Medication Activity (V2)
Reaction Observation (V2)
Service 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 template 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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 388
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 256: Procedure Activity Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09)
@classCode

1..1

SHALL

10988282

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10988237

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10988238

@root

1..1

SHALL

109810520

2.16.840.1.113883.10.20.22.4.13

@extension

1..1

SHALL

109832507

2014-06-09

id

1..*

SHALL

10988239

code

1..1

SHALL

109819197

originalText

0..1

SHOUL
D

109819198

reference

0..1

SHOUL
D

109819199

@value

0..1

SHOUL
D

109819200

1..1

SHALL

10988245

1..1

SHALL

109832365

effectiveTime

0..1

SHOUL
D

10988246

priorityCode

0..1

MAY

10988247

value

1..1

SHALL

109816846

0..1

MAY

109832778

methodCode

0..1

MAY

10988248

targetSiteCode

0..*

SHOUL
D

10988250

performer

0..*

SHOUL
D

10988251

1..1

SHALL

10988252

1..*

SHALL

10988253

statusCode
@code

@nullFlavor

assignedEntity
id

urn:oid:2.16.840.1.113883.11.20.
9.22 (ProcedureAct statusCode)

urn:oid:2.16.840.1.113883.1.11.1
6866 (Act Priority)

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 389
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

addr

1..*

SHALL

10988254

telecom

1..*

SHALL

10988255

representedOrganization

0..1

SHOUL
D

10988256

id

0..*

SHOUL
D

10988257

name

0..*

MAY

10988258

telecom

1..1

SHALL

10988260

addr

1..1

SHALL

10988259

author

1..*

SHOUL
D

109832478

participant

0..*

MAY

10988261

@typeCode

1..1

SHALL

10988262

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
LOC

participantRole

1..1

SHALL

109815904

Service Delivery Location
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.32

entryRelationship

0..*

MAY

10988264

@typeCode

1..1

SHALL

10988265

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

@inversionInd

1..1

SHALL

10988266

true

encounter

1..1

SHALL

10988267

@classCode

1..1

SHALL

10988268

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

@moodCode

1..1

SHALL

10988269

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

id

1..1

SHALL

10988270

0..1

MAY

10988272

@typeCode

1..1

SHALL

10988273

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

10988274

true

entryRelationship

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 390
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

act

1..1

SHALL

109831394

0..*

MAY

10988276

@typeCode

1..1

SHALL

10988277

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109815906

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..*

MAY

10988279

@typeCode

1..1

SHALL

10988280

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

substanceAdministration

1..1

SHALL

109815907

Medication Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.16:2014-06-09

0..*

MAY

109832470

@typeCode

1..1

SHALL

109832471

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

observation

1..1

SHALL

109832472

Reaction Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.9:2014-06-09

entryRelationship

entryRelationship

entryRelationship

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8282).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8237).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-8238) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13"
(CONF:1098-10520).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32507).
4. SHALL contain at least one [1..*] id (CONF:1098-8239).
5. SHALL contain exactly one [1..1] code (CONF:1098-19197).
a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19198).
i.

The originalText, if present, SHOULD contain zero or one [0..1] reference
(CONF:1098-19199).
1. The reference, if present, SHOULD contain zero or one [0..1] @value
(CONF:1098-19200).
a. This reference/@value SHALL begin with a '#' and SHALL
point to its corresponding narrative (using the approach

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 391
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

defined in CDA Release 2, section 4.3.5.1) (CONF:109819201).
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) or ICD10 PCS (CodeSystem:
2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13)
(CONF:1098-19202).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8245).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet ProcedureAct statusCode
urn:oid:2.16.840.1.113883.11.20.9.22 STATIC 2014-04-23 (CONF:109832365).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-8246).
8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act
Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-8247).
9. SHALL contain exactly one [1..1] value (CONF:1098-16846).
If nothing is appropriate for value, use an appropriate nullFlavor.
a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:1098-32778).
10. MAY contain zero or one [0..1] methodCode (CONF:1098-8248).
a. MethodCode SHALL NOT conflict with the method inherent in Observation / code
(CONF:1098-8249).
11. SHOULD contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet
Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:10988250).
12. SHOULD contain zero or more [0..*] performer (CONF:1098-8251).
a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-8252).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-8253).

ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:10988254).
iii. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10988255).
iv. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:1098-8256).
1. The representedOrganization, if present, SHOULD contain zero or
more [0..*] id (CONF:1098-8257).
2. The representedOrganization, if present, MAY contain zero or more
[0..*] name (CONF:1098-8258).
3. The representedOrganization, if present, SHALL contain exactly one
[1..1] telecom (CONF:1098-8260).
4. The representedOrganization, if present, SHALL contain exactly one
[1..1] addr (CONF:1098-8259).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 392
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

13. SHOULD contain at least one [1..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32478).
14. MAY contain zero or more [0..*] participant (CONF:1098-8261) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8262).
b. SHALL contain exactly one [1..1] Service Delivery Location (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-15904).
15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8264) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8265).
b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8266).
c. SHALL contain exactly one [1..1] encounter (CONF:1098-8267).
i.

This encounter SHALL contain exactly one [1..1] @classCode="ENC"
Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6
STATIC) (CONF:1098-8268).

ii. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event
(CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC)
(CONF:1098-8269).
iii. This encounter SHALL contain exactly one [1..1] id (CONF:1098-8270).
1. Set encounter/id to the id of an encounter in another section to
signify they are the same encounter (CONF:1098-16847).
16. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8272) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8273).
b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8274).
c. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831394).
17. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8276) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8277).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815906).
18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8279) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-8280).
b. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815907).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 393
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

19. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32470) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832471).
b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109832472).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 394
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 122: Procedure Activity Observation (V2) Example

1001 Village Avenue
Portland
OR
99123
US

Community Health and Hospitals

1001 Village Avenue
Portland
OR
99123
US

. . .

. . .

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 395
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

. . .

3.54.1 Provided Service Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.3 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 257: Provided Service Observation Contexts
Contained By:

Contains:

Services and Procedures Section (optional)

This template represents a service observation that has been provided. Examples of service
observations include examinations, blood tests, and imaging. To represent the provided service
observation, the moodCode value is constrained to "EVN" and the statusCode value is
constrained to "completed".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 396
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 258: Provided Service Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.3)
@classCode

1..1

SHALL

1106365

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106366

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106367

1..1

SHALL

1106368

1..1

SHALL

1106369

@code

1..1

SHALL

1106370

translation

0..*

MAY

1106371

1..1

SHALL

1106372

1..1

SHALL

1106373

1..1

SHALL

1106374

@root
code

@code
statusCode
@code

2.16.840.1.113883.10.20.34.3.3

urn:oid:2.16.840.1.113883.6.12
(CPT4)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. Conforms to Procedure Activity Observation (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-365).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-366).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-367) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.3"
(CONF:1106-368).
5. SHALL contain exactly one [1..1] code (CONF:1106-369).
a. This code SHALL contain exactly one [1..1] @code (CONF:1106-370).
Note: Inclusion of both SNOMED CT/LOINC and CPT/HCPCS codes is
recommended. When both codes are available, include the CPT code within the
translation element. When only the CPT code is available, include the CPT code
within the translation element and use @nullFlavor="OTH" in the code element.
i.

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) (CONF:1106-771).

b. This code MAY contain zero or more [0..*] translation (CONF:1106-371).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 397
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

i.

The translation, if present, SHALL contain exactly one [1..1] @code, which
SHOULD be selected from CodeSystem CPT4
(urn:oid:2.16.840.1.113883.6.12) (CONF:1106-372).

6. SHALL contain exactly one [1..1] statusCode (CONF:1106-373).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-374).
Figure 123: Provided Service Observation Example

3.55 Procedure Activity Procedure (V2)
[procedure: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 259: Procedure Activity Procedure (V2) Contexts
Contained By:

Contains:

Reaction Observation (V2) (optional)

Author Participation
Indication (V2)
Instruction (V2)
Medication Activity (V2)
Product Instance
Reaction Observation (V2)
Service 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).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 398
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

This template 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.
This template can be used with a contained Product Instance template to represent a device in
or on a patient. In this case, targetSiteCode is used to record the location of the device in or on
the patient's body. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is
represented by the Non-Medicinal Supply Activity (V2) template.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 399
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 260: Procedure Activity Procedure (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

procedure (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09)
@classCode

1..1

SHALL

10987652

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = PROC

@moodCode

1..1

SHALL

10987653

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987654

@root

1..1

SHALL

109810521

2.16.840.1.113883.10.20.22.4.14

@extension

1..1

SHALL

109832506

2014-06-09

id

1..*

SHALL

10987655

code

1..1

SHALL

10987656

originalText

0..1

SHOUL
D

109819203

reference

0..1

SHOUL
D

109819204

@value

0..1

SHOUL
D

109819205

1..1

SHALL

10987661

1..1

SHALL

109832366

effectiveTime

0..1

SHOUL
D

10987662

priorityCode

0..1

MAY

10987668

methodCode

0..1

MAY

10987670

targetSiteCode

0..*

SHOUL
D

10987683

@code

1..1

SHALL

109816082

specimen

0..*

MAY

10987697

1..1

SHALL

10987704

0..*

SHOUL
D

10987716

0..*

SHOUL
D

10987718

statusCode
@code

specimenRole
id
performer

urn:oid:2.16.840.1.113883.11.20.
9.22 (ProcedureAct statusCode)

urn:oid:2.16.840.1.113883.1.11.1
6866 (Act Priority)

urn:oid:2.16.840.1.113883.3.88.1
2.3221.8.9 (Body Site)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 400
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

assignedEntity

1..1

SHALL

10987720

id

1..*

SHALL

10987722

addr

1..*

SHALL

10987731

telecom

1..*

SHALL

10987732

representedOrganization

0..1

SHOUL
D

10987733

id

0..*

SHOUL
D

10987734

name

0..*

MAY

10987735

telecom

1..1

SHALL

10987737

addr

1..1

SHALL

10987736

author

1..*

SHOUL
D

109832479

participant

0..*

MAY

10987751

@typeCode

1..1

SHALL

10987752

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
DEV

participantRole

1..1

SHALL

109815911

Product Instance (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.37

0..*

MAY

10987765

@typeCode

1..1

SHALL

10987766

urn:oid:2.16.840.1.113883.5.90
(HL7ParticipationType) = LOC

participantRole

1..1

SHALL

109815912

Service Delivery Location
(identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.32

entryRelationship

0..*

MAY

10987768

@typeCode

1..1

SHALL

10987769

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

@inversionInd

1..1

SHALL

10988009

true

encounter

1..1

SHALL

10987770

1..1

SHALL

10987771

participant

@classCode

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ENC

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 401
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

@moodCode

1..1

SHALL

10987772

id

1..1

SHALL

10987773

0..1

MAY

10987775

@typeCode

1..1

SHALL

10987776

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

10987777

true

act

1..1

SHALL

109831395

Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.20:2014-06-09

0..*

MAY

10987779

@typeCode

1..1

SHALL

10987780

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

observation

1..1

SHALL

109815914

Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.19:2014-06-09

0..*

MAY

10987886

@typeCode

1..1

SHALL

10987887

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

substanceAdministration

1..1

SHALL

109815915

Medication Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.16:2014-06-09

0..*

MAY

109832473

@typeCode

1..1

SHALL

109832474

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
COMP

observation

1..1

SHALL

109832475

Reaction Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.9:2014-06-09

entryRelationship

entryRelationship

entryRelationship

entryRelationship

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

1. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7652).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7653).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7654) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14"
(CONF:1098-10521).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 402
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32506).
4. SHALL contain at least one [1..*] id (CONF:1098-7655).
5. SHALL contain exactly one [1..1] code (CONF:1098-7656).
a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19203).
i.

The originalText, if present, SHOULD contain zero or one [0..1] reference
(CONF:1098-19204).
1. The reference, if present, SHOULD contain zero or one [0..1] @value
(CONF:1098-19205).
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:109819206).

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) or ICD10 PCS (CodeSystem:
2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13)
(CONF:1098-19207).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7661).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet ProcedureAct statusCode
urn:oid:2.16.840.1.113883.11.20.9.22 STATIC 2014-04-23 (CONF:109832366).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7662).
8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act
Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-7668).
9. MAY contain zero or one [0..1] methodCode (CONF:1098-7670).
a. MethodCode SHALL NOT conflict with the method inherent in Procedure / code
(CONF:1098-7890).
In the case of an implanted medical device, targetSiteCode is used to record the location of the
device, in or on the patient's body.
10. SHOULD contain zero or more [0..*] targetSiteCode (CONF:1098-7683).
a. The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which SHALL
be selected from ValueSet Body Site
urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-16082).
11. MAY contain zero or more [0..*] specimen (CONF:1098-7697).
a. The specimen, if present, SHALL contain exactly one [1..1] specimenRole
(CONF:1098-7704).
i.

This specimenRole SHOULD contain zero or more [0..*] id (CONF:1098-7716).
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:1098-29744).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 403
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

b. This specimen is for representing specimens obtained from a procedure
(CONF:1098-16842).
12. SHOULD contain zero or more [0..*] performer (CONF:1098-7718) such that it
a. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-7720).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-7722).

ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:10987731).
iii. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10987732).
iv. This assignedEntity SHOULD contain zero or one [0..1]
representedOrganization (CONF:1098-7733).
1. The representedOrganization, if present, SHOULD contain zero or
more [0..*] id (CONF:1098-7734).
2. The representedOrganization, if present, MAY contain zero or more
[0..*] name (CONF:1098-7735).
3. The representedOrganization, if present, SHALL contain exactly one
[1..1] telecom (CONF:1098-7737).
4. The representedOrganization, if present, SHALL contain exactly one
[1..1] addr (CONF:1098-7736).
13. SHOULD contain at least one [1..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32479).
14. MAY contain zero or more [0..*] participant (CONF:1098-7751) such that it
a. SHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7752).
b. SHALL contain exactly one [1..1] Product Instance (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.37) (CONF:1098-15911).
15. MAY contain zero or more [0..*] participant (CONF:1098-7765) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:
HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10987766).
b. SHALL contain exactly one [1..1] Service Delivery Location (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-15912).
16. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7768) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7769).
b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8009).
c. SHALL contain exactly one [1..1] encounter (CONF:1098-7770).
i.

This encounter SHALL contain exactly one [1..1] @classCode="ENC"
Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6
STATIC) (CONF:1098-7771).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 404
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

ii. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event
(CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC)
(CONF:1098-7772).
iii. This encounter SHALL contain exactly one [1..1] id (CONF:1098-7773).
1. Set the encounter ID to the ID of an encounter in another section to
signify they are the same encounter (CONF:1098-16843).
17. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7775) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7776).
b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-7777).
c. SHALL contain exactly one [1..1] Instruction (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831395).
18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7779) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7780).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815914).
19. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7886) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7887).
b. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815915).
20. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32473) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832474).
b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109832475).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 405
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 124: Procedure Activity Procedure (V2) Example

...

3.55.1 Provided Service Procedure
[procedure: identifier urn:oid:2.16.840.1.113883.10.20.34.3.12 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 261: Provided Service Procedure Contexts
Contained By:

Contains:

Services and Procedures Section (optional)

This template represents a procedure service that has been provided. Examples of procedure
services include excisions of tissue and biopsies. To represent the provided procedure service,
the moodCode value is constrained to "EVN" and the statusCode value is constrained to
"completed".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 406
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 262: Provided Service Procedure Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

procedure (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.12)
@classCode

1..1

SHALL

1106145

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = PROC

@moodCode

1..1

SHALL

1106146

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106147

1..1

SHALL

1106148

1..1

SHALL

1106149

@code

0..1

SHOUL
D

translation

0..*

MAY

1106360

urn:oid:2.16.840.1.113883.6.12
(CPT4)

1..1

SHALL

1106376

urn:oid:2.16.840.1.113883.6.12
(CPT4)

1..1

SHALL

1106152

1..1

SHALL

1106377

@root
code

@code
statusCode
@code

CS

2.16.840.1.113883.10.20.34.3.12

1106150

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. Conforms to Procedure Activity Procedure (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09).
2. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1106-145).
3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-146).
4. SHALL contain exactly one [1..1] templateId (CONF:1106-147) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.12"
(CONF:1106-148).
5. SHALL contain exactly one [1..1] code (CONF:1106-149).
a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-150).
Note: Inclusion of both SNOMED CT/LOINC and CPT/HCPCS codes is
recommended. When both codes are available, include the CPT code within the
translation element. When only the CPT code is available, include the CPT code
within the translation element and use @nullFlavor="OTH" in the code element.
i.

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) (CONF:1106-770).

b. This code MAY contain zero or more [0..*] translation (CodeSystem: CPT4
urn:oid:2.16.840.1.113883.6.12) (CONF:1106-360).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 407
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

i.

The translation, if present, SHALL contain exactly one [1..1] @code, which
SHOULD be selected from CodeSystem CPT4
(urn:oid:2.16.840.1.113883.6.12) (CONF:1106-376).

6. SHALL contain exactly one [1..1] statusCode (CONF:1106-152).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-377).
Figure 125: Provided Service Procedure Example

3.56 Procedure Follow-Up Attempt Observation
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.42:2015-04-01
(open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
Table 263: Procedure Follow-Up Attempt Observation Contexts
Contained By:

Contains:

Current Outpatient Visit (V3) (optional)

Follow-up Attempt Outcome Observation

This template represents whether or not a follow-up attempt was made within 24-hours after
surgery and if so, the results of that follow-up. If this fact is unknown use nullFlavor="UNK".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 408
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 264: Procedure Follow-Up Attempt Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.42:2015-04-01)
@classCode

1..1

SHALL

11841127

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

11841128

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

11841121

@root

1..1

SHALL

11841125

2.16.840.1.113883.10.20.34.3.42

@extension

1..1

SHALL

11841134

2015-04-01

id

1..*

SHALL

11841129

code

1..1

SHALL

11841123

@code

1..1

SHALL

11841130

78027-0

@codeSystem

1..1

SHALL

11841131

2.16.840.1.113883.6.1

1..1

SHALL

11841122

1..1

SHALL

11841126

1..1

SHALL

@nullFlavor

0..1

MAY

11841132

@value

0..1

SHOUL
D

11841133

0..1

SHOUL
D

11841148

@typeCode

1..1

SHALL

11841149

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
REFR

observation

1..1

SHALL

11841150

Follow-up Attempt Outcome
Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.3.43:2015-04-01

statusCode
@code
value

entryRelationship

BL

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

11841124
UNK

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1184-1127).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-1128).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 409
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3. SHALL contain exactly one [1..1] templateId (CONF:1184-1121) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.42"
(CONF:1184-1125).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1134).
4. SHALL contain at least one [1..*] id (CONF:1184-1129).
5. SHALL contain exactly one [1..1] code (CONF:1184-1123).
a. This code SHALL contain exactly one [1..1] @code="78027-0" Follow-up attempt
made within 24-hours after surgery (CONF:1184-1130).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1184-1131).
6. SHALL contain exactly one [1..1] statusCode (CONF:1184-1122).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-1126).
Use @value="true" for "yes", @value="false" for "no" and @nullFlavor="UNK" for "unknown".
7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1184-1124).
a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-1132).
b. This value SHOULD contain zero or one [0..1] @value (CONF:1184-1133).
8. SHOULD contain zero or one [0..1] entryRelationship (CONF:1184-1148).
a. The entryRelationship, if present, SHALL contain exactly one [1..1]
@typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002) (CONF:1184-1149).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] Follow-up
Attempt Outcome Observation (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.3.43:2015-04-01) (CONF:11841150).
c. If a follow-up attempt was made then this entry SHALL be present (CONF:11841151).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 410
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 126: Procedure Follow-Up Attempt Observation

...

3.57 Product Instance
[participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.37 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 265: Product Instance Contexts
Contained By:

Contains:

Procedure Activity Procedure (V2) (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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 411
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

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 266: Product Instance Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

participantRole (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.37)
@classCode

1..1

SHALL

817900

templateId

1..1

SHALL

817901

1..1

SHALL

8110522

id

1..*

SHALL

817902

playingDevice

1..1

SHALL

817903

0..1

SHOUL
D

8116837

1..1

SHALL

817905

1..*

SHALL

817908

@root

code
scopingEntity
id

urn:oid:2.16.840.1.113883.5.110
(RoleClass) = MANU

2.16.840.1.113883.10.20.22.4.37

1. SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem:
RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:81-7900).
2. SHALL contain exactly one [1..1] templateId (CONF:81-7901) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.37"
(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).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 412
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 127: Product Instance Example

3.58 Prognosis Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.113 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 267: Prognosis Observation Contexts
Contained By:

Contains:

Problem Observation (V2) (optional)

This template represents the patient’s prognosis, which must be associated with a problem
observation. It may serve as an alert to scope intervention plans.
The effectiveTime represents the clinically relevant time of the observation. The
observation/value is not constrained and can represent the expected life duration in PQ, an
anticipated course of the disease in text, or coded term.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 413
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 268: Prognosis Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.113)
@classCode

1..1

SHALL

109829035

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

109829036

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109829037

1..1

SHALL

109829038

1..1

SHALL

109829039

@code

1..1

SHALL

109829468

75328-5

@codeSystem

1..1

SHALL

109831349

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

109831350

1..1

SHALL

109831351

effectiveTime

1..1

SHALL

109831123

value

1..1

SHALL

109829469

@root
code

statusCode
@code

2.16.840.1.113883.10.20.22.4.11
3

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-29035).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-29036).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-29037) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.113"
(CONF:1098-29038).
4. SHALL contain exactly one [1..1] code (CONF:1098-29039).
a. This code SHALL contain exactly one [1..1] @code="75328-5" Prognosis
(CONF:1098-29468).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31349).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-31350).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem:
ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1098-31351).
6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31123).
7. SHALL contain exactly one [1..1] value (CONF:1098-29469).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 414
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 128: Prognosis, Free Text Example

Presence of a life limiting condition(>50% possibility of death within 2 year)

Presence of a life limiting condition(>50% possibility of death
within 2 year

Figure 129: Prognosis, Coded Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 415
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.59 Reaction Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 269: Reaction Observation (V2) Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Procedure Activity Procedure (V2) (optional)
Procedure Activity Observation (V2) (optional)
Immunization Activity (V2) (optional)

Medication Activity (V2)
Procedure Activity Procedure (V2)
Severity Observation (V2)

This clinical statement represents the response to an undesired symptom, finding, etc. due to
administered or exposed substance. This reaction may be an undesired symptom, finding, etc.
or it could be a desired response to a treatment. A reaction can be defined with respect to its
severity, and can have been treated by one or more interventions.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 416
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 270: Reaction Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09)
@classCode

1..1

SHALL

10987325

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10987326

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987323

@root

1..1

SHALL

109810523

2.16.840.1.113883.10.20.22.4.9

@extension

1..1

SHALL

109832504

2014-06-09

id

1..*

SHALL

10987329

code

1..1

SHALL

109816851

@code

1..1

SHALL

109831124

ASSERTION

@codeSystem

1..1

SHALL

109832169

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

10987328

1..1

SHALL

109819114

0..1

SHOUL
D

10987332

low

0..1

SHOUL
D

10987333

high

0..1

SHOUL
D

10987334

value

1..1

SHALL

entryRelationship

0..*

MAY

10987337

@typeCode

1..1

SHALL

10987338

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

@inversionInd

1..1

SHALL

10987343

true

procedure

1..1

SHALL

109815920

Procedure Activity Procedure (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.14:2014-06-09

0..*

MAY

1098-

statusCode
@code
effectiveTime

entryRelationship

CD

10987335

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

urn:oid:2.16.840.1.113883.3.88.1
2.3221.7.4 (Problem)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 417
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

7340
@typeCode

1..1

SHALL

10987341

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
RSON

@inversionInd

1..1

SHALL

10987344

true

substanceAdministration

1..1

SHALL

109815921

Medication Activity (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.16:2014-06-09

0..1

MAY

10987580

@typeCode

1..1

SHALL

10987581

urn:oid:2.16.840.1.113883.5.100
2 (HL7ActRelationshipType) =
SUBJ

@inversionInd

1..1

SHALL

109810375

true

observation

1..1

SHALL

109815922

Severity Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.8:2014-06-09

entryRelationship

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7325).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7326).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7323) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.9"
(CONF:1098-10523).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32504).
4. SHALL contain at least one [1..*] id (CONF:1098-7329).
5. SHALL contain exactly one [1..1] code (CONF:1098-16851).
a. This code SHALL contain exactly one [1..1] @code="ASSERTION" (CONF:1098-31124).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:1098-32169).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7328).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819114).
7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7332).
a. The effectiveTime, if present, SHOULD contain zero or one [0..1] low (CONF:10987333).
b. The effectiveTime, if present, SHOULD contain zero or one [0..1] high (CONF:10987334).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 418
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4
DYNAMIC (CONF:1098-7335).
9. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7337) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7338).
b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7343).
This procedure activity is intended to contain information about procedures that were
performed in response to an allergy reaction.
c. SHALL contain exactly one [1..1] Procedure Activity Procedure (V2)
(identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09)
(CONF:1098-15920).
10. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7340) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7341).
b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7344).
This medication activity is intended to contain information about medications that were
administered in response to an allergy reaction.
c. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815921).
11. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7580) such that it
a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem:
HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC)
(CONF:1098-7581).
b. SHALL contain exactly one [1..1] @inversionInd="true" TRUE (CONF:1098-10375).
c. SHALL contain exactly one [1..1] Severity Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.8:2014-06-09) (CONF:109815922).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 419
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 130: Reaction Observation (V2) Example

. . .

3.60 Result Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 271: Result Observation (V2) Contexts
Contained By:

Contains:

Result Organizer (V2) (required)

Author Participation

This template represents the results of a laboratory, radiology, or other study performed on a
patient.
The result observation includes a statusCode to allow recording the status of an observation.
“Pending” results (e.g., a test has been run but results have not been reported yet) should be
represented as “active” ActStatus.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 420
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 272: Result Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2014-06-09)
@classCode

1..1

SHALL

10987130

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10987131

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987136

@root

1..1

SHALL

10989138

2.16.840.1.113883.10.20.22.4.2

@extension

1..1

SHALL

109832575

2014-06-09

id

1..*

SHALL

10987137

code

1..1

SHALL

10987133

statusCode

1..1

SHALL

10987134

1..1

SHALL

109814849

effectiveTime

1..1

SHALL

10987140

value

0..1

SHOUL
D

10987143

interpretationCode

0..*

SHOUL
D

10987147

1..1

SHALL

109832476

methodCode

0..1

MAY

SET

10987148

targetSiteCode

0..1

MAY

SET

10987153

author

0..*

SHOUL
D

10987149

referenceRange

0..*

SHOUL
D

10987150

1..1

SHALL

10987151

code

0..0

SHALL
NOT

10987152

value

1..1

SHALL

109832175

@code

@code

observationRange

urn:oid:2.16.840.1.113883.6.1
(LOINC)

urn:oid:2.16.840.1.113883.11.20.
9.39 (Result Status)

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT)

urn:oid:2.16.840.1.113883.1.11.7
8 (Observation Interpretation
(HL7))

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 421
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7130).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7131).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7136) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2"
(CONF:1098-9138).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32575).
4. SHALL contain at least one [1..*] id (CONF:1098-7137).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC
(urn:oid:2.16.840.1.113883.6.1) (CONF:1098-7133).
a. This code SHOULD be a code from the LOINC that identifies the result observation.
If an appropriate LOINC code does not exist, then the local code for this result
SHALL be sent (CONF:1098-19212).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7134).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet Result Status urn:oid:2.16.840.1.113883.11.20.9.39 STATIC
2013-08-09 (CONF:1098-14849).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-7140).
Note: Represents the biologically relevant time of the measurement (e.g., the time a blood
pressure reading is obtained, the time the blood sample was obtained for a chemistry test).
8. SHOULD contain zero or one [0..1] value, which SHOULD be selected from CodeSystem
SNOMED CT (urn:oid:2.16.840.1.113883.6.96) (CONF:1098-7143).
a. If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure
SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive
2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-31484).
b. A coded value MAY contain zero or more [0..*] translations, which can be used to
represent the original results as output by the lab (CONF:1098-31866).
c. If Observation/value is a CD (xsi:type="CD") the value SHOULD be SNOMED-CT
(CONF:1098-32610).
9. SHOULD contain zero or more [0..*] interpretationCode (CONF:1098-7147).
a. The interpretationCode, if present, SHALL contain exactly one [1..1] @code, which
SHALL be selected from ValueSet Observation Interpretation (HL7)
urn:oid:2.16.840.1.113883.1.11.78 STATIC 2014-09-01 (CONF:1098-32476).
10. MAY contain zero or one [0..1] methodCode (CONF:1098-7148).
11. MAY contain zero or one [0..1] targetSiteCode (CONF:1098-7153).
12. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-7149).
13. SHOULD contain zero or more [0..*] referenceRange (CONF:1098-7150).
a. The referenceRange, if present, SHALL contain exactly one [1..1] observationRange
(CONF:1098-7151).
i.

This observationRange SHALL NOT contain [0..0] code (CONF:1098-7152).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 422
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

ii. This observationRange SHALL contain exactly one [1..1] value (CONF:109832175).
Table 273: Result Status
Value Set: Result Status urn:oid:2.16.840.1.113883.11.20.9.39
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

aborted

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

aborted

active

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

active

cancelled

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

cancelled

completed

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

completed

held

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

held

suspended

ActStatus

urn:oid:2.16.840.1.11388
3.5.14

suspended

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 423
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 274: Observation Interpretation (HL7)
Value Set: Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

A

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

abnormal

B

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

better

Carrier

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

carrier

D

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

decreased

HX

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

above high threshold

I

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

intermediate

IND

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

indeterminate

LX

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

below low threshold

MS

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

moderately susceptible

N

HITSP-CS-83

urn:oid:2.16.840.1.11388
3.5.83

normal

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 424
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 131: Result Observation (V2) Example

1017 Health Drive
Portland
OR
99123
US

William
Bill
Beaker

Good Health Laboratory

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 425
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 132: Pending Result Observation (V2) Example

Figure 133: Original Lab Units in Example

6.7 billion per liter

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 426
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.61 Result Organizer (V2)
[organizer: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.1:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 275: Result Organizer (V2) Contexts
Contained By:

Contains:

Results Section (entries optional) (V2) (optional)

Author Participation
Result Observation (V2)

This template provides a mechanism for grouping result observations. It contains information
applicable to all of the contained result observations. The Result Organizer code categorizes the
contained results into one of several commonly accepted values (e.g., “Hematology”,
“Chemistry”, “Nuclear Medicine”).
If any Result Observation within the organizer has a statusCode of "active", the Result
Organizer must also have a statusCode of "active".

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 427
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 276: Result Organizer (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

organizer (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.1:2014-06-09)
@classCode

1..1

SHALL

10987121

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass)

@moodCode

1..1

SHALL

10987122

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987126

@root

1..1

SHALL

10989134

2.16.840.1.113883.10.20.22.4.1

@extension

1..1

SHALL

109832588

2014-06-09

id

1..*

SHALL

10987127

code

1..1

SHALL

10987128

statusCode

1..1

SHALL

10987123

1..1

SHALL

109814848

0..1

MAY

109831865

low

1..1

SHALL

109832488

high

1..1

SHALL

109832489

author

0..*

SHOUL
D

109831149

component

1..*

SHALL

10987124

1..1

SHALL

109814850

@code
effectiveTime

observation

urn:oid:2.16.840.1.113883.11.20.
9.39 (Result Status)

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

Result Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.2:2014-06-09

1. SHALL contain exactly one [1..1] @classCode (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7121).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7122).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7126) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.1"
(CONF:1098-9134).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32588).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 428
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4. SHALL contain at least one [1..*] id (CONF:1098-7127).
5. SHALL contain exactly one [1..1] code (CONF:1098-7128).
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:1098-19218).
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 (CONF:109819219).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7123).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected
from ValueSet Result Status urn:oid:2.16.840.1.113883.11.20.9.39 STATIC
2013-08-09 (CONF:1098-14848).
7. MAY contain zero or one [0..1] effectiveTime (CONF:1098-31865).
Note: The effectiveTime is an interval that spans the effectiveTimes of the contained result
observations. Because all contained result observations have a required time stamp, it is
not required that this effectiveTime be populated.
a. The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:109832488).
b. The effectiveTime, if present, SHALL contain exactly one [1..1] high (CONF:109832489).
8. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31149).
9. SHALL contain at least one [1..*] component (CONF:1098-7124) such that it
a. SHALL contain exactly one [1..1] Result Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2014-06-09) (CONF:109814850).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 429
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 134: Result Organizer (V2) Example

. . .

. . .

3.62 Service Delivery Location
[participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.32 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 277: Service Delivery Location Contexts
Contained By:

Contains:

Procedure Activity Act (V2) (optional)
Procedure Activity Procedure (V2) (optional)
Procedure Activity Observation (V2) (optional)
Encounter Activity (V2) (optional)
Hospital Admission Encounter (required)

This clinical statement represents the location of a service event where an act, observation or
procedure took place.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 430
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 278: Service Delivery Location Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

participantRole (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32)
@classCode

1..1

SHALL

817758

templateId

1..1

SHALL

817635

1..1

SHALL

8110524

2.16.840.1.113883.10.20.22.4.32

code

1..1

SHALL

8116850

urn:oid:2.16.840.1.113883.1.11.2
0275 (HealthcareServiceLocation)

addr

0..*

SHOUL
D

817760

telecom

0..*

SHOUL
D

817761

playingEntity

0..1

MAY

817762

@classCode

1..1

SHALL

817763

name

0..1

MAY

8116037

@root

urn:oid:2.16.840.1.113883.5.111
(RoleCode) = SDLOC

urn:oid:2.16.840.1.113883.5.41
(EntityClass) = PLC

1. SHALL contain exactly one [1..1] @classCode="SDLOC" (CodeSystem: RoleCode
urn:oid:2.16.840.1.113883.5.111 STATIC) (CONF:81-7758).
2. SHALL contain exactly one [1..1] templateId (CONF:81-7635) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.32"
(CONF:81-10524).
3. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet
HealthcareServiceLocation urn:oid: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 urn:oid:2.16.840.1.113883.5.41 STATIC) (CONF:817763).
b. The playingEntity, if present, MAY contain zero or one [0..1] name (CONF:81-16037).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 431
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 279: HealthcareServiceLocation
Value Set: HealthcareServiceLocation urn:oid:2.16.840.1.113883.1.11.20275
A 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: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1162-7

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

24-Hour observation area

1184-1

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Administrative area

1210-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Adult Mixed Acuity Unit

1099-1

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Adult step down unit
[post-critical care]

1110-6

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Allergy clinic

1166-8

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Ambulatory surgical
setting

1212-0

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Any Age Mixed Acuity
Unit

1106-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Assisted living area

1145-2

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Behavioral health clinic

1185-8

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Blood bank

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 432
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 135: Service Delivery Location Example

17 Daws Rd.
Blue Bell
MA
02368
US

Community Health and Hospitals

3.63 Severity Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.8:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 280: Severity Observation (V2) Contexts
Contained By:

Contains:

Reaction Observation (V2) (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.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 433
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 281: Severity Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.8:2014-06-09)
@classCode

1..1

SHALL

10987345

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10987346

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987347

@root

1..1

SHALL

109810525

2.16.840.1.113883.10.20.22.4.8

@extension

1..1

SHALL

109832577

2014-06-09

1..1

SHALL

109819168

@code

1..1

SHALL

109819169

SEV

@codeSystem

1..1

SHALL

109832170

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

10987352

1..1

SHALL

109819115

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

10987356

urn:oid:2.16.840.1.113883.3.88.1
2.3221.6.8 (Problem Severity)

code

statusCode
@code
value

CD

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7345).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7346).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7347) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.8"
(CONF:1098-10525).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32577).
4. SHALL contain exactly one [1..1] code (CONF:1098-19168).
a. This code SHALL contain exactly one [1..1] @code="SEV" Severity (CONF:109819169).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:1098-32170).
5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7352).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 434
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819115).
6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Problem Severity
urn:oid:2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC (CONF:1098-7356).
Table 282: Problem Severity
Value Set: Problem Severity urn:oid:2.16.840.1.113883.3.88.12.3221.6.8
This is a description of the level of the severity of the problem.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

255604002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Mild (qualifier value)

371923003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Mild to moderate
(qualifier value)

6736007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Moderate (severity
modifier) (qualifier value)

371924009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Moderate to severe
(qualifier value)

24484000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Severe (severity modifier)
(qualifier value)

399166001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Fatal (qualifier value)

Figure 136: Severity Observation (V2) Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 435
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.64 Smoking Status - Meaningful Use (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 283: Smoking Status - Meaningful Use (V2) Contexts
Contained By:

Contains:

Social History Section (V2) (optional)
Patient Information Section (V3) (optional)

Author Participation

This template represents the current smoking status of the patient as specified in Meaningful
Use (MU) Stage 2 requirements. Historic smoking status observations as well as details about
the smoking habit (e.g., how many per day) would be represented in the Tobacco Use template.
This template represents a “snapshot in time” observation, simply reflecting what the patient’s
current smoking status is at the time of the observation. As a result, the effectiveTime is
constrained to a time stamp, and will approximately correspond with the author/time. Details
regarding the time period when the patient is/was smoking would be recorded in the Tobacco
Use template.
If the patient's current smoking status is unknown, the value element must be populated with
SNOMED CT code 266927001 to communicate "Unknown if ever smoked" from the Current
Smoking Status Value Set.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 436
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 284: Smoking Status - Meaningful Use (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09)
@classCode

1..1

SHALL

109814806

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

109814807

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109814815

@root

1..1

SHALL

109814816

2.16.840.1.113883.10.20.22.4.78

@extension

1..1

SHALL

109832573

2014-06-09

id

1..*

SHALL

109832401

code

1..1

SHALL

109819170

@code

1..1

SHALL

109831039

72166-2

@codeSystem

1..1

SHALL

109832157

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

109814809

1..1

SHALL

109819116

1..1

SHALL

109831928

low

0..0

SHALL
NOT

109832894

width

0..0

SHALL
NOT

109832895

high

0..0

SHALL
NOT

109832896

center

0..0

SHALL
NOT

109832897

1..1

SHALL

1..1

SHALL

109814817

urn:oid:2.16.840.1.113883.11.20.
9.38 (Current Smoking Status)

0..*

SHOUL
D

109831148

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

statusCode
@code
effectiveTime

value
@code
author

CD

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

109814810

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-14806).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 437
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-14807).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-14815) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.78"
(CONF:1098-14816).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32573).
4. SHALL contain at least one [1..*] id (CONF:1098-32401).
5. SHALL contain exactly one [1..1] code (CONF:1098-19170).
a. This code SHALL contain exactly one [1..1] @code="72166-2" Tobacco smoking
status NHIS (CONF:1098-31039).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32157).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-14809).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819116).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31928).
Note: This template represents a “snapshot in time” observation, simply reflecting what the
patient’s current smoking status is at the time of the observation. As a result, the
effectiveTime is constrained to just a time stamp, and will approximately correspond with
the author/time.
a. This effectiveTime SHALL NOT contain [0..0] low (CONF:1098-32894).
b. This effectiveTime SHALL NOT contain [0..0] width (CONF:1098-32895).
c. This effectiveTime SHALL NOT contain [0..0] high (CONF:1098-32896).
d. This effectiveTime SHALL NOT contain [0..0] center (CONF:1098-32897).
8. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1098-14810).
a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from
ValueSet Current Smoking Status urn:oid:2.16.840.1.113883.11.20.9.38
STATIC 2014-09-01 (CONF:1098-14817).
b. If the patient's current smoking status is unknown, @code SHALL contain
'266927001' (Unknown if ever smoked) from ValueSet Current Smoking Status
(2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01) (CONF:1098-31019).
9. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31148).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 438
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 285: Current Smoking Status
Value Set: Current Smoking Status urn:oid:2.16.840.1.113883.11.20.9.38
This value set indicates the current smoking status of a patient.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

449868002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Current every day smoker

428041000124106

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Current some day smoker

8517006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Former smoker

266919005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Never smoker (Never
Smoked)

77176002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Smoker, current status
unknown

266927001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Unknown if ever smoked

428071000124103

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Heavy tobacco smoker

428061000124105

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Light tobacco smoker

Figure 137: Smoking Status - Meaningful Use (V2) Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 439
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.65 Social History Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 286: Social History Observation (V2) Contexts
Contained By:

Contains:

Social History Section (V2) (optional)

Author Participation

This template represents a patient's occupations, lifestyle, and environmental health risk
factors. Demographic data (e.g., marital status, race, ethnicity, religious affiliation) are
captured in the header. Though tobacco use and exposure may be represented with a Social
History Observation, it is recommended to use the Current Smoking Status template or the
Tobacco Use template instead, to represent smoking or tobacco habits.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 440
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 287: Social History Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2014-06-09)
@classCode

1..1

SHALL

10988548

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10988549

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10988550

@root

1..1

SHALL

109810526

2.16.840.1.113883.10.20.22.4.38

@extension

1..1

SHALL

109832495

2014-06-09

id

1..*

SHALL

10988551

code

1..1

SHALL

10988558

originalText

0..1

SHOUL
D

109819221

reference

0..1

SHOUL
D

109819222

@value

0..1

SHOUL
D

109819223

1..1

SHALL

10988553

1..1

SHALL

109819117

effectiveTime

1..1

SHALL

109831868

value

0..1

SHOUL
D

10988559

author

0..*

SHOUL
D

109831869

statusCode
@code

urn:oid:2.16.840.1.113883.6.1
(LOINC)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8548).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8549).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-8550) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.38"
(CONF:1098-10526).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32495).
4. SHALL contain at least one [1..*] id (CONF:1098-8551).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 441
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC
(urn:oid:2.16.840.1.113883.6.1) DYNAMIC (CONF:1098-8558).
a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19221).
i.

The originalText, if present, SHOULD contain zero or one [0..1] reference
(CONF:1098-19222).
1. The reference, if present, SHOULD contain zero or one [0..1] @value
(CONF:1098-19223).
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:109819224).

6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8553).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819117).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31868).
8. SHOULD contain zero or one [0..1] value (CONF:1098-8559).
a. If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure
SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive
(2.16.840.1.113883.1.11.12839) DYNAMIC (CONF:1098-8555).
9. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31869).
Figure 138: Social History Observation (V2) Example

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 442
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.66 Substance Administered Act
[act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.118 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 288: Substance Administered Act Contexts
Contained By:

Contains:

Medication Activity (V2) (optional)
Immunization Activity (V2) (optional)

This template represents the administration course in a series. The
entryRelationship/sequenceNumber in the containing template shows the order of this
particular administration in that medication series.
Table 289: Substance Administered Act Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.118)
@classCode

1..1

SHALL

109831500

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = ACT

@moodCode

1..1

SHALL

109831501

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109831502

1..1

SHALL

109831503

id

1..*

SHALL

109831504

code

1..1

SHALL

109831506

@code

1..1

SHALL

109831507

416118004

@codeSystem

1..1

SHALL

109831508

urn:oid:2.16.840.1.113883.6.96
(SNOMED CT) =
2.16.840.1.113883.6.96

statusCode

1..1

SHALL

109831505

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

effectiveTime

0..1

MAY

109831509

@root

2.16.840.1.113883.10.20.22.4.11
8

1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1098-31500).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-31501).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-31502) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 443
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.118"
(CONF:1098-31503).
4. SHALL contain at least one [1..*] id (CONF:1098-31504).
5. SHALL contain exactly one [1..1] code (CONF:1098-31506).
a. This code SHALL contain exactly one [1..1] @code="416118004" Administration
(CONF:1098-31507).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT
urn:oid:2.16.840.1.113883.6.96) (CONF:1098-31508).
6. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem:
ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1098-31505).
7. MAY contain zero or one [0..1] effectiveTime (CONF:1098-31509).
Figure 139: Substance Administered Act Example

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 444
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.67 Tobacco Use (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 290: Tobacco Use (V2) Contexts
Contained By:

Contains:

Social History Section (V2) (optional)
Patient Information Section (V3) (optional)

Author Participation

This template represents a patient’s tobacco use.
All the types of tobacco use are represented using the codes from the tobacco use and
exposure-finding hierarchy in SNOMED CT, including codes required for recording smoking
status in Meaningful Use Stage 2.
The effectiveTime element is used to describe dates associated with the patient's tobacco use.
Whereas the Smoking Status - Meaningful Use (V2) template
(2.16.840.1.113883.10.20.22.4.78:2014-06-09) represents a “snapshot in time” observation,
simply reflecting what the patient’s current smoking status is at the time of the observation,
this Tobacco Use template uses effectiveTime to represent the biologically relevant time of the
observation. Thus, to record a former smoker, an observation of “cigarette smoker” will have an
effectiveTime/low defining the time the patient started to smoke cigarettes and an
effectiveTime/high defining the time the patient ceased to smoke cigarettes. To record a current
smoker, the effectiveTime/low will define the time the patient started smoking and will have no
effectiveTime/high to indicated that the patient is still smoking.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 445
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 291: Tobacco Use (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09)
@classCode

1..1

SHALL

109816558

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

109816559

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

109816566

@root

1..1

SHALL

109816567

2.16.840.1.113883.10.20.22.4.85

@extension

1..1

SHALL

109832589

2014-06-09

id

1..*

SHALL

109832400

code

1..1

SHALL

109819174

@code

1..1

SHALL

109819175

11367-0

@codeSystem

1..1

SHALL

109832172

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

109816561

1..1

SHALL

109819118

1..1

SHALL

109816564

low

1..1

SHALL

109816565

high

0..1

MAY

109831431

1..1

SHALL

1..1

SHALL

109816563

urn:oid:2.16.840.1.113883.11.20.
9.41 (Tobacco Use)

0..*

SHOUL
D

109831152

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

statusCode
@code
effectiveTime

value
@code
author

CD

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

109816562

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-16558).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-16559).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-16566) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 446
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.85"
(CONF:1098-16567).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32589).
4. SHALL contain at least one [1..*] id (CONF:1098-32400).
5. SHALL contain exactly one [1..1] code (CONF:1098-19174).
a. This code SHALL contain exactly one [1..1] @code="11367-0" History of tobacco use
(CONF:1098-19175).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32172).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-16561).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819118).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-16564).
Note: The effectiveTime represents the biologically relevant time of the observation. A
“former smoker” is recorded with the proper code “current smoker” with an
effectiveTime/low and effectiveTime/high defining the time during which the patient was a
smoker.
a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1098-16565).
b. This effectiveTime MAY contain zero or one [0..1] high (CONF:1098-31431).
8. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1098-16562).
a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from
ValueSet Tobacco Use urn:oid:2.16.840.1.113883.11.20.9.41 DYNAMIC
(CONF:1098-16563).
9. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31152).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 447
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 292: Tobacco Use
Value Set: Tobacco Use urn:oid:2.16.840.1.113883.11.20.9.41
Contains values descending from the SNOMED CT® Finding of tobacco use and exposure (finding)
(365980008) hierarchy excluding temporal findings such as 'Former Smoker' 'Never Chewed', etc.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

81703003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Chews tobacco

228494002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Snuff user

59978006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Cigar smoker

43381005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Passive smoker

228524006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Exposed to tobacco
smoke at home

427189007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Maternal tobacco use

394871007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Thinking about stopping
smoking

65568007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Cigarette smoker

160619003

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Rolls own cigarettes

266927001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Pipe smoker

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 448
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 140: Tobacco Use (V2) Example

3.68 Transport Mode to Hospital Observation
[observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.24 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1 - US
Realm
Table 293: Transport Mode to Hospital Observation Contexts
Contained By:

Contains:

Current Emergency Department Visit (V2) (optional)

This template represents the patient's mode of transport to the hospital.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 449
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 294: Transport Mode to Hospital Observation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.24)
@classCode

1..1

SHALL

1106614

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

1106615

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

1106609

1..1

SHALL

1106611

id

1..*

SHALL

1106682

code

1..1

SHALL

1106610

@code

1..1

SHALL

1106612

74286-6

@codeSystem

1..1

SHALL

1106613

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

1106683

1..1

SHALL

1106684

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

1..1

SHALL

1106616

urn:oid:2.16.840.1.114222.4.11.7
277 (Transport Mode to Hospital
(NCHS))

0..1

MAY

@root

statusCode
@code
value

@nullFlavor

CD

2.16.840.1.113883.10.20.34.3.24

1106866

1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-614).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-615).
3. SHALL contain exactly one [1..1] templateId (CONF:1106-609) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.24"
(CONF:1106-611).
4. SHALL contain at least one [1..*] id (CONF:1106-682).
5. SHALL contain exactly one [1..1] code (CONF:1106-610).
a. This code SHALL contain exactly one [1..1] @code="74286-6" Transport mode to
hospital (CONF:1106-612).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1106-613).
6. SHALL contain exactly one [1..1] statusCode (CONF:1106-683).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 450
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-684).
7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be
selected from ValueSet Transport Mode to Hospital (NCHS)
urn:oid:2.16.840.1.114222.4.11.7277 DYNAMIC (CONF:1106-616).
a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:1106-866).
i.

NullFlavor SHALL be "UNK" Unknown, "OTH" Other, or "NA" Not Applicable
(CONF:1106-867).
Table 295: Transport Mode to Hospital (NCHS)

Value Set: Transport Mode to Hospital (NCHS) urn:oid:2.16.840.1.114222.4.11.7277
The mode of transport (e.g., ground ambulance, walk-in, police) delivering the patient to a hospital.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7277
Code

Code System

Code System OID

Print Name

44613004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Ground transport
ambulance

32472009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Medical helicopter

73957001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Air transport ambulance

46160005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Motor vehicle

257250006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Pedestrian conveyance

442301000124107

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Police vehicle

Figure 141: Transport Mode to Hospital Observation Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 451
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.69 Vital Sign Observation (V2)
[observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 296: Vital Sign Observation (V2) Contexts
Contained By:

Contains:

Vital Signs Organizer (V2) (required)

Author Participation

This template represents measurement of common vital signs. Vital signs are represented with
additional vocabulary constraints for type of vital sign and unit of measure.
The following is a list of recommended units for common types of vital sign measurements:
Name

Unit

PulseOx

%

Height/Head Circumf

cm

Weight

kg

Temp

Cel

BP

mm[Hg]

Pulse/Resp Rate

/min

BMI

kg/m2

BSA

m2

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 452
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 297: Vital Sign Observation (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09)
@classCode

1..1

SHALL

10987297

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = OBS

@moodCode

1..1

SHALL

10987298

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987299

@root

1..1

SHALL

109810527

2.16.840.1.113883.10.20.22.4.27

@extension

1..1

SHALL

109832574

2014-06-09

id

1..*

SHALL

10987300

code

1..1

SHALL

10987301

statusCode

1..1

SHALL

10987303

1..1

SHALL

109819119

effectiveTime

1..1

SHALL

10987304

value

1..1

SHALL

1..1

SHALL

109831579

0..1

MAY

10987307

1..1

SHALL

109832886

methodCode

0..1

MAY

SET

10987308

targetSiteCode

0..1

MAY

SET

10987309

author

0..*

SHOUL
D

@code

@unit

interpretationCode
@code

PQ

urn:oid:2.16.840.1.113883.3.88.1
2.80.62 (Vital Sign Result)

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

10987305

10987310

urn:oid:2.16.840.1.113883.1.11.1
2839
(UnitsOfMeasureCaseSensitive)

urn:oid:2.16.840.1.113883.1.11.7
8 (Observation Interpretation
(HL7))

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7297).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7298).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 453
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3. SHALL contain exactly one [1..1] templateId (CONF:1098-7299) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.27"
(CONF:1098-10527).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32574).
4. SHALL contain at least one [1..*] id (CONF:1098-7300).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Vital Sign
Result urn:oid:2.16.840.1.113883.3.88.12.80.62 DYNAMIC (CONF:1098-7301).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7303).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819119).
7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-7304).
8. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:1098-7305).
a. This value SHALL contain exactly one [1..1] @unit, which SHALL be selected from
ValueSet UnitsOfMeasureCaseSensitive
urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-31579).
9. MAY contain zero or one [0..1] interpretationCode (CONF:1098-7307).
a. The interpretationCode, if present, SHALL contain exactly one [1..1] @code (ValueSet:
Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78
STATIC 2014-09-01) (CONF:1098-32886).
10. MAY contain zero or one [0..1] methodCode (CONF:1098-7308).
11. MAY contain zero or one [0..1] targetSiteCode (CONF:1098-7309).
12. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-7310).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 454
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 298: Vital Sign Result
Value Set: Vital Sign Result urn:oid:2.16.840.1.113883.3.88.12.80.62
This identifies the vital sign result type.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

8310-5

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Body Temperature

8462-4

LOINC

urn:oid:2.16.840.1.11388
3.6.1

BP Diastolic

8480-6

LOINC

urn:oid:2.16.840.1.11388
3.6.1

BP Systolic

8287-5

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Head Circumference

8867-4

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Heart Rate

8302-2

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Height

39156-5

LOINC

urn:oid:2.16.840.1.11388
3.6.1

BMI (Body Mass Index)

2710-2

LOINC

urn:oid:2.16.840.1.11388
3.6.1

O2 % BldC Oximetry

9279-1

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Respiratory Rate

3141-9

LOINC

urn:oid:2.16.840.1.11388
3.6.1

Weight Measured

...

Figure 142: Vital Sign Observation (V2) Example

....

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 455
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

3.70 Vital Signs Organizer (V2)
[organizer: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09
(open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 299: Vital Signs Organizer (V2) Contexts
Contained By:

Contains:

Vital Signs Section (entries optional) (V2) (optional)
Vital Signs Section (entries required) (V2) (required)

Author Participation
Vital Sign Observation (V2)

This template provides a mechanism for grouping vital signs (e.g., grouping systolic blood
pressure and diastolic blood pressure).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 456
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 300: Vital Signs Organizer (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

organizer (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09)
@classCode

1..1

SHALL

10987279

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = CLUSTER

@moodCode

1..1

SHALL

10987280

urn:oid:2.16.840.1.113883.5.100
1 (ActMood) = EVN

templateId

1..1

SHALL

10987281

@root

1..1

SHALL

109810528

2.16.840.1.113883.10.20.22.4.26

@extension

1..1

SHALL

109832582

2014-06-09

id

1..*

SHALL

10987282

code

0..1

MAY

109832740

@code

1..1

SHALL

109832741

74728-7

@codeSystem

1..1

SHALL

109832742

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

1..1

SHALL

10987284

1..1

SHALL

109819120

effectiveTime

0..1

MAY

10987288

author

0..*

SHOUL
D

109831153

component

1..*

SHALL

10987285

1..1

SHALL

109815946

statusCode
@code

observation

urn:oid:2.16.840.1.113883.5.14
(ActStatus) = completed

Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.4.119

Vital Sign Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.4.27:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="CLUSTER" CLUSTER (CodeSystem:
HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7279).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7280).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-7281) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.26"
(CONF:1098-10528).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32582).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 457
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4. SHALL contain at least one [1..*] id (CONF:1098-7282).
5. MAY contain zero or one [0..1] code (CONF:1098-32740).
a. The code, if present, SHALL contain exactly one [1..1] @code="74728-7" Vital signs,
weight, height, head circumference, oximetry, BMI, and BSA panel - HL7.CCDAr1.1
(CONF:1098-32741).
b. The code, if present, SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1 " LOINC (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32742).
6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7284).
a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed
(CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819120).
7. MAY contain zero or one [0..1] effectiveTime (CONF:1098-7288).
Note: The effectiveTime is an interval that spans the effectiveTimes of the contained vital
signs observations. Because all contained vital signs observations have a required time
stamp, it is not required that this effectiveTime be populated.
8. SHOULD contain zero or more [0..*] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31153).
9. SHALL contain at least one [1..*] component (CONF:1098-7285) such that it
a. SHALL contain exactly one [1..1] Vital Sign Observation (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09) (CONF:109815946).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 458
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 143: Vital Signs Organizer (V2) Example

...

...

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 459
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4

PARTICIPATION AND OTHER TEMPLATES

4.1

Author Participation
[author: identifier urn:oid:2.16.840.1.113883.10.20.22.4.119 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 301: Author Participation Contexts

Contained By:

Contains:

Social History Observation (V2) (optional)
Medication Activity (V2) (optional)
Procedure Activity Act (V2) (optional)
Procedure Activity Procedure (V2) (optional)
Procedure Activity Observation (V2) (optional)
Problem Observation (V2) (optional)
Immunization Activity (V2) (optional)
Planned Act (V2) (optional)
Planned Procedure (V2) (optional)
Planned Observation (V2) (optional)
Planned Medication Activity (V2) (optional)
Smoking Status - Meaningful Use (V2) (optional)
Vital Sign Observation (V2) (optional)
Result Observation (V2) (optional)
Vital Signs Organizer (V2) (optional)
Priority Preference (optional)
Result Organizer (V2) (optional)
Tobacco Use (V2) (optional)
Planned Coverage (optional)
Planned Immunization Activity (optional)

This template represents the Author Participation (including the author timestamp). CDA R2
requires that Author and Author timestamp be asserted in the document header. From there,
authorship propagates to contained sections and contained entries, unless explicitly
overridden.
The Author Participation template was added to those templates in scope for analysis in R2.
Although it is not explicitly stated in all templates the Author Participation template can be
used in any template.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 460
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 302: Author Participation Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

author (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119)
templateId

1..1

SHALL

109832017

1..1

SHALL

109832018

time

1..1

SHALL

109831471

assignedAuthor

1..1

SHALL

109831472

id

1..*

SHALL

109831473

code

0..1

SHOUL
D

109831671

assignedPerson

0..1

MAY

109831474

0..*

MAY

109831475

0..1

MAY

109831476

id

0..*

MAY

109831478

name

0..*

MAY

109831479

telecom

0..*

MAY

109831480

addr

0..*

MAY

109831481

@root

name
representedOrganization

2.16.840.1.113883.10.20.22.4.11
9

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

1. SHALL contain exactly one [1..1] templateId (CONF:1098-32017) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.119"
(CONF:1098-32018).
2. SHALL contain exactly one [1..1] time (CONF:1098-31471).
3. SHALL contain exactly one [1..1] assignedAuthor (CONF:1098-31472).
a. This assignedAuthor SHALL contain at least one [1..*] id (CONF:1098-31473).
Note: This id may be set equal to (a pointer to) an id on a participant elsewhere in
the document (header or entries) or a new author participant can be described here.
If the id is pointing to a participant already described elsewhere in the document,
assignedAuthor/id is sufficient to identify this participant and none of the
remaining details of assignedAuthor are required to be set. Application Software
must be responsible for resolving the identifier back to its original object and then
rendering the information in the correct place in the containing section's narrative
text. This id must be a pointer to another author participant.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 461
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

i.

If the ID isn't referencing an author described elsewhere in the document,
then the author components required in US Realm Header are required here
as well (CONF:1098-32628).

b. This assignedAuthor SHOULD contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-31671).
i.

If the content is patient authored the code SHOULD be selected from
Personal And Legal Relationship Role Type (2.16.840.1.113883.11.20.12.1)
(CONF:1098-32315).

c. This assignedAuthor MAY contain zero or one [0..1] assignedPerson (CONF:109831474).
i.

The assignedPerson, if present, MAY contain zero or more [0..*] name
(CONF:1098-31475).

d. This assignedAuthor MAY contain zero or one [0..1] representedOrganization
(CONF:1098-31476).
i.

The representedOrganization, if present, MAY contain zero or more [0..*] id
(CONF:1098-31478).

ii. The representedOrganization, if present, MAY contain zero or more [0..*] name
(CONF:1098-31479).
iii. The representedOrganization, if present, MAY contain zero or more [0..*]
telecom (CONF:1098-31480).
iv. The representedOrganization, if present, MAY contain zero or more [0..*] addr
(CONF:1098-31481).
Figure 144: New Author Participant Example

Nurse
Nightingale
RN

Good Health Hospital

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 462
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Figure 145: Existing Author Reference Example

4.2

US Realm Address (AD.US.FIELDED)
[addr: identifier urn:oid:2.16.840.1.113883.10.20.22.5.2 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 303: US Realm Address (AD.US.FIELDED) Contexts

Contained By:

Contains:

US Realm Header (V2) (required)
Medication Dispense (V2) (optional)
Policy Activity (V2) (optional)

Reusable address template, for use in US Realm CDA Header.
Table 304: 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
D

817290

urn:oid:2.16.840.1.113883.1.11.1
0637 (PostalAddressUse)

country

0..1

SHOUL
D

817295

urn:oid:2.16.840.1.113883.3.88.1
2.80.63 (Country)

state

0..1

SHOUL
D

817293

urn:oid:2.16.840.1.113883.3.88.1
2.80.1 (StateValueSet)

city

1..1

SHALL

817292

postalCode

0..1

SHOUL
D

817294

streetAddressLine

1..1

SHALL

817291

urn:oid:2.16.840.1.113883.3.88.1
2.80.2 (PostalCode)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 463
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet
PostalAddressUse urn:oid: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
urn:oid: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
urn:oid: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 urn:oid: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 exactly one [1..1] streetAddressLine (CONF:81-7291).
7. SHALL NOT have mixed content except for white space (CONF:81-7296).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 464
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 305: PostalAddressUse
Value Set: PostalAddressUse urn:oid:2.16.840.1.113883.1.11.10637
A value set of HL7 Codes for address use.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

BAD

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

bad address

CONF

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

confidential

DIR

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

direct

H

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

home address

HP

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

primary home

HV

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

vacation home

PHYS

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

physical visit address

PST

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

postal address

PUB

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

public

TMP

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

temporary

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 465
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 306: StateValueSet
Value Set: StateValueSet urn:oid:2.16.840.1.113883.3.88.12.80.1
Identifies 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 area
Value Set Source: http://www.census.gov/geo/reference/ansi_statetables.html
Code

Code System

Code System OID

Print Name

AL

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Alabama

AK

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Alaska

AZ

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Arizona

AR

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Arkansas

CA

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

California

CO

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Colorado

CT

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Connecticut

DE

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Delaware

DC

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

District of Columbia

FL

FIPS 5-2 (State)

urn:oid:2.16.840.1.11388
3.6.92

Florida

...

Figure 146: US Realm Address Example

22 Sample Street
Beaverton
OR
97867
US

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 466
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4.3

US Realm Date and Time (DTM.US.FIELDED)
[effectiveTime: identifier urn:oid:2.16.840.1.113883.10.20.22.5.4 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 307: US Realm Date and Time (DTM.US.FIELDED) Contexts

Contained By:

Contains:

US Realm Header (V2) (required)

The US Realm Clinical Document Date and Time datatype flavor records date and time
information. If no time zone offset is provided, you can make no assumption about time, unless
you have made a local exchange agreement.
This data type uses the same rules as US Realm Date and Time (DT.US.FIELDED), but is used
with elements having a datatype of TS.
Table 308: US Realm Date and Time (DTM.US.FIELDED) Constraints Overview
X Card.
P
a
t
h

Verb

Data
Type

CONF#

Value

effectiveTime (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4)

1. SHALL be precise to the day (CONF:81-10127).
2. SHOULD be precise to the minute (CONF:81-10128).
3. MAY be precise to the second (CONF:81-10129).
4. If more precise than day, SHOULD include time-zone offset (CONF:81-10130).
Figure 147: US Realm Date and Time Example

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 467
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

4.4

US Realm Patient Name (PTN.US.FIELDED)
[name: identifier urn:oid:2.16.840.1.113883.10.20.22.5.1 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 309: US Realm Patient Name (PTN.US.FIELDED) Contexts

Contained By:

Contains:

Drug Monitoring Act (required)

The US Realm Patient Name datatype flavor is a set of reusable constraints that can be used
for the patient or any other person. It requires a first (given) and last (family) name. If a patient
or person has only one name part (e.g., patient with first name only) place the name part in the
field required by the organization. Use the appropriate nullFlavor, "Not Applicable" (NA), in the
other field.
For information on mixed content see the Extensible Markup Language reference
(http://www.w3c.org/TR/2008/REC-xml-20081126/).
Table 310: US Realm Patient Name (PTN.US.FIELDED) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

817154

urn:oid:2.16.840.1.113883.1.11.1
5913 (EntityNameUse)

name (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1)
@use

0..1

MAY

family

1..1

SHALL

0..1

MAY

1..*

SHALL

0..1

MAY

0..*

MAY

0..1

MAY

0..1

MAY

0..1

MAY

@qualifier

given
@qualifier

prefix
@qualifier

suffix
@qualifier

ST

817159
817160

ST

817157
817158

ST

urn:oid:2.16.840.1.113883.11.20.
9.26
(EntityPersonNamePartQualifier)

817155
817156

ST

urn:oid:2.16.840.1.113883.11.20.
9.26
(EntityPersonNamePartQualifier)

urn:oid:2.16.840.1.113883.11.20.
9.26
(EntityPersonNamePartQualifier)

817161
817162

urn:oid:2.16.840.1.113883.11.20.
9.26
(EntityPersonNamePartQualifier)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 468
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

1. MAY contain zero or one [0..1] @use, which SHALL be selected from ValueSet EntityNameUse
urn:oid:2.16.840.1.113883.1.11.15913 STATIC 2005-05-01 (CONF:81-7154).
2. SHALL contain exactly one [1..1] family (CONF:81-7159).
a. This family MAY contain zero or one [0..1] @qualifier, which SHALL be selected from
ValueSet EntityPersonNamePartQualifier
urn:oid:2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:81-7160).
3. SHALL contain at least one [1..*] given (CONF:81-7157).
a. Such givens MAY contain zero or one [0..1] @qualifier, which SHALL be selected
from ValueSet EntityPersonNamePartQualifier
urn:oid:2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:81-7158).
b. The second occurrence of given (given2]) if provided, SHALL include middle name or
middle initial (CONF:81-7163).
4. MAY contain zero or more [0..*] prefix (CONF:81-7155).
a. The prefix, if present, MAY contain zero or one [0..1] @qualifier, which SHALL be
selected from ValueSet EntityPersonNamePartQualifier
urn:oid:2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:81-7156).
5. MAY contain zero or one [0..1] suffix (CONF:81-7161).
a. The suffix, if present, MAY contain zero or one [0..1] @qualifier, which SHALL be
selected from ValueSet EntityPersonNamePartQualifier
urn:oid:2.16.840.1.113883.11.20.9.26 STATIC 2011-09-30 (CONF:81-7162).
6. SHALL NOT have mixed content except for white space (CONF:81-7278).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 469
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 311: EntityNameUse
Value Set: EntityNameUse urn:oid:2.16.840.1.113883.1.11.15913
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

A

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Artist/Stage

ABC

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Alphabetic

ASGN

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Assigned

C

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

License

I

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Indigenous/Tribal

IDE

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Ideographic

L

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Legal

P

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Pseudonym

PHON

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Phonetic

R

EntityNameUse

urn:oid:2.16.840.1.11388
3.5.45

Religious

...

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 470
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 312: EntityPersonNamePartQualifier
Value Set: EntityPersonNamePartQualifier urn:oid:2.16.840.1.113883.11.20.9.26
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

AC

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

academic

AD

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

adopted

BR

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

birth

CL

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

callme

IN

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

initial

NB

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

nobility

PR

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

professional

SP

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

spouse

TITLE

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

title

VV

EntityNamePartQualifier

urn:oid:2.16.840.1.11388
3.5.43

voorvoegsel

Figure 148: US Realm Patient Name Example

Rep
Evelyn
Eve
Everywoman
J.D.

4.5

US Realm Person Name (PN.US.FIELDED)
[name: identifier urn:oid:2.16.840.1.113883.10.20.22.5.1.1 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
Table 313: US Realm Person Name (PN.US.FIELDED) Contexts

Contained By:

Contains:

US Realm Header (V2) (required)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 471
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

The US Realm Clinical Document Person Name datatype flavor is a set of reusable constraints
that can be used for Persons.
Table 314: 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

819368

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).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 472
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

5

TEMPLATE IDS IN THIS GUIDE
Table 315: Template List

Template Title

Template Type

templateId

Emergency Department Encounter
(NHCS-ED, NHAMCS-ED) (V3)

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.4:2016-07-01

Inpatient Encounter (NHCS-IP) (V3)

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.2:2016-07-01

National Health Care Surveys (V2)

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.1:2015-04-01

Outpatient Encounter (NHCS-OPD,
NAMCS, NHAMCS-OPD) (V3)

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.3:2016-07-01

US Realm Header (V2)

document

urn:hl7ii:2.16.840.1.113883.10.20.
22.1.1:2014-06-09

Chief Complaint and Reason for
Visit Section

section

urn:oid:2.16.840.1.113883.10.20.2
2.2.13

Emergency Department
Encounters Section (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.13:2016-07-01

Encounters Section (entries
optional) (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.22:2014-06-09

Immunizations Section

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.7

Inpatient Encounters Section (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.12:2016-07-01

Medications Section

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.1

Medications Section (entries
optional) (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.1:2014-06-09

Outpatient Encounters Section (V3)

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.8:2016-07-01

Patient Information Section (V3)

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01

Payers Section (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.18:2014-06-09

Payment Sources Section

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.4

Problems Section (V3)

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2016-07-01

Reasons for Visit Section (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2016-07-01

Results Section (entries optional)
(V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.3:2014-06-09

Services and Procedures Section

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.3

Social History Section (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 473
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
22.2.17:2014-06-09

Triage Section

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.10

Vital Signs Section (entries
optional) (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.4:2014-06-09

Vital Signs Section (entries
required) (V2)

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.4.1:2014-06-09

Admission Diagnosis Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.34:2015-04-01

Admission Priority Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.35:2015-04-01

Adverse Effect of Medical
Treatment

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.14

Age Observation

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.31

Assessment Scale Observation

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.69

Assessment Scale Supporting
Observation

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.86

Asthma Diagnosis Observation
(RETIRED)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.5:2016-07-01

Caregiver Characteristics

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.72

Cause of Injury, Poisoning, or
Adverse Effect

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.27

Characteristics of Home
Environment

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.109

Clinical Note and External
Document Reference

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.44:2016-07-01

Co-morbid Condition Observation
(RETIRED)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.4:2016-07-01

Condition Control Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.21

Coverage Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.60:2014-06-09

Cultural and Religious Observation

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.111

Current Emergency Department
Visit (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.40:2016-07-01

Current Inpatient Visit

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.39:2015-04-01

Current Outpatient Visit (V3)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.10:2016-07-01

Discharge Status Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.28

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 474
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
2.4.123

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Encounter Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.49:2014-06-09

Encounter Diagnosis (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.80:2014-06-09

Episode of Care Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.32:2015-04-01

Estimated Date of Delivery

entry

urn:oid:2.16.840.1.113883.10.20.1
5.3.1

Follow-up Attempt Outcome
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.43:2015-04-01

Hospital Admission Encounter

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.18

Hospital Discharge Diagnosis (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.33:2014-06-09

Immunization Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.52:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Immunization Refusal Reason

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.53

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Injury or Poisoning Observation
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.17:2015-04-01

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Listed for Admission to Hospital
Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.15

Major Reason for Visit

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.7

Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

New Patient Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.9

Number of Visits in the Last 12

entry

urn:oid:2.16.840.1.113883.10.20.3

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 475
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

Months

templateId
4.3.26

Observation Unit Stay Encounter

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.33

On Oxygen on Arrival Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.29

Ordered Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.19

Ordered Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.2

Ordered Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.11

Pain Assessment Scale Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.22

Patient Residence Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.25

Patient Seen in this ED in last 72
Hours and Discharged

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.31

Patient's Reason for Visit
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.41:2015-04-01

Planned Act (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.39:2014-06-09

Planned Coverage

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.129

Planned Immunization Activity

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.120

Planned Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.42:2014-06-09

Planned Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.44:2014-06-09

Planned Procedure (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.41:2014-06-09

Point of Origin Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.36:2015-04-01

Policy Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.61:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Pregnancy Observation

entry

urn:oid:2.16.840.1.113883.10.20.1
5.3.8

Present on Admission Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

Primary Diagnosis Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.6:2015-04-01

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

Problem Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 476
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
22.4.4:2014-06-09

Problem Status (DEPRECATED)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.6:2014-06-09

Problem/Diagnosis/Symptom/Con
dition Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.1:2015-04-01

Procedure Activity Act (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.12:2014-06-09

Procedure Activity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.13:2014-06-09

Procedure Activity Procedure (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.14:2014-06-09

Procedure Follow-Up Attempt
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.42:2015-04-01

Product Instance

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.37

Prognosis Observation

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.113

Provided Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.20

Provided Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.3

Provided Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.12

Reaction Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.9:2014-06-09

Result Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.2:2014-06-09

Result Organizer (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.1:2014-06-09

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

Severity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09

Smoking Status - Meaningful Use
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.78:2014-06-09

Social History Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.38:2014-06-09

Specialty Unit Stay Encounter

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.38:2015-04-01

Substance Administered Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Tobacco Use (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.85:2014-06-09

Transport Mode to Hospital
Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.24

Triage Level Assigned Observation

entry

urn:oid:2.16.840.1.113883.10.20.3

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 477
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
4.3.23

Vital Sign Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.27:2014-06-09

Vital Signs Organizer (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.26:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

US Realm Address
(AD.US.FIELDED)

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

US Realm Date and Time
(DTM.US.FIELDED)

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.4

US Realm Patient Name
(PTN.US.FIELDED)

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

US Realm Person Name
(PN.US.FIELDED)

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1.1

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 478
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Table 316: Template Containments
Template Title

Template Type

templateId

Emergency Department Encounter
(NHCS-ED, NHAMCS-ED) (V3)

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.4:2016-07-01

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.13:2016-07-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.40:2016-07-01

Clinical Note and External
Document Reference

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.44:2016-07-01

Episode of Care Observation
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.32:2015-04-01

Major Reason for Visit

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.7

Patient Seen in this ED in last
72 Hours and Discharged

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.31

Point of Origin Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.36:2015-04-01

Transport Mode to Hospital
Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.24

Hospital Admission Encounter

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.18

Discharge Status Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.28

Hospital Discharge Diagnosis
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.33:2014-06-09

Problem Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.4:2014-06-09

Age Observation

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.31

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Problem Status
(DEPRECATED)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.6:2014-06-09

Prognosis Observation

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.113

Listed for Admission to
Hospital Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.15

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.33

Emergency Department
Encounters Section (V2)
Current Emergency Department
Visit (V2)

Author Participation

Observation Unit Stay
Encounter

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 479
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.7

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.52:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Immunization Refusal Reason

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.53

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Supply Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Reaction Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.9:2014-06-09

Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Immunizations Section
Immunization Activity (V2)

US Realm Address
(AD.US.FIELDED)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 480
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization
Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Substance Administered
Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Procedure Activity Procedure

entry

urn:hl7ii:2.16.840.1.113883.10.20.

US Realm Patient Name
(PTN.US.FIELDED)

US Realm Address
(AD.US.FIELDED)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 481
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

(V2)

templateId
22.4.14:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization
Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply
Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization
Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.

US Realm Patient Name
(PTN.US.FIELDED)

US Realm Address
(AD.US.FIELDED)

Immunization

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 482
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

Medication Information
(V2)

templateId
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for
Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Substance Administered
Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Product Instance

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.37

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

Severity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09

Substance Administered Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Planned Immunization Activity

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.120

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.1

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

entry

urn:oid:2.16.840.1.113883.10.20.2

Author Participation
Medications Section
Medication Activity (V2)

US Realm Patient Name
(PTN.US.FIELDED)
Drug Vehicle

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 483
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Reaction Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.9:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.14:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Product Instance

entry

urn:oid:2.16.840.1.113883.10.20.2

US Realm Address
(AD.US.FIELDED)

Procedure Activity Procedure
(V2)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 484
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
2.4.37

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

Severity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09

Substance Administered Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Planned Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.42:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01

Patient Residence Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.25

Pregnancy Observation

entry

urn:oid:2.16.840.1.113883.10.20.1
5.3.8

Estimated Date of Delivery

entry

urn:oid:2.16.840.1.113883.10.20.1
5.3.1

Smoking Status - Meaningful
Use (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.78:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.85:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.4

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.129

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:hl7ii:2.16.840.1.113883.10.20.

Author Participation
Patient Information Section (V3)

Author Participation
Tobacco Use (V2)
Author Participation
Payment Sources Section
Planned Coverage
Author Participation
Problems Section (V3)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 485
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
34.2.2:2016-07-01

Admission Diagnosis
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.34:2015-04-01

Adverse Effect of Medical
Treatment

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.14

Cause of Injury, Poisoning, or
Adverse Effect

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.27

Injury or Poisoning Observation
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.17:2015-04-01

Cause of Injury, Poisoning, or
Adverse Effect

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.27

Present on Admission
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.6:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.1:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2016-07-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.41:2015-04-01

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.3:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.1:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Result Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.2:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.3

Ordered Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.19

Ordered Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.2

Ordered Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.11

Provided Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.20

Provided Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3

Primary Diagnosis Observation
(V2)
Present on Admission
Observation
Problem/Diagnosis/Symptom/
Condition Observation (V2)
Present on Admission
Observation
Reasons for Visit Section (V2)
Patient's Reason for Visit
Observation
Results Section (entries optional)
(V2)
Result Organizer (V2)

Author Participation
Services and Procedures Section

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 486
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
4.3.3

Provided Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.12

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.10

On Oxygen on Arrival
Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.29

Pain Assessment Scale
Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.22

Triage Level Assigned
Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.23

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.4.1:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.26:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Vital Sign Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.27:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.2:2016-07-01

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.7

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.52:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Immunization Refusal Reason

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.53

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order

entry

urn:hl7ii:2.16.840.1.113883.10.20.

Triage Section

Vital Signs Section (entries
required) (V2)
Vital Signs Organizer (V2)

Author Participation
Inpatient Encounter (NHCS-IP) (V3)
Immunizations Section
Immunization Activity (V2)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 487
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

(V2)

templateId
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Supply Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Reaction Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.9:2014-06-09

Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization
Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

US Realm Address
(AD.US.FIELDED)

US Realm Patient Name
(PTN.US.FIELDED)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 488
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Substance Administered
Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Procedure Activity Procedure
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.14:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

US Realm Address
(AD.US.FIELDED)

US Realm Patient Name
(PTN.US.FIELDED)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 489
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

Immunization
Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply
Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization
Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization
Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for
Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Substance Administered
Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Product Instance

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.37

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

Severity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09

Substance Administered Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Planned Immunization Activity

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.120

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

US Realm Address
(AD.US.FIELDED)

Author Participation

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 490
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.12:2016-07-01

Current Inpatient Visit

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.39:2015-04-01

Admission Priority
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.35:2015-04-01

Point of Origin Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.36:2015-04-01

Specialty Unit Stay Encounter

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.38:2015-04-01

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.1

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Author Participation
Inpatient Encounters Section (V2)

Medications Section
Medication Activity (V2)

US Realm Patient Name
(PTN.US.FIELDED)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 491
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Reaction Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.9:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.14:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Product Instance

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.37

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

Severity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09

Substance Administered Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Planned Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.42:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

US Realm Address
(AD.US.FIELDED)

Procedure Activity Procedure
(V2)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 492
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01

Patient Residence Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.25

Pregnancy Observation

entry

urn:oid:2.16.840.1.113883.10.20.1
5.3.8

Estimated Date of Delivery

entry

urn:oid:2.16.840.1.113883.10.20.1
5.3.1

Smoking Status - Meaningful
Use (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.78:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.85:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.4

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.129

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2016-07-01

Admission Diagnosis
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.34:2015-04-01

Adverse Effect of Medical
Treatment

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.14

Cause of Injury, Poisoning, or
Adverse Effect

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.27

Injury or Poisoning Observation
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.17:2015-04-01

Cause of Injury, Poisoning, or
Adverse Effect

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.27

Present on Admission
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

Author Participation
Patient Information Section (V3)

Author Participation
Tobacco Use (V2)
Author Participation
Payment Sources Section
Planned Coverage
Author Participation
Problems Section (V3)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 493
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.6:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.1:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.3:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.1:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Result Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.2:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.3

Ordered Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.19

Ordered Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.2

Ordered Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.11

Provided Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.20

Provided Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.3

Provided Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.12

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.4.1:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.26:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Vital Sign Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.27:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

National Health Care Surveys (V2)

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.1:2015-04-01

Outpatient Encounter (NHCS-OPD,
NAMCS, NHAMCS-OPD) (V3)

document

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.3:2016-07-01

Primary Diagnosis Observation
(V2)
Present on Admission
Observation
Problem/Diagnosis/Symptom/
Condition Observation (V2)
Present on Admission
Observation
Results Section (entries optional)
(V2)
Result Organizer (V2)

Author Participation
Services and Procedures Section

Vital Signs Section (entries
required) (V2)
Vital Signs Organizer (V2)

Author Participation

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 494
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.7

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.52:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Immunization Refusal Reason

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.53

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Supply Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Reaction Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.9:2014-06-09

Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Immunizations Section
Immunization Activity (V2)

US Realm Address
(AD.US.FIELDED)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 495
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization
Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Substance Administered
Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Procedure Activity Procedure

entry

urn:hl7ii:2.16.840.1.113883.10.20.

US Realm Patient Name
(PTN.US.FIELDED)

US Realm Address
(AD.US.FIELDED)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 496
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

(V2)

templateId
22.4.14:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

Drug Vehicle

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization
Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply
Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization
Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.

US Realm Patient Name
(PTN.US.FIELDED)

US Realm Address
(AD.US.FIELDED)

Immunization

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 497
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

Medication Information
(V2)

templateId
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for
Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Substance Administered
Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Product Instance

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.37

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

Severity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09

Substance Administered Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Planned Immunization Activity

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.120

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.1

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.16:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Drug Monitoring Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.123

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1

entry

urn:oid:2.16.840.1.113883.10.20.2

Author Participation
Medications Section
Medication Activity (V2)

US Realm Patient Name
(PTN.US.FIELDED)
Drug Vehicle

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 498
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
2.4.24

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Dispense (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.18:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

Medication Free Text Sig

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.147

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Medication Supply Order (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.17:2014-06-09

Immunization Medication
Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.54:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Reaction Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.9:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.14:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Product Instance

entry

urn:oid:2.16.840.1.113883.10.20.2

US Realm Address
(AD.US.FIELDED)

Procedure Activity Procedure
(V2)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 499
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
2.4.37

Service Delivery Location

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.32

Severity Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09

Substance Administered Act

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.118

Planned Medication Activity (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.42:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Indication (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.19:2014-06-09

Instruction (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.20:2014-06-09

Medication Information (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.23:2014-06-09

Precondition for Substance
Administration (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.25:2014-06-09

Priority Preference

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.143

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.8:2016-07-01

Current Outpatient Visit (V3)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.10:2016-07-01

Clinical Note and External
Document Reference

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.44:2016-07-01

Episode of Care Observation
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.32:2015-04-01

Major Reason for Visit

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.7

New Patient Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.9

Number of Visits in the Last
12 Months

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.26

Procedure Follow-Up Attempt
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.42:2015-04-01

Follow-up Attempt Outcome
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.43:2015-04-01

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01

Patient Residence Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.25

Pregnancy Observation

entry

urn:oid:2.16.840.1.113883.10.20.1

Author Participation
Outpatient Encounters Section
(V3)

Patient Information Section (V3)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 500
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
5.3.8

Estimated Date of Delivery

entry

urn:oid:2.16.840.1.113883.10.20.1
5.3.1

Smoking Status - Meaningful
Use (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.78:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.85:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.4

entry

urn:oid:2.16.840.1.113883.10.20.2
2.4.129

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2016-07-01

Admission Diagnosis
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.34:2015-04-01

Adverse Effect of Medical
Treatment

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.14

Cause of Injury, Poisoning, or
Adverse Effect

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.27

Injury or Poisoning Observation
(V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.17:2015-04-01

Cause of Injury, Poisoning, or
Adverse Effect

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.27

Present on Admission
Observation

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.6:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.1:2015-04-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01

section

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2016-07-01

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.41:2015-04-01

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.3:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.

Author Participation
Tobacco Use (V2)
Author Participation
Payment Sources Section
Planned Coverage
Author Participation
Problems Section (V3)

Primary Diagnosis Observation
(V2)
Present on Admission
Observation
Problem/Diagnosis/Symptom/
Condition Observation (V2)
Present on Admission
Observation
Reasons for Visit Section (V2)
Patient's Reason for Visit
Observation
Results Section (entries optional)
(V2)
Result Organizer (V2)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 501
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Template Title

Template Type

templateId
22.4.1:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Result Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.2:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

section

urn:oid:2.16.840.1.113883.10.20.3
4.2.3

Ordered Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.19

Ordered Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.2

Ordered Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.11

Provided Service Act

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.20

Provided Service Observation

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.3

Provided Service Procedure

entry

urn:oid:2.16.840.1.113883.10.20.3
4.3.12

section

urn:hl7ii:2.16.840.1.113883.10.20.
22.2.4.1:2014-06-09

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.26:2014-06-09

Author Participation

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

Vital Sign Observation (V2)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
22.4.27:2014-06-09

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.4.119

document

urn:hl7ii:2.16.840.1.113883.10.20.
22.1.1:2014-06-09

US Realm Address
(AD.US.FIELDED)

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.2

US Realm Date and Time
(DTM.US.FIELDED)

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.4

US Realm Person Name
(PN.US.FIELDED)

unspecified

urn:oid:2.16.840.1.113883.10.20.2
2.5.1.1

Asthma Diagnosis Observation
(RETIRED)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.5:2016-07-01

Co-morbid Condition Observation
(RETIRED)

entry

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.4:2016-07-01

Author Participation
Services and Procedures Section

Vital Signs Section (entries
required) (V2)
Vital Signs Organizer (V2)

Author Participation
US Realm Header (V2)

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 502
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

6

VALUE SETS IN THIS GUIDE
Table 317: Value Sets

Name

OID

URL

Act Priority

urn:oid:2.16.840.1.113883.1.11.16
866

https://vsac.nlm.nih.gov/

ActStatus

urn:oid:2.16.840.1.113883.1.11.15
9331

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=
2.16.840.1.113883.1.11.15933

AdministrationUnitDoseForm

urn:oid:2.16.840.1.113762.1.4.102
1.30

N/A

Administrative Gender (HL7 V3)

urn:oid:2.16.840.1.113883.1.11.1

https://vsac.nlm.nih.gov/

AgePQ_UCUM

urn:oid:2.16.840.1.113883.11.20.9
.21

http://unitsofmeasure.org/ucum.h
tml

Body Site

urn:oid:2.16.840.1.113883.3.88.12
.3221.8.9

https://vsac.nlm.nih.gov/

Clinical Substance

urn:oid:2.16.840.1.113762.1.4.101
0.2

https://vsac.nlm.nih.gov/

Condition Control (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
33

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7433

Country

urn:oid:2.16.840.1.113883.3.88.12
.80.63

http://www.iso.org/iso/country_co
des/iso_3166_code_lists.htm

Coverage Role Type

urn:oid:2.16.840.1.113883.1.11.18
877

https://vsac.nlm.nih.gov/

Current Smoking Status

urn:oid:2.16.840.1.113883.11.20.9
.38

https://vsac.nlm.nih.gov/

CVX Vaccines Administered Vaccine Set

urn:oid:2.16.840.1.113762.1.4.101
0.6

http://www2a.cdc.gov/vaccines/ii
s/iisstandards/vaccines.asp?rpt=c
vx

Detailed Ethnicity

urn:oid:2.16.840.1.114222.4.11.87
7

http://phinvads.cdc.gov/vads/Vie
wValueSet.action?id=34D34BBC617F-DD11-B38D00188B398520#

Discharge Disposition IP (NCHS)

urn:oid:2.16.840.1.114222.4.11.73
60

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7360

Disposition (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
36

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7436

Disposition ED (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
37

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7437

Disposition OPD (NCHS)

urn:oid:2.16.840.1.114222.4.11.73
61

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7361

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 503
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Name

OID

URL

EncounterTypeCode

urn:oid:2.16.840.1.113883.3.88.12
.80.32

https://vsac.nlm.nih.gov/

EntityNameUse

urn:oid:2.16.840.1.113883.1.11.15
913

https://vsac.nlm.nih.gov/

EntityPersonNamePartQualifier

urn:oid:2.16.840.1.113883.11.20.9
.26

https://vsac.nlm.nih.gov/

Episode of Care (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
39

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7439

Ethnicity

urn:oid:2.16.840.1.114222.4.11.83
7

https://vsac.nlm.nih.gov/

Follow-up Attempt Outcome
(NCHS)

urn:oid:2.16.840.1.114222.4.11.73
62

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7362

Healthcare Provider Taxonomy
(HIPAA)

urn:oid:2.16.840.1.114222.4.11.10
66

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.1066

HealthcareServiceLocation

urn:oid:2.16.840.1.113883.1.11.20
275

https://vsac.nlm.nih.gov/

HL7 BasicConfidentialityKind

urn:oid:2.16.840.1.113883.1.11.16
926

https://vsac.nlm.nih.gov/

HL7FinanciallyResponsiblePartyTy
pe

urn:oid:2.16.840.1.113883.1.11.10
416

https://vsac.nlm.nih.gov/

Hospital Discharge Status (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
40

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7440

INDRoleclassCodes

urn:oid:2.16.840.1.113883.11.20.9
.33

https://vsac.nlm.nih.gov/

Injury or Poisoning (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
03

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7403

Language

urn:oid:2.16.840.1.113883.1.11.11
526

http://www.loc.gov/standards/iso
639-2/php/code_list.php

LanguageAbilityMode

urn:oid:2.16.840.1.113883.1.11.12
249

https://vsac.nlm.nih.gov/

LanguageAbilityProficiency

urn:oid:2.16.840.1.113883.1.11.12
199

https://vsac.nlm.nih.gov/

Major Reason for Visit (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
04

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7404

Marital Status

urn:oid:2.16.840.1.113883.1.11.12
212

https://vsac.nlm.nih.gov/

Medication Clinical Drug

urn:oid:2.16.840.1.113762.1.4.101
0.4

http://phinvads.cdc.gov/vads/Vie
wValueSet.action?id=239BEF3E971C-DF11-B334-0015173D1785

Medication Fill Status

urn:oid:2.16.840.1.113883.3.88.12
.80.64

https://vsac.nlm.nih.gov/

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 504
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Name

OID

URL

Medication Route FDA

urn:oid:2.16.840.1.113883.3.88.12
.3221.8.7

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
13883.3.88.12.3221.8.7

MoodCodeEvnInt

urn:oid:2.16.840.1.113883.11.20.9
.18

https://vsac.nlm.nih.gov/

No Immunization Reason Value Set

urn:oid:2.16.840.1.113883.1.11.19
717

https://vsac.nlm.nih.gov/

NullValues_UNK_OTH

urn:oid:2.16.840.1.113883.10.20.5
.9.1

N/A

Observation Interpretation (HL7)

urn:oid:2.16.840.1.113883.1.11.78

https://vsac.nlm.nih.gov/

ParticipationFunction

urn:oid:2.16.840.1.113883.1.11.10
267

https://vsac.nlm.nih.gov/

Patient Education

urn:oid:2.16.840.1.113883.11.20.9
.34

https://vsac.nlm.nih.gov/

Patient Residence (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
02

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7402

PatientLanguage

urn:oid:2.16.840.1.113883.11.20.9
.64

http://www.loc.gov/standards/iso
639-2/php/code_list.php

Payer

urn:oid:2.16.840.1.114222.4.11.35
91

https://vsac.nlm.nih.gov/

Personal And Legal Relationship
Role Type

urn:oid:2.16.840.1.113883.11.20.1
2.1

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
13883.11.20.12.1

Planned moodCode
(Act/Encounter/Procedure)

urn:oid:2.16.840.1.113883.11.20.9
.23

https://vsac.nlm.nih.gov/

Planned moodCode (Observation)

urn:oid:2.16.840.1.113883.11.20.9
.25

https://vsac.nlm.nih.gov/

Planned moodCode
(SubstanceAdministration/Supply)

urn:oid:2.16.840.1.113883.11.20.9
.24

https://vsac.nlm.nih.gov/

Point of Origin (NCHS)

urn:oid:2.16.840.1.114222.4.11.73
59

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7359

PostalAddressUse

urn:oid:2.16.840.1.113883.1.11.10
637

https://vsac.nlm.nih.gov/

PostalCode

urn:oid:2.16.840.1.113883.3.88.12
.80.2

http://ushik.ahrq.gov/ViewItemDe
tails?system=mdr&itemKey=86671
000

Priority (Type) of Admission or Visit
(NCHS)

urn:oid:2.16.840.1.114222.4.11.73
65

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7365

Priority Level

urn:oid:2.16.840.1.113883.11.20.9
.60

https://vsac.nlm.nih.gov/

Problem

urn:oid:2.16.840.1.113883.3.88.12
.3221.7.4

http://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
13883.3.88.12.3221.7.4

Problem Severity

urn:oid:2.16.840.1.113883.3.88.12

https://vsac.nlm.nih.gov/

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 505
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Name

OID

URL

.3221.6.8
Problem Status

urn:oid:2.16.840.1.113883.3.88.12
.80.68

https://vsac.nlm.nih.gov/

Problem Type

urn:oid:2.16.840.1.113883.3.88.12
.3221.7.2

http://www.loinc.org

ProcedureAct statusCode

urn:oid:2.16.840.1.113883.11.20.9
.22

https://vsac.nlm.nih.gov/

Provider ED (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
19

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7419

Race

urn:oid:2.16.840.1.113883.1.11.14
914

https://vsac.nlm.nih.gov/

Race Category Excluding Nulls

urn:oid:2.16.840.1.113883.3.2074.
1.1.3

https://vsac.nlm.nih.gov/

Religious Affiliation

urn:oid:2.16.840.1.113883.1.11.19
185

https://vsac.nlm.nih.gov/

Residence and Accommodation
Type

urn:oid:2.16.840.1.113883.11.20.9
.49

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
13883.11.20.9.49

Result Status

urn:oid:2.16.840.1.113883.11.20.9
.39

https://vsac.nlm.nih.gov/

Specialty Unit Type (NCHS)

urn:oid:2.16.840.1.114222.4.11.73
63

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7363

Specific Vaccine Clinical Drug

urn:oid:2.16.840.1.113762.1.4.101
0.10

https://vsac.nlm.nih.gov/

StateValueSet

urn:oid:2.16.840.1.113883.3.88.12
.80.1

http://www.census.gov/geo/refere
nce/ansi_statetables.html

Telecom Use (US Realm Header)

urn:oid:2.16.840.1.113883.11.20.9
.20

https://vsac.nlm.nih.gov/

Tobacco Use

urn:oid:2.16.840.1.113883.11.20.9
.41

https://vsac.nlm.nih.gov/

Transport Mode to Hospital (NCHS)

urn:oid:2.16.840.1.114222.4.11.72
77

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7277

Triage System (NCHS)

urn:oid:2.16.840.1.114222.4.11.74
01

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7401

Type of clinic/location (NCHS)

urn:oid:2.16.840.1.114222.4.11.73
64

https://phinvads.cdc.gov/vads/Vie
wValueSet.action?oid=2.16.840.1.1
14222.4.11.7364

UnitsOfMeasureCaseSensitive

urn:oid:2.16.840.1.113883.1.11.12
839

http://unitsofmeasure.org/ucum.h
tml

Vaccine Clinical Drug

urn:oid:2.16.840.1.113762.1.4.101
0.8

https://vsac.nlm.nih.gov/

Vital Sign Result

urn:oid:2.16.840.1.113883.3.88.12
.80.62

https://vsac.nlm.nih.gov/

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 506
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Name

OID

URL

x_ServiceEventPerformer

urn:oid:2.16.840.1.113883.1.11.19
601

http://www.hl7.org/documentcent
er/public/standards/vocabulary/v
ocabulary_tables/infrastructure/vo
cabulary/vocabulary.html

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 507
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

7

CODE SYSTEMS IN THIS GUIDE
Table 318: Code Systems

Name

OID

ActCode

urn:oid:2.16.840.1.113883.5.4

ActMood

urn:oid:2.16.840.1.113883.5.1001

ActPriority

urn:oid:2.16.840.1.113883.5.7

ActReason

urn:oid:2.16.840.1.113883.5.8

ActStatus

urn:oid:2.16.840.1.113883.5.14

AddressUse

urn:oid:2.16.840.1.113883.5.1119

AdministrativeGender

urn:oid:2.16.840.1.113883.5.1

CDC Vaccine Code (CVX)

urn:oid:2.16.840.1.113883.12.292

ConfidentialityCode

urn:oid:2.16.840.1.113883.5.25

Country

urn:oid:2.16.840.1.113883.3.88.12.80.63

CPT4

urn:oid:2.16.840.1.113883.6.12

EntityClass

urn:oid:2.16.840.1.113883.5.41

EntityNamePartQualifier

urn:oid:2.16.840.1.113883.5.43

EntityNameUse

urn:oid:2.16.840.1.113883.5.45

FIPS 5-2 (State)

urn:oid:2.16.840.1.113883.6.92

Healthcare Provider Taxonomy (HIPAA)

urn:oid:2.16.840.1.113883.6.101

HITSP-CS-83

urn:oid:2.16.840.1.113883.5.83

HL7 Discharge disposition

urn:oid:2.16.840.1.113883.12.112

HL7 HealthcareServiceLocation

urn:oid:2.16.840.1.113883.6.259

HL7 Race

urn:oid:2.16.840.1.113883.5.104

HL7ActClass

urn:oid:2.16.840.1.113883.5.6

HL7ActRelationshipType

urn:oid:2.16.840.1.113883.5.1002

HL7NullFlavor

urn:oid:2.16.840.1.113883.5.1008

HL7ParticipationType

urn:oid:2.16.840.1.113883.5.90

ICD10

urn:oid:2.16.840.1.113883.6.3

ICD-10-CM

urn:oid:2.16.840.1.113883.6.90

Language

urn:oid:2.16.840.1.113883.6.121

LanguageAbilityMode

urn:oid:2.16.840.1.113883.5.60

LanguageAbilityProficiency

urn:oid:2.16.840.1.113883.5.61

LOINC

urn:oid:2.16.840.1.113883.6.1

MaritalStatus

urn:oid:2.16.840.1.113883.5.2

NCI Thesaurus (NCIt)

urn:oid:2.16.840.1.113883.3.26.1.1

participationFunction

urn:oid:2.16.840.1.113883.5.88

Participationsignature

urn:oid:2.16.840.1.113883.5.89

PHIN VADS code system

urn:oid:2.16.840.1.114222.4.5.274

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 508
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Name

OID

Race & Ethnicity - CDC

urn:oid:2.16.840.1.113883.6.238

ReligiousAffiliation

urn:oid:2.16.840.1.113883.5.1076

RoleClass

urn:oid:2.16.840.1.113883.5.110

RoleCode

urn:oid:2.16.840.1.113883.5.111

RxNorm

urn:oid:2.16.840.1.113883.6.88

SNOMED CT

urn:oid:2.16.840.1.113883.6.96

Source of Payment Typology (PHDSC)

urn:oid:2.16.840.1.113883.3.221.5

UCUM

urn:oid:2.16.840.1.113883.6.8

Unique Ingredient Identifier (UNII)

urn:oid:2.16.840.1.113883.4.9

USPostalCodes

urn:oid:2.16.840.1.113883.6.231

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 509
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8

CHANGES FROM PREVIOUS VERSION

8.1

Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3)

Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3)
(urn:hl7ii:2.16.840.1.113883.10.20.34.1.4:2016-07-01)
Change

Old

New

Name

Emergency Department Encounter
(NHCS-ED, NHAMCS-ED) (V2)

Emergency Department Encounter
(NHCS-ED, NHAMCS-ED) (V3)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.4:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.4:2016-07-01

CONF #: 3256-571 Modified

SHALL contain exactly one [1..1]
component (CONF:1184-571).

Heading: component
SHALL contain exactly one [1..1]
component (CONF:3256-571).

CONF #: 3256-572 Modified

Heading: structuredBody
This component SHALL contain
exactly one [1..1] structuredBody
(CONF:1184-572).

This component SHALL contain
exactly one [1..1] structuredBody
(CONF:3256-572).

CONF #: 3256-667 Modified

MAY contain zero or more [0..*]
documentationOf (CONF:1184667).

Heading: documentationOf
MAY contain zero or more [0..*]
documentationOf (CONF:3256667).

CONF #: 3256-668 Modified

Heading: serviceEvent
The documentationOf, if present,
SHALL contain exactly one [1..1]
serviceEvent (CONF:1184-668).

The documentationOf, if present,
SHALL contain exactly one [1..1]
serviceEvent (CONF:3256-668).

CONF #: 3256-671 Modified

SHALL contain exactly one [1..1]
componentOf (CONF:1184-671).

Heading: componentOf
SHALL contain exactly one [1..1]
componentOf (CONF:3256-671).

CONF #: 3256-672 Modified

Heading: encompassingEncounter
See National Health Care Surveys
template for other
encompassingEncounter elements.
This componentOf SHALL contain
exactly one [1..1]
encompassingEncounter
(CONF:1184-672).

See National Health Care Surveys
template for other
encompassingEncounter elements.
This componentOf SHALL contain
exactly one [1..1]
encompassingEncounter
(CONF:3256-672).

CONF #: 3256-585 Modified

SHALL contain exactly one [1..1]
Patient's Reasons for Visit Section
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2015-04-01) (CONF:1184585).

SHALL contain exactly one [1..1]
Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2016-07-01) (CONF:3256585).

CONF #: 3256-586 Modified

SHALL contain exactly one [1..1]
Problems Section (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2015-04-01) (CONF:1184586).

SHALL contain exactly one [1..1]
Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2016-07-01) (CONF:3256586).

CONF #: 3256-760 Modified

SHALL contain exactly one [1..1]

SHALL contain exactly one [1..1]

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 510
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Change

Old

New

Emergency Department
Encounters Section (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.13:2015-04-01) (CONF:1184760).

Emergency Department
Encounters Section (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.13:2016-07-01) (CONF:3256760).

CONF #: 3256-810 Modified

SHALL contain exactly one [1..1]
Patient Information Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2015-04-01) (CONF:1184810).

SHALL contain exactly one [1..1]
Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01) (CONF:3256810).

CONF #: 3256-866 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-866).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-866).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 511
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.2

Inpatient Encounter (NHCS-IP) (V3)

Inpatient Encounter (NHCS-IP) (V3) (urn:hl7ii:2.16.840.1.113883.10.20.34.1.2:201607-01)
Change

Old

New

Name

Inpatient Encounter (NHCS-IP) (V2)

Inpatient Encounter (NHCS-IP) (V3)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.2:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.2:2016-07-01

CONF #: 3256-250 Modified

SHALL contain exactly one [1..1]
componentOf (CONF:1184-250).

Heading: componentOf
SHALL contain exactly one [1..1]
componentOf (CONF:3256-250).

CONF #: 3256-251 Modified

Heading: encompassingEncounter
See National Health Care Surveys
template for other
encompassingEncounter elements.
This componentOf SHALL contain
exactly one [1..1]
encompassingEncounter
(CONF:1184-251).

See National Health Care Surveys
template for other
encompassingEncounter elements.
This componentOf SHALL contain
exactly one [1..1]
encompassingEncounter
(CONF:3256-251).

CONF #: 3256-422 Modified

MAY contain zero or more [0..*]
documentationOf (CONF:1184422).

Heading: documentationOf
MAY contain zero or more [0..*]
documentationOf (CONF:3256422).

CONF #: 3256-423 Modified

Heading: serviceEvent
See National Health Care Surveys
template for other serviceEvent
elements.
The documentationOf, if present,
SHALL contain exactly one [1..1]
serviceEvent (CONF:1184-423).

See National Health Care Surveys
template for other serviceEvent
elements.
The documentationOf, if present,
SHALL contain exactly one [1..1]
serviceEvent (CONF:3256-423).

CONF #: 3256-247 Modified

SHALL contain exactly one [1..1]
Patient Information Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2015-04-01) (CONF:1184247).

SHALL contain exactly one [1..1]
Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01) (CONF:3256247).

CONF #: 3256-259 Modified

SHALL contain exactly one [1..1]
Inpatient Encounters Section
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.12:2015-04-01) (CONF:1184259).

SHALL contain exactly one [1..1]
Inpatient Encounters Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.12:2016-07-01) (CONF:3256259).

CONF #: 3256-261 Modified

SHALL contain exactly one [1..1]
Problems Section (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2015-04-01) (CONF:1184261).

SHALL contain exactly one [1..1]
Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2016-07-01) (CONF:3256261).

CONF #: 3256-767 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-767).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-767).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 512
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.3

Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3)

Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3)
(urn:hl7ii:2.16.840.1.113883.10.20.34.1.3:2016-07-01)
Change

Old

New

Name

Outpatient Encounter (NHCS-OPD,
NAMCS, NHAMCS-OPD) (V2)

Outpatient Encounter (NHCS-OPD,
NAMCS, NHAMCS-OPD) (V3)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.3:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.1.3:2016-07-01

CONF #: 3256-284 Modified

SHALL contain exactly one [1..1]
component (CONF:1184-284).

Heading: component
SHALL contain exactly one [1..1]
component (CONF:3256-284).

CONF #: 3256-285 Modified

Heading: structuredBody
This component SHALL contain
exactly one [1..1] structuredBody
(CONF:1184-285).

This component SHALL contain
exactly one [1..1] structuredBody
(CONF:3256-285).

CONF #: 3256-455 Modified

MAY contain zero or more [0..*]
documentationOf (CONF:1184455).

Heading: documentationOf
MAY contain zero or more [0..*]
documentationOf (CONF:3256455).

CONF #: 3256-456 Modified

Heading: serviceEvent
See National Health Care Surveys
template for other serviceEvent
elements.
The documentationOf, if present,
SHALL contain exactly one [1..1]
serviceEvent (CONF:1184-456).

See National Health Care Surveys
template for other serviceEvent
elements.
The documentationOf, if present,
SHALL contain exactly one [1..1]
serviceEvent (CONF:3256-456).

CONF #: 3256-287 Modified

SHALL contain exactly one [1..1]
Patient Information Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2015-04-01) (CONF:1184287).

SHALL contain exactly one [1..1]
Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01) (CONF:3256287).

CONF #: 3256-293 Modified

SHALL contain exactly one [1..1]
Patient's Reasons for Visit Section
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2015-04-01) (CONF:1184293).

SHALL contain exactly one [1..1]
Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2016-07-01) (CONF:3256293).

CONF #: 3256-295 Modified

SHALL contain exactly one [1..1]
Outpatient Encounters Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.8:2015-04-01) (CONF:1184295).

SHALL contain exactly one [1..1]
Outpatient Encounters Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.8:2016-07-01) (CONF:3256295).

CONF #: 3256-297 Modified

SHALL contain exactly one [1..1]
Problems Section (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2015-04-01) (CONF:1184297).

SHALL contain exactly one [1..1]
Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2016-07-01) (CONF:3256297).

CONF #: 3256-768 Modified

SHALL contain exactly one [1..1]

SHALL contain exactly one [1..1]

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 513
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Change

Old

New

@extension="2015-04-01"
(CONF:1184-768).

@extension="2016-07-01"
(CONF:3256-768).

CONF #: 3256-917 Modified

MAY contain zero or one [0..1]
componentOf (CONF:1184-917).

Heading: componentOf
MAY contain zero or one [0..1]
componentOf (CONF:3256-917).

CONF #: 3256-918 Modified

Heading: encompassingEncounter
The componentOf, if present,
SHALL contain exactly one [1..1]
encompassingEncounter
(CONF:1184-918).

The componentOf, if present,
SHALL contain exactly one [1..1]
encompassingEncounter
(CONF:3256-918).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 514
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.4

Asthma Diagnosis Observation (RETIRED)

Asthma Diagnosis Observation (RETIRED)
(urn:hl7ii:2.16.840.1.113883.10.20.34.3.5:2016-07-01)
Change

Old

New

Name

Asthma Diagnosis Observation (V2)

Asthma Diagnosis Observation
(RETIRED)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.5:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.5:2016-07-01

Description

This template represents a
diagnosis of Asthma.

This template represents a
diagnosis of Asthma.
Retired as per STU Comment:
http://www.hl7.org/dstucomment
s/showdetail_comment.cfm?comm
entid=925
Asthma Diagnoses are now
represented using the
Problem/Diagnosis/Symptom/Con
dition Observation.

Implied Template

Diagnosis Observation
(urn:oid:2.16.840.1.113883.10.20.
34.3.1)

CONF #: 1184-397 Removed

SHALL contain exactly one [1..1]
Condition Control Observation
(identifier:
urn:oid:2.16.840.1.113883.10.20.3
4.3.21) (CONF:1184-397).

CONF #: 1184-916 Removed

SHALL contain exactly one [1..1]
Present on Admission Observation
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01) (CONF:1184916).

CONF #: 1184-517 Removed

SHALL contain exactly one [1..1]
Severity Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
22.4.8:2014-06-09) (CONF:1184517).

CONF #: 1184-394 Removed

MAY contain zero or one [0..1]
entryRelationship (CONF:1184394) such that it

CONF #: 1184-443 Removed

SHALL contain exactly one [1..1]
templateId (CONF:1184-443) such
that it

CONF #: 1184-515 Removed

MAY contain zero or one [0..1]
entryRelationship (CONF:1184515) such that it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 515
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Change

Old

CONF #: 1184-334 Removed

SHALL contain exactly one [1..1]
@classCode="OBS" Observation
(CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6)
(CONF:1184-334).

CONF #: 1184-335 Removed

SHALL contain exactly one [1..1]
@moodCode="EVN" Event
(CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001)
(CONF:1184-335).

CONF #: 1184-336 Removed

SHALL contain exactly one [1..1]
value with @xsi:type="CD", where
the code SHALL be selected from
ValueSet Asthma (NCHS)
urn:oid:2.16.840.1.114222.4.11.74
32 DYNAMIC (CONF:1184-336).

CONF #: 1184-395 Removed

SHALL contain exactly one [1..1]
@typeCode="SUBJ" Subject
(CodeSystem:
HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002)
(CONF:1184-395).

CONF #: 1184-396 Removed

SHALL contain exactly one [1..1]
@inversionInd="true" True
(CONF:1184-396).

CONF #: 1184-444 Removed

SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.3
4.3.5" (CONF:1184-444).

CONF #: 1184-516 Removed

SHALL contain exactly one [1..1]
@typeCode="SUBJ" (CodeSystem:
HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002)
(CONF:1184-516).

CONF #: 1184-913 Removed

MAY contain zero or one [0..1]
entryRelationship (CONF:1184913) such that it

CONF #: 1184-914 Removed

SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has subject
(CodeSystem:
HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002)
(CONF:1184-914).

CONF #: 1184-915 Removed

SHALL contain exactly one [1..1]
@inversionInd="true" (CONF:1184915).

New

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 516
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.5

Co-morbid Condition Observation (RETIRED)

Co-morbid Condition Observation (RETIRED)
(urn:hl7ii:2.16.840.1.113883.10.20.34.3.4:2016-07-01)
Change

Old

New

Name

Co-morbid Condition Observation
(V2)

Co-morbid Condition Observation
(RETIRED)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.4:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.4:2016-07-01

Description

This template represents a comorbid condition.

This template represents a comorbid condition.
Retired as per STU Comment:
http://www.hl7.org/dstucomment
s/showdetail_comment.cfm?comm
entid=921
Co-morbid conditions are now
represented using the
Problem/Diagnosis/Symptom/Con
dition Observation.

Implied Template

Problem Observation (V2)
(urn:hl7ii:2.16.840.1.113883.10.20
.22.4.4:2014-06-09)

CONF #: 1184-1090 Removed

The entryRelationship, if present,
SHALL contain exactly one [1..1]
Present on Admission Observation
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.37:2015-04-01) (CONF:11841090).

CONF #: 1184-328 Removed

SHALL contain exactly one [1..1]
templateId (CONF:1184-328) such
that it

CONF #: 1184-402 Removed

SHALL contain exactly one [1..1]
code (CONF:1184-402).

CONF #: 1184-326 Removed

SHALL contain exactly one [1..1]
@classCode="OBS" Observation
(CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6)
(CONF:1184-326).

CONF #: 1184-327 Removed

SHALL contain exactly one [1..1]
@moodCode="EVN" Event
(CodeSystem: ActMood
urn:oid:2.16.840.1.113883.5.1001)
(CONF:1184-327).

CONF #: 1184-329 Removed

SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.3
4.3.4" (CONF:1184-329).

CONF #: 1184-403 Removed

This code SHALL contain exactly

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 517
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

Change

Old

New

one [1..1] @code="75618-9"
Comorbid condition (CONF:1184403).
CONF #: 1184-404 Removed

This code SHALL contain exactly
one [1..1]
@codeSystem="2.16.840.1.113883.
6.1" (CONF:1184-404).

CONF #: 1184-330 Removed

SHALL contain exactly one [1..1]
value, which SHALL be selected
from ValueSet Problem
urn:oid:2.16.840.1.113883.3.88.12
.3221.7.4 DYNAMIC (CONF:1184330).

CONF #: 1184-1087 Removed

MAY contain zero or one [0..1]
entryRelationship (CONF:11841087).

CONF #: 1184-1088 Removed

The entryRelationship, if present,
SHALL contain exactly one [1..1]
@typeCode="SUBJ" Has subject
(CodeSystem:
HL7ActRelationshipType
urn:oid:2.16.840.1.113883.5.1002)
(CONF:1184-1088).

CONF #: 1184-1089 Removed

The entryRelationship, if present,
SHALL contain exactly one [1..1]
@inversionInd="true" (CONF:11841089).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 518
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.6

Current Emergency Department Visit (V2)

Current Emergency Department Visit (V2)
(urn:hl7ii:2.16.840.1.113883.10.20.34.3.40:2016-07-01)
Change

Old

New

Name

Current Emergency Department
Visit

Current Emergency Department
Visit (V2)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.40:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.40:2016-07-01

Description

This template represents the
patient's current emergency
department visit. The major reason
for this visit is represented by the
Major Reason for this Visit
template. To indicate whether this
is an initial or follow-up visit use
the Episode of Care template. The
method of transport to the hospital
is recorded in the Transport Mode
to Hospital Observation. The point
of origin of the patient is entered in
the Point of Origin Observation
template. The External Document
Reference is used to record
clinician notes (e.g., physicians',
nurses', P.A.s', N.P.s' and C.N.M.s'
notes).

This template represents the
patient's current emergency
department visit. The major reason
for this visit is represented by the
Major Reason for this Visit
template. To indicate whether this
is an initial or follow-up visit use
the Episode of Care template. The
method of transport to the hospital
is recorded in the Transport Mode
to Hospital Observation. The point
of origin of the patient is entered in
the Point of Origin Observation
template. The Clinical Note and
External Document Reference
template is used to record clinician
notes (e.g., physicians', nurses',
P.A.s', N.P.s' and C.N.M.s' notes)
such as Triage, Intake, History of
Present Illness, Clinical Impression
and Discharge.

CONF #: 3256-1011 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-1011).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-1011).

CONF #: 3256-1157 Modified

The reference, if present, SHALL
contain exactly one [1..1] External
Document Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
22.4.115:2014-06-09)
(CONF:1184-1157).

The reference, if present, SHALL
contain exactly one [1..1] Clinical
Note and External Document
Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.44:2016-07-01) (CONF:32561157).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 519
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.7

Current Outpatient Visit (V3)

Current Outpatient Visit (V3) (urn:hl7ii:2.16.840.1.113883.10.20.34.3.10:2016-0701)
Change

Old

New

Name

Current Outpatient Visit (V2)

Current Outpatient Visit (V3)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.10:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.3.10:2016-07-01

Description

This template represents the
patient's current outpatient visit to
the facility. If the current visit is
the result of a referral, the referral
document is referenced through
the External Document Reference
template. If the patient is an
established patient, then a count of
all visits in the last 12 months
(excluding this visit) is entered in
the Number of Visits in the Last 12
Months template. If the patient is a
new patient, this is indicated using
the New Patient Act template. The
major reason for this visit is
represented by the Major Reason
for this Visit template. To indicate
whether this is an initial or followup visit use the Episode of Care
template. Information about followup after surgery is contained in the
Procedure Follow-up Attempt
Observation template.

This template represents the
patient's current outpatient visit to
the facility. If the current visit is
the result of a referral, the referral
document is referenced through
the Clinical Note and External
Document Reference template. If
the patient is an established
patient, then a count of all visits in
the last 12 months (excluding this
visit) is entered in the Number of
Visits in the Last 12 Months
template. If the patient is a new
patient, this is indicated using the
New Patient Act template. The
major reason for this visit is
represented by the Major Reason
for this Visit template. To indicate
whether this is an initial or followup visit use the Episode of Care
template. Information about followup after surgery is contained in the
Procedure Follow-up Attempt
Observation template.

CONF #: 3256-993 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-993).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-993).

CONF #: 3256-1160 Modified

The reference, if present, SHALL
contain exactly one [1..1] External
Document Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
22.4.115:2014-06-09)
(CONF:1184-1160).

The reference, if present, SHALL
contain exactly one [1..1] Clinical
Note and External Document
Reference (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.44:2016-07-01) (CONF:32561160).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 520
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.8

Emergency Department Encounters Section (V2)

Emergency Department Encounters Section (V2)
(urn:hl7ii:2.16.840.1.113883.10.20.34.2.13:2016-07-01)
Change

Old

New

Name

Emergency Department
Encounters Section

Emergency Department
Encounters Section (V2)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.13:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.13:2016-07-01

CONF #: 3256-1051 Modified

SHALL contain exactly one [1..1]
Current Emergency Department
Visit (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.40:2015-04-01) (CONF:11841051).

SHALL contain exactly one [1..1]
Current Emergency Department
Visit (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.40:2016-07-01) (CONF:32561051).

CONF #: 3256-1053 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-1053).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-1053).

8.9

Inpatient Encounters Section (V2)

Inpatient Encounters Section (V2) (urn:hl7ii:2.16.840.1.113883.10.20.34.2.12:201607-01)
Change

Old

New

Name

Inpatient Encounters Section

Inpatient Encounters Section (V2)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.12:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.12:2016-07-01

CONF #: 3256-1047 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-1047).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-1047).

CONF #: 3256-1064 Modified

MAY contain zero or one [0..1]
entry (CONF:1184-1064) such that
it

MAY contain zero or more [0..*]
entry (CONF:3256-1064) such that
it

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 521
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.10 Outpatient Encounters Section (V3)
Outpatient Encounters Section (V3) (urn:hl7ii:2.16.840.1.113883.10.20.34.2.8:201607-01)
Change

Old

New

Name

Outpatient Encounters Section (V2)

Outpatient Encounters Section (V3)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.8:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.8:2016-07-01

CONF #: 3256-440 Modified

SHALL contain exactly one [1..1]
Current Outpatient Visit (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.10:2015-04-01) (CONF:1184440).

SHALL contain exactly one [1..1]
Current Outpatient Visit (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.10:2016-07-01) (CONF:3256440).

CONF #: 3256-1048 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-1048).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-1048).

8.11 Patient Information Section (V3)
Patient Information Section (V3) (urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-0701)
Change

Old

New

Name

Patient Information Section (V2)

Patient Information Section (V3)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.5:2016-07-01

CONF #: 3256-205 Modified

MAY contain zero or one [0..1]
entry (CONF:1184-205) such that it

MAY contain zero or more [0..*]
entry (CONF:3256-205) such that it

CONF #: 3256-663 Modified

If the document is an Outpatient
Encounter then this entry SHALL
be present (CONF:1184-663).

If the document is an Outpatient
Encounter then at least one of this
entry SHALL be present
(CONF:3256-663).

CONF #: 3256-1108 Modified

SHALL contain exactly one [1..1]
@extension="2015-04-01"
(CONF:1184-1108).

SHALL contain exactly one [1..1]
@extension="2016-07-01"
(CONF:3256-1108).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 522
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.12 Problems Section (V3)
Problems Section (V3) (urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
Change

Old

New

Name

Problems Section (V2)

Problems Section (V3)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.2:2016-07-01

CONF #: 1184-337 Removed

SHOULD contain zero or more [0..*]
entry (CONF:1184-337) such that it

CONF #: 1184-346 Removed

MAY contain zero or one [0..1]
entry (CONF:1184-346) such that it

CONF #: 1184-338 Removed

SHALL contain exactly one [1..1]
Co-morbid Condition Observation
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.4:2015-04-01) (CONF:1184338).

CONF #: 1184-347 Removed

SHALL contain exactly one [1..1]
Asthma Diagnosis Observation (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.
34.3.5:2015-04-01) (CONF:1184347).

CONF #: 3256-74 Modified

SHALL contain exactly one [1..1]
entry (CONF:1184-74) such that it

If no other means of determination
is possible, use first listed
diagnosis as the primary diagnosis.
SHALL contain exactly one [1..1]
entry (CONF:3256-74) such that it

CONF #: 3256-1175 Modified

MAY contain zero or one [0..1]
@extension (CONF:1184-1175).

MAY contain zero or one [0..1]
@extension="2016-07-01"
(CONF:3256-1175).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 523
August 2016
© 2016 Health Level Seven, International. All rights reserved.

Appendix T - EHR Implementation Guide Templates

8.13 Reasons for Visit Section (V2)
Reasons for Visit Section (V2) (urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-0701)
Change

Old

New

Name

Patient's Reasons for Visit Section

Reasons for Visit Section (V2)

Oid

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2015-04-01

urn:hl7ii:2.16.840.1.113883.10.20.
34.2.14:2016-07-01

Description

This section records the patient's
reason for visit (the patient’s own
description).

This section records the patient's
chief complaint (the NHCS calls
this the "patient's reason for visit")
in the patient's own words and/or
the reason for the patient's visit in
the provider's words. It can also
contain a coded reason for visit in
the contained Patient's Reason for
Visit Observation.

Implied Template

Chief Complaint and Reason for
Visit Section
(urn:oid:2.16.840.1.113883.10.20.
22.2.13)

CONF #: 1184-1067 Removed

SHALL contain exactly one [1..1]
code (CONF:1184-1067).

CONF #: 1184-1069 Removed

SHALL contain exactly one [1..1]
title (CONF:1184-1069).

CONF #: 1184-1070 Removed

SHALL contain exactly one [1..1]
text (CONF:1184-1070).

CONF #: 1184-1071 Removed

This code SHALL contain exactly
one [1..1] @code=" 29298-7"
Reason for Visit (CONF:11841071).

CONF #: 1184-1072 Removed

This code SHALL contain exactly
one [1..1]
@codeSystem="2.16.840.1.113883.
6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1)
(CONF:1184-1072).

CONF #: 3256-1161 Modified

MAY contain zero or one [0..1]
@extension="2015-04-01"
(CONF:1184-1161).

MAY contain zero or one [0..1]
@extension="2016-07-01"
(CONF:3256-1161).

CDA® R2 NHCS Release 1, DSTU Release 1.2, Vol. 2: Templates and Supporting Material
Page 524
August 2016
© 2016 Health Level Seven, International. All rights reserved.