Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

SHALL contain exactly one [1..1] componentOf (CONF:1198-8386). a. This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-8387). i. This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-8388). ii. This encompassingEncounter SHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:1198-8389). iii. This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8391). 1. The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32904). a. This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).

Proposed Wording

All Encounter Summaries need to have stronger clarity about requiring the physician of record for the encounter to be identified. They all should have the constraint on responsible party be tightened from a MAY to a SHOULD [0..1]: iii. This encompassingEncounter SHOULD contain zero or one [0..1] responsibleParty (CONF:1198-8391). 1. The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32904). a. This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). This constraint would be added to Consultation Note, Discharge Summary, H&P, Progress Note, Procedure Note, Operative Note, Referral Note, and Care Plan