CDAの活用「診療情報提供書」
HL7 Japan CDA WG1
平井正明
2010年3月19日
診療情報提供書
2
本日のプログラム
XML
CDA
診療情報提供書
3
XMLとは
XML (eXtensible Markup Language)：拡張可能な情報記述言語
XMLはSGML (Standard Generalized Markup Language)から発展
1979年 IBMの Charles Goldfarbは、Edward MosherおよびRaymond Lorieらとともに、「GML」(Generalized Markup Language) を発表、1986年
SGMLとしてISOになる
XMLはSGMLのサブセットとして規定されたが、独自に発展を遂げている。
最たるものはDTDのみならずXMLで書かれた仕様書Schemaである
HL7 V3の実装技術(ITS: Implementation Technology Specification)のITS‐
XML等で規定されている
CDAはXMLで記述される
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XML eXtensible Markup Language
互換性・記述性・(変換が)容易性
SGML
DTD
HTML
XML
XHTML
Schema
XSL
5
XMLの基礎
“<”と“>”で括られたタグで記述される
<名前>平井正明</名前>のように記述される
<要素>内容・データ等</要素>
開始タグ
終了タグ
｛“内容・データ”が無いときは<要素/>と記述できる｝
という風に記述される。さらに一般的には
<要素名 属性、属性....>内容・データ等</要素名>
この要素名、属性名はHL7 V3で決められた名称が使用される。
6
XML記述
<?xml version=“1.0” encoding=“UTF‐8” ?>
<!‐‐ XML宣言が必要 (XML文章の先頭にコメントは書けない)‐‐>
<人>
コメントの開始
<姓名 ID=“00001”>
平井正明
属性値
</姓名>
属性名
<性別>
要素名
男
</性別>
<年齢/>
内容が空の場合<XXXX/>と記述できます
<住所>
東京都港区虎ノ門１丁目１９番９号
</住所>
</人>
コメントの終了
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XML (eXtensible Markup Language)
<名前>平井正明</名前>
開始タグ
終了タグ
<要素名>データ</要素名> データが無いときは<要素名/>と記述できます
一般型
<要素名 属性名=“属性値” 属性名=“属性値” ・・・・>データ</要素名>
CDAでは
<name use="IDE">
<family>平井</family>
<given>正明</given>
</name>
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整形式(Well Formed) XML文書
XML宣言がある
ルート要素を一つだけ持つ
CDA文書（R2）は
<ClinicalDocument ...... で始まり
</ClinicalDocument> で終わる
開始タグと終了タグがある。
例<name/>は可能
要素はネスト構造で、入れ子構造は使用できない
要素名、属性名は大文字と小文字は区別する
属性値は””で囲む
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検証済み(Valid) XML文書
Schema(XML)：XML文書の内容、構造・構文、記述ルールを説明
した仕様書
Schemaにより検証された文書
原則としてV3のXML文書はスキーマ(Schema)により検証されます
例：CDAのスキーマは先頭にCDA.xsdとして記述されています
<ClinicalDocument xmlns="urn:hl7‐org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema‐instance"
xsi:schemaLocation="urn:hl7‐org:v3 CDA.xsd">
スキーマCDA.xsdは次のように記述されています
本スキーマは日本向け診療情報提供書用に定義された、CDAスキーマPOCD_MT000040JP00.xsdが
Includeする必要があることを示しています
<?xml version="1.0" encoding="UTF‐8" standalone="no" ?>
<xs:schema targetNamespace="urn:hl7‐org:v3" xmlns:mif="urn:hl7‐org:v3/mif" xmlns="urn:hl7‐org:v3"
xmlns:xs="http://www.w3.org/2001/XMLSchema" elementFormDefault="qualified">
<xs:include schemaLocation="../schemas/POCD_MT000040JP00.xsd" />
<xs:element name="ClinicalDocument" type="POCD_MT000040JP00.ClinicalDocument" />
</xs:schema>
さらに、Ｖ３共通の用語、データタイプやCDAのNarrative部のスキーマが用意されています。
2006年 Normative Editionでは次の5つスキーマが共通定義されています
datatypes.xsd、datatypes‐base.xsd、 infrastructureRoot.xsd、 voc.xsd、 NarrativeBlock.xsd
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XML宣言
XML処理を行うための宣言：必ずXML文書の先頭に書く必要があります
例： <?xml version="1.0" encoding="UTF‐8" ?>
“<?xml” で始まり “?> “終わります。<及び>と?の間に空白などは許されません
version=“1.0“バージョン番号を示します。通常”1.0”で問題はありません。
encoding=“UTF‐8”文字コードを示します。日本語では”ShiftーJIS”、”ISO‐2022‐JP”等が使えま
すが、フォントのインターナショナルな互換性を考えると”UTF‐8”を推奨します
その他、外部参照ファイルの有無”standalone”がありますが、デフォルトは”yes”として使用
されます。
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名前空間 (Namespace)
<ClinicalDocument xmlns="urn:hl7‐org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema‐instance"
xsi:schemaLocation="urn:hl7‐org:v3 CDA.xsd">
要素名が異なったグループで重複する名前が必要なとき、空間(名前空間)を分
けて使用する
xmlns=“名前空間”で記述します
HL7のデフォルト空間(名前空間を明示しない)はurn:hl7‐org:v3
CDAではスキーマの名前空間xsiを定義しています
名前空間名は一般にURIが使用されますが、実在のURIである必要はありません
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XML記述
コメント
“<!‐‐” と “‐‐>”の間に記述します
例：<!‐‐ コメントです ‐‐>
特殊文字
&と；で括って書きます
文字
記述
&
&amp;
<
&lt;
>
&gt;
‘
&apos;
“
&quot;
10進コード
&#数字;
16進コード
&#x数字;
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診療情報提供書のボトムアップ的記述とCDA記述
ボトムアップ記述
<?xml version=“1.0” encoding=“Shift‐JIS” ?>
<診療情報提供書>
<患者情報>
<氏名 形式=“姓名”>
<姓>日本</姓>
<名>次郎</名>
</氏名>
<氏名 形式=“フリガナ”>
<姓>ニホン</姓>
<名>ジロウ</名>
</氏名>
<生年月日>
<年号>昭和</年号>
<月日>27年7月17日</月日>
<年齢>50</年齢>
</生年月日>
・
・
</患者情報>
・
・
</診療情報提供書>
CDA記述
<?xml version="1.0" encoding="UTF‐8" ?>
<ClinicalDocument xmlns="urn:hl7‐org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema‐instance"
xsi:schemaLocation="urn:hl7‐org:v3 CDA.xsd">
<typeId extension="POCD_HD000040JP00"
root="2.16.840.1.113883.2.2.3.2" />
<templateId root="2.16.840.1.113883.2.2.3.6.100" /> <title>診療情報提供書</title> ・
・
<recordTarget>
<patientRole classCode="PAT">
<id extension="01234567"
root="2.16.840.1.113883.2.12.2.1" />
・
・
<patient>
<name use="IDE">
<family>日本</family>
<given>次郎</given>
</name>
<name use="SYL">
<family>ニホン</family>
<given>ジロウ</given>
</name>
・
・
</ClinicalDocument >
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V3はそんな不便な方法でなくても
V3 HDF
RIM
Reference Information Model
D‐MIM
基本仕様書・設計書
部門別設計書
Domain Message Information Model
R‐MIM
Refined Message Information Model
詳細設計書
HMD・メッセージ表
Hierarchical Message Description
Schema
診療情報提供書
XMLインスタンス
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V3 RIM (Reference Information Model)
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V3 RIM (Reference Information Model)
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クロン化(患者属性 RIMÎR‐MIMÎXML)
<patient>
<name use="IDE">
<family>日本</family>
<given>次郎</given>
</name>
<name use="SYL">
<family>ニホン</family>
<given>ジロウ</given>
</name>
<desc>職業 会社員</desc>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" />
<birthTime value="19590707" />
</patient>
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患者情報 はrecordTarget
Organization
0..1 providerOrganization
Patient
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
0..1 patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
<recordTarget>
<patientRole classCode="PAT">
<!-- 患者ＩＤ -->
<!-- id extension="01234567"
root="2.16.840.1.113883.2.2.99.2"/ -->
<id nullFlavor="OTH" />
<!-- 患者住所 -->
<addr>
<country>JP</country>
<postalCode>113-0024</postalCode>
<streetName>西片１丁目17番８号
</streetName>
<city>文京区</city>
<state>東京都</state>
</addr>
<!-- 患者連絡電話番号 -->
<telecom use="H" value="tel:03-5805-8201" />
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
<patient>
<!‐‐ 患者名 ‐‐>
<name use="IDE">
<family>日本</family>
<given>次郎</given>
</name>
<name use="SYL">
<family>ニホン</family>
<given>ジロウ</given>
</name>
<!‐‐ 職業など諸情報 ‐‐>
<desc>職業 会社員</desc>
<!‐‐ 性別 ‐‐>
<administrativeGenderCode code="M"
codeSystem="2.16.840.1.113883.5.1" />
<!‐‐ 誕生日 ‐‐>
<birthTime value="19590707" />
</patient>
</patientRole>
</recordTarget>
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R‐MIMÎV3データタイプÎXML
<birthTime value="19590707" />
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R‐MIMÎV3用語(Vocabulary)ÎXML
<administrativeGenderCode code="M"
codeSystem="2.16.840.1.113883.5.1" />
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HMD (Hierarchical Message Description)
22
診療情報提供書
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CDA詳細設計書(CDA R2 R‐MIM)
entryRelationship
Organization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 asOrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
Constraint: ParentDocument.text
ParentDocument.text can be used to indicate
the MIME type of the related document. It is
not to be used to embed the related document,
and thus ParentDocument.text.BIN is precluded
from use.
ParentDocument
0..* assignedEntity
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
0..1 receivedOrganization
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
0..* assignedEntity
ServiceEvent
0..* serviceEvent
documentationOf
typeCode*: <= DOC
AssignedEntity
0..1 representedOrganization
performer
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1]
effectiveTime: IVL<TS> [0..1]
typeCode*: <= x_ServiceEventPerformer
functionCode: CE CWE [0..1] <= ParticipationFunction
time: IVL<TS> [0..1]
0..*
informant
0..1 assignedPerson
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..1 informationRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 representedOrganization
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
1..* assignedAuthor
authorization
author
typeCode*: <= AUTH
1..1 assignedCustodian
0..1 assignedAuthorChoice
custodian
AssignedCustodian
typeCode*: <= CST
classCode*: <= ASSIGNED
AuthoringDevice
1..1 representedCustodianOrganization
0..* asMaintainedEntity
MaintainedEntity
classCode*: <= MNT
effectiveTime: IVL<TS> [0..1]
1..1 maintainingPerson
Person
typeCode*: <= LOC
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..* assignedEntity
typeCode*: <= x_EncounterParticipant
time: IVL<TS> [0..1]
1..1 manufacturedDrugOrOtherMaterial
product
bodyChoice
classCode*: <= DOCBODY
moodCode*: <= EVN
text: ED [1..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
Organization
0..1 providerOrganization
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
recordTarget
PatientRole
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
LanguageCommunication
(LanguageCommunication)
languageCode: CS CNE [0..1] <= HumanLanguage
modeCode: CE CWE [0..1] <= LanguageAbilityMode
proficiencyLevelCode: CE CWE [0..1] <= LanguageAbilityProficiency
preferenceInd: BL [0..1]
component
1..* section
0..*
author
Person
0..* guardian
Guardian
0..*
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
informant
RelatedSubject
0..1
classCode*: <= x_DocumentSubject
code: CE CWE [0..1] <= PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
informantChoice
1..1 guardianChoice
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
Person
RelatedEntity
0..1 relatedPerson
Organization
classCode*: <= RoleClassMutualRelationship
code: CE CWE [0..1] <=
PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
effectiveTime: IVL<TS> [0..1]
0..* informantChoice
informant
typeCode*: <= INF
contextControlCode*: CS CNE [1..1] <= "OP"
0..1 relatedSubject
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
participant
typeCode*: <= ParticipationType
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
awarenessCode: CE CWE [0..1] <= TargetAwareness
Entity
classCode*: <= ENT
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
code: CE CWE [0..1] <= EntityCode
desc: ED [0..1]
typeCode*: <= SBJ
contextControlCode*: CS CNE [1..1] <= "OP"
awarenessCode: CE CWE [0..1] <= TargetAwareness
ExternalAct
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
0..* externalActChoice
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
Encounter
ExternalProcedure
classCode*: <= ENC
moodCode*: <= x_DocumentEncounterMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActEncounterCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
classCode*: <= PROC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
Organizer
classCode*: <= x_ActClassDocumentEntryOrganizer
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
0..* clinicalStatement
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
seperatableInd: BL [0..1]
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
0..1 subject
SubjectPerson
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
classCode*: <= PROC
moodCode*: <= x_DocumentProcedureMood
id: SET<II> [0..*]
code: CD CWE [0..1]
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
methodCode: SET<CE> CWE [0..*]
approachSiteCode: SET<CD> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* section
subject
Constraint: Section.text
Section.text.mediaType
fixed as "text/x-hl7-text+xml".
See section "Section Narrative
Block" for details.
0..* associatedEntity
AssociatedEntity
0..* participantRole
0..1 scopingEntity
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
0..1 scopingOrganization
Person
Procedure
0..1 specimenPlayingEntity
classCode*: <= ROL
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
CDA R-MIM
This RMIM is used to generate
the CDA specification.
typeCode*: <= SPC
classCode*: <= SPEC
id: SET<II> [0..*]
ParticipantRole
(POCD_RM000040)
GuardianChoice
SpecimenRole
specimen
0..1 playingEntityChoice
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..*
languageCommunication
classCode*: <= SPLY
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: SET<CE> CWE [0..*] <= ActPriority
repeatNumber: IVL<INT> [0..1]
independentInd: BL [0..1]
quantity: PQ [0..1]
expectedUseTime: IVL<TS> [0..1]
0..* specimenRole
externalActChoice
classCode*: <= ENT
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
quantity: SET<PQ> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 birthplace
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
PlayingEntity
1..1 bodyChoice
component
Birthplace
classCode*: <= BIRTHPL
typeCode*: <= PRCN
Supply
typeCode*: <= PRD
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1]
<= ManufacturerModelName
softwareName: SC CWE [0..1]
<= SoftwareName
NonXMLBody
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
0..1 assignedPerson
Criterion
0..* criterion
precondition
0..1 manufacturedProduct *
Device
0..1 location
classCode*: <= PLC
determinerCode*: <= INSTANCE
name: EN [0..1]
addr: AD [0..1]
0..1 patient
consumable
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1]
<= MaterialEntityClassType
name: EN [0..1]
lotNumberText: ST [0..1]
0..1 healthCareFacility
1..1 place
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
1..1 manufacturedProduct
Material
0..1 assignedPerson
Place
dataEnterer
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
SubstanceAdministration
classCode*: <= MANU
id: SET<II> [0..*]
typeCode*: <= CSM
encounterParticipant
classCode*: <= SDLOC
id: SET<II> [0..*]
code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType
Organization
typeCode*: <= REFV
classCode*: <= SBADM
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= SubstanceAdministrationActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
routeCode: CE CWE [0..1] <= RouteOfAdministration
approachSiteCode: SET<CD> CWE [0..*] <= ActSite
doseQuantity: IVL<PQ> [0..1]
rateQuantity: IVL<PQ> [0..1]
maxDoseQuantity: RTO<PQ,PQ> [0..1]
administrationUnitCode: CE CWE [0..1] <=
AdministrableDrugForm
ManufacturedProduct
EntityChoice
0..1 representedOrganization
AssignedEntity
Patient
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
DrugOrOtherMaterial
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1] <=
DrugEntity
name: EN [0..1]
typeCode*: <= RESP
HealthCareFacility
0..1 serviceProviderOrganization
0..1 assignedEntity
Place
ObservationMedia
performer
LabeledDrug
AssignedEntity
0..1 representedOrganization
responsibleParty
classCode*: <= ENC
moodCode*: <= EVN
componentOf
id: SET<II> [0..*]
typeCode*: <= COMP
0..1 encompassingEncounter code: CE CWE [0..1] <= ActEncounterCode
effectiveTime*: IVL<TS> [1..1]
dischargeDispositionCode: CE CWE [0..1]
<= EncounterDischargeDisposition
location
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1] <= ManufacturerModelName
softwareName: SC CWE [0..1] <= SoftwareName
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
0..* observationRange
referenceRange
0..1 manufacturerOrganization
0..1 assignedEntity
EncompassingEncounter
0..* assignedEntity
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
Consent
classCode*: <= CONS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= completed
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
AssignedEntity
0..1 representedOrganization
Organization
0..1 assignedPerson
0..* consent
Organization
subject
classCode*: <= ACT
moodCode*: <= RQO
id*: SET<II> [1..*]
code: CE CWE [0..1] <= ActCode
priorityCode: CE CWE [0..1] <= ActPriority
0..* intendedRecipient
classCode*: <= ROIOVL
moodCode*: <= EVN
id*: SET<II> [1..*]
code*: CS CNE [1..1] <= ROIOverlayShape
value*: LIST<INT> [1..*]
0..1
Order
typeCode*: <= FLFS
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
RegionOfInterest
0..* order
inFulfillmentOf
Person
ObservationRange
clinicalStatement
Observation
0..* parentDocument
0..1 representedOrganization
Person
Organization
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
Constraint: relatedDocument.typeCode
A conformant CDA document can have a single
relatedDocument with typeCode "APND"; a single
relatedDocument with typeCode "RPLC"; a single
relatedDocument with typeCode "XFRM"; two
relatedDocuments with typeCodes "XFRM" and
"RPLC"; or two relatedDocuments with typeCodes
"XFRM" and "APND".
OrganizationPartOf
0..1 wholeOrganization
Constraint: Organizer
Act
classCode*: <= x_ActClassDocumentEntryAct
moodCode*: <= x_DocumentActMood
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
The Organizer clone can be the source
of the component relationship or
the reference relationship, but not
the entryRelationship relationship.
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
24
診療情報提供書とR‐MIMの関係
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..1 wholeOrganization
Organization
classCode*: <= ORG
0..1 asOrganizationPartOf
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 representedOrganization
ParentDocument
0..* parentDocument
0..* assignedEntity
Person
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
versionNumber: INT [0..1]
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
ObservationRange
clinicalStatement
Observation
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* observationRange
referenceRange
typeCode*: <= REFV
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
Criterion
0..1 receivedOrganization
0..* criterion
precondition
typeCode*: <= PRCN
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
Organization
AssignedEntity
0..1 representedOrganization
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 assignedPerson
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
1..* assignedAuthor
0..1 representedOrganization
author
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
AssignedCustodian
classCode*: <= ASSIGNED
0..1 assignedCustodian
custodian
typeCode*: <= CST
1..1 representedCustodianOrganization
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..1 assignedEntity
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
bodyChoice
dataEnterer
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
externalActChoice
Organization
1..1 bodyChoice
component
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 providerOrganization
0..1 patient
Patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
PREF RMIM
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
(POCD_RM000040JP00)
This RMIM is used for patient referral document
component
1..* section
0..*
GuardianChoice
author
Person
0..* externalActChoice
component
0..* guardian
Guardian
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* section
1..1 guardianChoice
0..* clinicalStatement
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Organization
0..1 scopingOrganization
0..* associatedEntity
Person
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
25
診療情報提供書の本文の記述
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..1 wholeOrganization
Organization
classCode*: <= ORG
0..1 asOrganizationPartOf
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 representedOrganization
ParentDocument
0..* parentDocument
0..* assignedEntity
Person
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
versionNumber: INT [0..1]
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
ObservationRange
clinicalStatement
Observation
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* observationRange
referenceRange
typeCode*: <= REFV
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
Criterion
0..1 receivedOrganization
0..* criterion
precondition
typeCode*: <= PRCN
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
Organization
AssignedEntity
0..1 representedOrganization
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 assignedPerson
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
1..* assignedAuthor
0..1 representedOrganization
author
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
AssignedCustodian
classCode*: <= ASSIGNED
0..1 assignedCustodian
custodian
typeCode*: <= CST
1..1 representedCustodianOrganization
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..1 assignedEntity
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
bodyChoice
dataEnterer
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
externalActChoice
Organization
1..1 bodyChoice
component
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 providerOrganization
0..1 patient
Patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
PREF RMIM
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
(POCD_RM000040JP00)
This RMIM is used for patient referral document
component
1..* section
0..*
GuardianChoice
author
Person
0..* externalActChoice
component
0..* guardian
Guardian
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* section
1..1 guardianChoice
0..* clinicalStatement
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Organization
0..1 scopingOrganization
0..* associatedEntity
Person
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
26
患者情報 はrecordTargetで記述
Organization
0..1 providerOrganization
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]OrganizationPartOf
Organization
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
ClinicalDocument
maritalStatusCode: CEAssignedEntity
CWE [0..1] <=
MaritalStatus
authenticator
religiousAffiliationCode:
CE CWE [0..1] <= ReligiousAffiliation
Person
raceCode: CE CWE [0..1] <= Race legalAuthenticator
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
0..1 wholeOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 asOrganizationPartOf
0..* assignedEntity
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..1 assignedEntity
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 receivedOrganization
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
Constraint: relatedDocument.typeCode
A conformant CDA document can have a single
relatedDocument with typeCode "APND"; a single
relatedDocument with typeCode "RPLC"; a single
relatedDocument with typeCode "XFRM"; two
relatedDocuments with typeCodes "XFRM" and
"RPLC"; or two relatedDocuments with typeCodes
"XFRM" and "APND".
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..1 representedOrganization
1..* patientRole
PatientRole
0..1 patient
Patient
ParentDocument
0..* parentDocument
relatedDocument
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
0..* assignedEntity
ServiceEvent
0..* serviceEvent
documentationOf
typeCode*: <= DOC
AssignedEntity
0..1 representedOrganization
performer
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1]
effectiveTime: IVL<TS> [0..1]
typeCode*: <= x_ServiceEventPerformer
functionCode: CE CWE [0..1] <= ParticipationFunction
time: IVL<TS> [0..1]
0..*
informant
0..1 assignedPerson
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..1 informationRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 representedOrganization
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
1..* assignedAuthor
authorization
author
typeCode*: <= AUTH
1..1 assignedCustodian
0..1 assignedAuthorChoice
custodian
AssignedCustodian
typeCode*: <= CST
classCode*: <= ASSIGNED
AuthoringDevice
1..1 representedCustodianOrganization
0..* asMaintainedEntity
MaintainedEntity
classCode*: <= MNT
effectiveTime: IVL<TS> [0..1]
1..1 maintainingPerson
Person
typeCode*: <= LOC
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..* assignedEntity
typeCode*: <= x_EncounterParticipant
time: IVL<TS> [0..1]
1..1 manufacturedDrugOrOtherMaterial
product
bodyChoice
classCode*: <= DOCBODY
moodCode*: <= EVN
text: ED [1..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
classCode*: <= PLC
determinerCode*: <= INSTANCE
name: EN [0..1]
addr: AD [0..1]
Organization
recordTarget
typeCode*: <=
<= RCT
RCT
typeCode*:
contextControlCode*: CS
CS CNE
CNE [1..1]
[1..1] <=
<= "OP"
"OP"
contextControlCode*:
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
classCode*: <= PSN
determinerCode*: <= INSTANCE
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
患者情報
0..*
languageCommunication
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
PatientRole
0..1 patient
0..1 patient
Patient
Patient
languageCode: CS CNE [0..1] <= HumanLanguage
modeCode: CE CWE [0..1] <= LanguageAbilityMode
proficiencyLevelCode: CE CWE [0..1] <= LanguageAbilityProficiency
preferenceInd: BL [0..1]
CDA R-MIM
component
1..* section
0..*
author
0..* guardian
Guardian
0..*
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
informant
RelatedSubject
0..1
classCode*: <= x_DocumentSubject
code: CE CWE [0..1] <= PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
informantChoice
1..1 guardianChoice
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
Person
RelatedEntity
0..1 relatedPerson
Organization
classCode*: <= RoleClassMutualRelationship
code: CE CWE [0..1] <=
PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
effectiveTime: IVL<TS> [0..1]
0..* informantChoice
informant
typeCode*: <= INF
contextControlCode*: CS CNE [1..1] <= "OP"
0..1 relatedSubject
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
participant
typeCode*: <= ParticipationType
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
awarenessCode: CE CWE [0..1] <= TargetAwareness
Entity
classCode*: <= ENT
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
code: CE CWE [0..1] <= EntityCode
desc: ED [0..1]
typeCode*: <= SBJ
contextControlCode*: CS CNE [1..1] <= "OP"
awarenessCode: CE CWE [0..1] <= TargetAwareness
ExternalAct
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
0..* externalActChoice
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
Encounter
ExternalProcedure
classCode*: <= ENC
moodCode*: <= x_DocumentEncounterMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActEncounterCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
classCode*: <= PROC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
Organizer
classCode*: <= x_ActClassDocumentEntryOrganizer
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
0..* clinicalStatement
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
seperatableInd: BL [0..1]
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
0..1 subject
SubjectPerson
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
classCode*: <= PROC
moodCode*: <= x_DocumentProcedureMood
id: SET<II> [0..*]
code: CD CWE [0..1]
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
methodCode: SET<CE> CWE [0..*]
approachSiteCode: SET<CD> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* section
subject
Constraint: Section.text
Section.text.mediaType
fixed as "text/x-hl7-text+xml".
See section "Section Narrative
Block" for details.
0..* associatedEntity
AssociatedEntity
0..* participantRole
0..1 scopingEntity
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
0..1 scopingOrganization
Person
Procedure
0..1 specimenPlayingEntity
classCode*: <= ROL
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
(POCD_RM000040)
This RMIM is used to generate
the CDA specification.
typeCode*: <= SPC
classCode*: <= SPEC
id: SET<II> [0..*]
ParticipantRole
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
LanguageCommunication
(LanguageCommunication)
SpecimenRole
specimen
0..1 playingEntityChoice
component
GuardianChoice
Person
classCode*: <= SPLY
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: SET<CE> CWE [0..*] <= ActPriority
repeatNumber: IVL<INT> [0..1]
independentInd: BL [0..1]
quantity: PQ [0..1]
expectedUseTime: IVL<TS> [0..1]
0..* specimenRole
externalActChoice
classCode*: <= ENT
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
quantity: SET<PQ> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 providerOrganization
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
PlayingEntity
1..1 bodyChoice
component
Birthplace
classCode*: <= BIRTHPL
typeCode*: <= PRCN
Supply
typeCode*: <= PRD
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1]
<= ManufacturerModelName
softwareName: SC CWE [0..1]
<= SoftwareName
NonXMLBody
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
0..1 assignedPerson
Criterion
0..* criterion
precondition
0..1 manufacturedProduct *
Device
0..1 location
1..1 place
0..1 birthplace
consumable
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1]
<= MaterialEntityClassType
name: EN [0..1]
lotNumberText: ST [0..1]
Place
dataEnterer
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
患者情報
1..1 manufacturedProduct
EntityChoice
0..1 representedOrganization
AssignedEntity
Place
classCode*: <= MANU
id: SET<II> [0..*]
Material
0..1 assignedPerson
classCode*: <= SDLOC
id: SET<II> [0..*]
code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType
Organization
typeCode*: <= REFV
classCode*: <= SBADM
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= SubstanceAdministrationActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
routeCode: CE CWE [0..1] <= RouteOfAdministration
approachSiteCode: SET<CD> CWE [0..*] <= ActSite
doseQuantity: IVL<PQ> [0..1]
rateQuantity: IVL<PQ> [0..1]
maxDoseQuantity: RTO<PQ,PQ> [0..1]
administrationUnitCode: CE CWE [0..1] <=
AdministrableDrugForm
ManufacturedProduct
typeCode*: <= CSM
encounterParticipant
0..1 healthCareFacility
HealthCareFacility
0..1 serviceProviderOrganization
0..1 assignedEntity
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
0..* observationRange
referenceRange
SubstanceAdministration
DrugOrOtherMaterial
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1] <=
DrugEntity
name: EN [0..1]
typeCode*: <= RESP
location
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1] <= ManufacturerModelName
softwareName: SC CWE [0..1] <= SoftwareName
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
LabeledDrug
AssignedEntity
0..1 representedOrganization
responsibleParty
classCode*: <= ENC
moodCode*: <= EVN
componentOf
id: SET<II> [0..*]
typeCode*: <= COMP
0..1 encompassingEncounter code: CE CWE [0..1] <= ActEncounterCode
effectiveTime*: IVL<TS> [1..1]
dischargeDispositionCode: CE CWE [0..1]
<= EncounterDischargeDisposition
ObservationMedia
performer
0..1 manufacturerOrganization
0..1 assignedEntity
EncompassingEncounter
0..* assignedEntity
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
Consent
classCode*: <= CONS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= completed
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
AssignedEntity
0..1 representedOrganization
Organization
0..1 assignedPerson
0..* consent
Organization
subject
classCode*: <= ACT
moodCode*: <= RQO
id*: SET<II> [1..*]
code: CE CWE [0..1] <= ActCode
priorityCode: CE CWE [0..1] <= ActPriority
0..* intendedRecipient
classCode*: <= ROIOVL
moodCode*: <= EVN
id*: SET<II> [1..*]
code*: CS CNE [1..1] <= ROIOverlayShape
value*: LIST<INT> [1..*]
0..1
Order
typeCode*: <= FLFS
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
RegionOfInterest
0..* order
inFulfillmentOf
Person
ObservationRange
clinicalStatement
Observation
Constraint: ParentDocument.text
ParentDocument.text can be used to indicate
the MIME type of the related document. It is
not to be used to embed the related document,
and thus ParentDocument.text.BIN is precluded
from use.
Constraint: Organizer
Act
classCode*: <= x_ActClassDocumentEntryAct
moodCode*: <= x_DocumentActMood
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
The Organizer clone can be the source
of the component relationship or
the reference relationship, but not
the entryRelationship relationship.
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
27
患者情報
Organization
0..1 providerOrganization
Patient
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
0..1 patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
<recordTarget>
<patientRole classCode="PAT">
<id extension="01234567"
root="2.16.840.1.113883.2.2.99.2"/ >
<addr>
<country>JP</country>
<postalCode>113-0024</postalCode>
<streetName>西片１丁目17番８号
</streetName>
<city>文京区</city>
<state>東京都</state>
</addr>
<telecom use="H" value="tel:03-58058201" />
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
<patient>
<name use="IDE">
<family>日本</family>
<given>次郎</given>
</name>
<name use="SYL">
<family>ニホン</family>
<given>ジロウ</given>
</name>
<desc>職業 会社員</desc>
<administrativeGenderCode code="M"
codeSystem="2.16.840.1.113883.5.1" />
<birthTime value="19590707" />
</patient>
</patientRole>
</recordTarget>
28
診療情報提供書記載者（紹介元）
1..* assignedAuthor
0..1 representedOrganization
Organization
author
AssignedAuthor
AuthorChoice
Constraint: relatedDocument.typeCode
A conformant CDA document can have a single
relatedDocument with typeCode "APND"; a single
relatedDocument with typeCode "RPLC"; a single
relatedDocument with typeCode "XFRM"; two
relatedDocuments with typeCodes "XFRM" and
"RPLC"; or two relatedDocuments with typeCodes
"XFRM" and "APND".
OrganizationPartOf
Person
0..1 wholeOrganization
Organization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 asOrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..1 representedOrganization
0..* assignedEntity
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
0..1 receivedOrganization
0..1 assignedAuthorChoice
ParentDocument
0..* parentDocument
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)
typeCode*: <= x_ActRelationshipDocument
Constraint: ParentDocument.text
ParentDocument.text can be used to indicate
the MIME type of the related document. It is
not to be used to embed the related document,
and thus ParentDocument.text.BIN is precluded
from use.
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
0..* assignedEntity
ServiceEvent
0..* serviceEvent
documentationOf
typeCode*: <= DOC
AssignedEntity
0..1 representedOrganization
performer
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1]
effectiveTime: IVL<TS> [0..1]
typeCode*: <= x_ServiceEventPerformer
functionCode: CE CWE [0..1] <= ParticipationFunction
time: IVL<TS> [0..1]
0..*
informant
0..1 assignedPerson
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..1 informationRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 representedOrganization
1..* assignedAuthor
authorization
author
typeCode*: <= AUTH
作成者
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
1..1 assignedCustodian
0..1 assignedAuthorChoice
custodian
AssignedCustodian
typeCode*: <= CST
classCode*: <= ASSIGNED
AuthoringDevice
1..1 representedCustodianOrganization
0..* asMaintainedEntity
MaintainedEntity
classCode*: <= MNT
effectiveTime: IVL<TS> [0..1]
1..1 maintainingPerson
Person
typeCode*: <= LOC
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..* assignedEntity
typeCode*: <= x_EncounterParticipant
time: IVL<TS> [0..1]
1..1 manufacturedDrugOrOtherMaterial
product
NonXMLBody
classCode*: <= DOCBODY
moodCode*: <= EVN
text: ED [1..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
Organization
0..1 providerOrganization
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
recordTarget
PatientRole
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
modeCode: CE CWE [0..1] <= LanguageAbilityMode
proficiencyLevelCode: CE CWE [0..1] <= LanguageAbilityProficiency
preferenceInd: BL [0..1]
CDA R-MIM
component
1..* section
0..*
author
Person
0..* guardian
Guardian
0..*
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
informant
RelatedSubject
0..1
classCode*: <= x_DocumentSubject
code: CE CWE [0..1] <= PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
informantChoice
1..1 guardianChoice
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
Person
RelatedEntity
0..1 relatedPerson
Organization
ParticipantRole
(POCD_RM000040)
This RMIM is used to generate
the CDA specification.
classCode*: <= RoleClassMutualRelationship
code: CE CWE [0..1] <=
PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
effectiveTime: IVL<TS> [0..1]
0..* informantChoice
informant
typeCode*: <= INF
contextControlCode*: CS CNE [1..1] <= "OP"
0..1 relatedSubject
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
participant
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
participant
typeCode*: <= ParticipationType
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
awarenessCode: CE CWE [0..1] <= TargetAwareness
Entity
classCode*: <= ENT
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
code: CE CWE [0..1] <= EntityCode
desc: ED [0..1]
ExternalAct
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
0..* externalActChoice
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
Encounter
ExternalProcedure
classCode*: <= ENC
moodCode*: <= x_DocumentEncounterMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActEncounterCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
classCode*: <= PROC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
Organizer
classCode*: <= x_ActClassDocumentEntryOrganizer
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
0..* clinicalStatement
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
seperatableInd: BL [0..1]
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
0..1 subject
SubjectPerson
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
classCode*: <= PROC
moodCode*: <= x_DocumentProcedureMood
id: SET<II> [0..*]
code: CD CWE [0..1]
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
methodCode: SET<CE> CWE [0..*]
approachSiteCode: SET<CD> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* section
subject
typeCode*: <= SBJ
contextControlCode*: CS CNE [1..1] <= "OP"
awarenessCode: CE CWE [0..1] <= TargetAwareness
Constraint: Section.text
Section.text.mediaType
fixed as "text/x-hl7-text+xml".
See section "Section Narrative
Block" for details.
0..* associatedEntity
AssociatedEntity
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..* participantRole
0..1 scopingEntity
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
0..1 scopingOrganization
Person
Procedure
0..1 specimenPlayingEntity
classCode*: <= ROL
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
GuardianChoice
typeCode*: <= SPC
classCode*: <= SPEC
id: SET<II> [0..*]
0..1 playingEntityChoice
component
LanguageCommunication
(LanguageCommunication)
specimen
externalActChoice
classCode*: <= ENT
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
quantity: SET<PQ> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 birthplace
0..*
languageCommunication
classCode*: <= SPLY
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: SET<CE> CWE [0..*] <= ActPriority
repeatNumber: IVL<INT> [0..1]
independentInd: BL [0..1]
quantity: PQ [0..1]
expectedUseTime: IVL<TS> [0..1]
0..* specimenRole
SpecimenRole
PlayingEntity
1..1 bodyChoice
component
Birthplace
classCode*: <= BIRTHPL
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
Supply
typeCode*: <= PRD
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1]
<= ManufacturerModelName
softwareName: SC CWE [0..1]
<= SoftwareName
bodyChoice
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
0..1 assignedPerson
Criterion
0..* criterion
precondition
typeCode*: <= PRCN
0..1 manufacturedProduct *
Device
0..1 location
classCode*: <= PLC
determinerCode*: <= INSTANCE
name: EN [0..1]
addr: AD [0..1]
0..1 patient
consumable
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1]
<= MaterialEntityClassType
name: EN [0..1]
lotNumberText: ST [0..1]
0..1 healthCareFacility
1..1 place
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
1..1 manufacturedProduct
Material
0..1 assignedPerson
Place
dataEnterer
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
SubstanceAdministration
classCode*: <= MANU
id: SET<II> [0..*]
typeCode*: <= CSM
encounterParticipant
classCode*: <= SDLOC
id: SET<II> [0..*]
code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType
Organization
typeCode*: <= REFV
classCode*: <= SBADM
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= SubstanceAdministrationActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
routeCode: CE CWE [0..1] <= RouteOfAdministration
approachSiteCode: SET<CD> CWE [0..*] <= ActSite
doseQuantity: IVL<PQ> [0..1]
rateQuantity: IVL<PQ> [0..1]
maxDoseQuantity: RTO<PQ,PQ> [0..1]
administrationUnitCode: CE CWE [0..1] <=
AdministrableDrugForm
ManufacturedProduct
EntityChoice
0..1 representedOrganization
AssignedEntity
Patient
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
DrugOrOtherMaterial
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1] <=
DrugEntity
name: EN [0..1]
typeCode*: <= RESP
HealthCareFacility
0..1 serviceProviderOrganization
0..1 assignedEntity
Place
ObservationMedia
performer
LabeledDrug
AssignedEntity
0..1 representedOrganization
responsibleParty
classCode*: <= ENC
moodCode*: <= EVN
componentOf
id: SET<II> [0..*]
typeCode*: <= COMP
0..1 encompassingEncounter code: CE CWE [0..1] <= ActEncounterCode
effectiveTime*: IVL<TS> [1..1]
dischargeDispositionCode: CE CWE [0..1]
<= EncounterDischargeDisposition
location
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1] <= ManufacturerModelName
softwareName: SC CWE [0..1] <= SoftwareName
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
0..* observationRange
referenceRange
0..1 manufacturerOrganization
0..1 assignedEntity
EncompassingEncounter
0..* assignedEntity
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
Consent
classCode*: <= CONS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= completed
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
AssignedEntity
0..1 representedOrganization
Organization
0..1 assignedPerson
0..* consent
Organization
subject
classCode*: <= ACT
moodCode*: <= RQO
id*: SET<II> [1..*]
code: CE CWE [0..1] <= ActCode
priorityCode: CE CWE [0..1] <= ActPriority
0..* intendedRecipient
classCode*: <= ROIOVL
moodCode*: <= EVN
id*: SET<II> [1..*]
code*: CS CNE [1..1] <= ROIOverlayShape
value*: LIST<INT> [1..*]
0..1
Order
typeCode*: <= FLFS
IntendedRecipient
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
RegionOfInterest
0..* order
inFulfillmentOf
Person
ObservationRange
clinicalStatement
Observation
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
Person
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Constraint: Organizer
Act
classCode*: <= x_ActClassDocumentEntryAct
moodCode*: <= x_DocumentActMood
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
The Organizer clone can be the source
of the component relationship or
the reference relationship, but not
the entryRelationship relationship.
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
29
診療情報提供書記載者（紹介元）
Organization
1..* assignedAuthor
0..1 representedOrganization
author
AssignedAuthor
AuthorChoice
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
<author>
<time value="20060530" />
<assignedAuthor>
<id extension="12345" root="2.16.840.1.113883.2.2.99.3" />
<addr>
<country>JP</country>
<streetName>虎ノ門１丁目19番9号</streetName>
<city>港区</city>
<state>東京都</state>
<postalCode>105‐0001</postalCode>
</addr>
<telecom use="WP" value="tel:03‐3560‐8070" />
<assignedPerson>
<name use="IDE">
<family>東京</family>
<given>太郎</given>
</name>
</assignedPerson>
<representedOrganization>
<id extension="93"
root="2.16.840.1.113883.2.2.99.4" />
<name>JAHIS病院 内科</name>
</representedOrganization>
</assignedAuthor>
</author>
30
診療情報提供書記載者（紹介先）
0..1 receivedOrganization
Organization
IntendedRecipient
Constraint: relatedDocument.typeCode
A conformant CDA document can have a single
relatedDocument with typeCode "APND"; a single
relatedDocument with typeCode "RPLC"; a single
relatedDocument with typeCode "XFRM"; two
relatedDocuments with typeCodes "XFRM" and
"RPLC"; or two relatedDocuments with typeCodes
"XFRM" and "APND".
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
Person
0..1 wholeOrganization
Organization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 asOrganizationPartOf
0..1 informationRecipient
0..* parentDocument
0..1 representedOrganization
0..* assignedEntity
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
ParentDocument
0..1 receivedOrganization
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
entryRelationship
0..* intendedRecipient
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
informationRecipient
0..* clinicalStatement
0..*
author
0..* assignedEntity
ServiceEvent
0..* serviceEvent
documentationOf
typeCode*: <= DOC
AssignedEntity
0..1 representedOrganization
performer
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1]
effectiveTime: IVL<TS> [0..1]
typeCode*: <= x_ServiceEventPerformer
functionCode: CE CWE [0..1] <= ParticipationFunction
time: IVL<TS> [0..1]
0..*
informant
0..1 assignedPerson
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..1 informationRecipient
informationRecipient
typeCode*: <=
<= x_InformationRecipient
x_InformationRecipient
typeCode*:
0..1 representedOrganization
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
1..* assignedAuthor
authorization
author
typeCode*: <= AUTH
1..1 assignedCustodian
0..1 assignedAuthorChoice
custodian
AssignedCustodian
typeCode*: <= CST
classCode*: <= ASSIGNED
AuthoringDevice
1..1 representedCustodianOrganization
0..* asMaintainedEntity
MaintainedEntity
classCode*: <= MNT
effectiveTime: IVL<TS> [0..1]
1..1 maintainingPerson
Person
typeCode*: <= LOC
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..* assignedEntity
typeCode*: <= x_EncounterParticipant
time: IVL<TS> [0..1]
0..1 healthCareFacility
1..1 manufacturedDrugOrOtherMaterial
NonXMLBody
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
0..1 assignedPerson
classCode*: <= DOCBODY
moodCode*: <= EVN
text: ED [1..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
Organization
0..1 providerOrganization
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
recordTarget
PatientRole
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..*
languageCommunication
languageCode: CS CNE [0..1] <= HumanLanguage
modeCode: CE CWE [0..1] <= LanguageAbilityMode
proficiencyLevelCode: CE CWE [0..1] <= LanguageAbilityProficiency
preferenceInd: BL [0..1]
CDA R-MIM
component
1..* section
0..*
author
Person
0..* guardian
Guardian
0..*
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
informant
RelatedSubject
0..1
classCode*: <= x_DocumentSubject
code: CE CWE [0..1] <= PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
informantChoice
1..1 guardianChoice
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
Person
RelatedEntity
0..1 relatedPerson
Organization
ParticipantRole
(POCD_RM000040)
This RMIM is used to generate
the CDA specification.
classCode*: <= RoleClassMutualRelationship
code: CE CWE [0..1] <=
PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
effectiveTime: IVL<TS> [0..1]
0..* informantChoice
informant
typeCode*: <= INF
contextControlCode*: CS CNE [1..1] <= "OP"
0..1 relatedSubject
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
participant
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
participant
typeCode*: <= ParticipationType
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
awarenessCode: CE CWE [0..1] <= TargetAwareness
Entity
classCode*: <= ENT
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
code: CE CWE [0..1] <= EntityCode
desc: ED [0..1]
ExternalAct
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
0..* externalActChoice
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
Encounter
ExternalProcedure
classCode*: <= ENC
moodCode*: <= x_DocumentEncounterMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActEncounterCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
classCode*: <= PROC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
Organizer
classCode*: <= x_ActClassDocumentEntryOrganizer
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
0..* clinicalStatement
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
seperatableInd: BL [0..1]
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
0..1 subject
SubjectPerson
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
classCode*: <= PROC
moodCode*: <= x_DocumentProcedureMood
id: SET<II> [0..*]
code: CD CWE [0..1]
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
methodCode: SET<CE> CWE [0..*]
approachSiteCode: SET<CD> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* section
subject
typeCode*: <= SBJ
contextControlCode*: CS CNE [1..1] <= "OP"
awarenessCode: CE CWE [0..1] <= TargetAwareness
Constraint: Section.text
Section.text.mediaType
fixed as "text/x-hl7-text+xml".
See section "Section Narrative
Block" for details.
0..* associatedEntity
AssociatedEntity
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..* participantRole
0..1 scopingEntity
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
0..1 scopingOrganization
Person
Procedure
0..1 specimenPlayingEntity
classCode*: <= ROL
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
GuardianChoice
typeCode*: <= SPC
classCode*: <= SPEC
id: SET<II> [0..*]
0..1 playingEntityChoice
component
LanguageCommunication
(LanguageCommunication)
specimen
externalActChoice
classCode*: <= ENT
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
quantity: SET<PQ> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 birthplace
0..1 patient
classCode*: <= SPLY
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: SET<CE> CWE [0..*] <= ActPriority
repeatNumber: IVL<INT> [0..1]
independentInd: BL [0..1]
quantity: PQ [0..1]
expectedUseTime: IVL<TS> [0..1]
0..* specimenRole
SpecimenRole
PlayingEntity
1..1 bodyChoice
component
Birthplace
classCode*: <= BIRTHPL
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
Supply
typeCode*: <= PRD
Place
dataEnterer
Criterion
0..* criterion
precondition
typeCode*: <= PRCN
0..1 manufacturedProduct *
product
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1]
<= ManufacturerModelName
softwareName: SC CWE [0..1]
<= SoftwareName
bodyChoice
classCode*: <= PLC
determinerCode*: <= INSTANCE
name: EN [0..1]
addr: AD [0..1]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
consumable
Device
0..1 location
1..1 place
Patient
1..1 manufacturedProduct
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1]
<= MaterialEntityClassType
name: EN [0..1]
lotNumberText: ST [0..1]
EntityChoice
0..1 representedOrganization
AssignedEntity
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
SubstanceAdministration
classCode*: <= MANU
id: SET<II> [0..*]
Material
0..1 assignedPerson
classCode*: <= SDLOC
id: SET<II> [0..*]
code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType
Organization
typeCode*: <= REFV
classCode*: <= SBADM
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= SubstanceAdministrationActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
routeCode: CE CWE [0..1] <= RouteOfAdministration
approachSiteCode: SET<CD> CWE [0..*] <= ActSite
doseQuantity: IVL<PQ> [0..1]
rateQuantity: IVL<PQ> [0..1]
maxDoseQuantity: RTO<PQ,PQ> [0..1]
administrationUnitCode: CE CWE [0..1] <=
AdministrableDrugForm
ManufacturedProduct
typeCode*: <= CSM
encounterParticipant
HealthCareFacility
0..1 serviceProviderOrganization
0..1 assignedEntity
Place
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
DrugOrOtherMaterial
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1] <=
DrugEntity
name: EN [0..1]
typeCode*: <= RESP
location
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1] <= ManufacturerModelName
softwareName: SC CWE [0..1] <= SoftwareName
ObservationMedia
performer
LabeledDrug
AssignedEntity
0..1 representedOrganization
responsibleParty
classCode*: <= ENC
moodCode*: <= EVN
componentOf
id: SET<II> [0..*]
typeCode*: <= COMP
0..1 encompassingEncounter code: CE CWE [0..1] <= ActEncounterCode
effectiveTime*: IVL<TS> [1..1]
dischargeDispositionCode: CE CWE [0..1]
<= EncounterDischargeDisposition
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
0..* observationRange
referenceRange
0..1 manufacturerOrganization
0..1 assignedEntity
EncompassingEncounter
0..* assignedEntity
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
Consent
classCode*: <= CONS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= completed
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
AssignedEntity
0..1 representedOrganization
Organization
0..1 assignedPerson
0..* consent
Organization
subject
classCode*: <= ACT
moodCode*: <= RQO
id*: SET<II> [1..*]
code: CE CWE [0..1] <= ActCode
priorityCode: CE CWE [0..1] <= ActPriority
0..* intendedRecipient
紹介先
Person
classCode*: <= ROIOVL
moodCode*: <= EVN
id*: SET<II> [1..*]
code*: CS CNE [1..1] <= ROIOverlayShape
value*: LIST<INT> [1..*]
0..1
Order
typeCode*: <= FLFS
IntendedRecipient
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
RegionOfInterest
0..* order
inFulfillmentOf
ObservationRange
clinicalStatement
Observation
typeCode*: <= x_InformationRecipient
Constraint: ParentDocument.text
ParentDocument.text can be used to indicate
the MIME type of the related document. It is
not to be used to embed the related document,
and thus ParentDocument.text.BIN is precluded
from use.
Constraint: Organizer
Act
classCode*: <= x_ActClassDocumentEntryAct
moodCode*: <= x_DocumentActMood
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
The Organizer clone can be the source
of the component relationship or
the reference relationship, but not
the entryRelationship relationship.
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
31
紹介先
Organization
0..1 receivedOrganization
IntendedRecipient
Person
0..1 informationRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
<informationRecipient typeCode="PRCP">
<intendedRecipient classCode="ASSIGNED">
<id extension="1234" root="2.16.840.1.113883.2.2" />
<!‐‐ 紹介先医療機関住所 ‐‐>
<addr>
<country>JP</country>
<postalCode>161‐0001</postalCode>
<streetName>西落合１丁目31番4号
</streetName>
<city>新宿区</city>
<state>東京都</state>
</addr>
<!‐‐ 紹介先医療機関電話番号 ‐‐>
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
<telecom use="WP" value="tel:03‐3506‐8010" />
<informationRecipient>
<!‐‐ 紹介先医師名 ‐‐>
<name use="IDE">
<family>港</family>
<given>次郎</given>
</name>
</informationRecipient>
<!‐‐ 紹介先医療機関名 ‐‐>
<receivedOrganization>
<id extension="111111"
root="2.16.840.1.113883.2.1.2" />
<name>HL7病院 内科</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
32
診療情報提供書とR‐MIMの関係 (ヘッダ部)
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..1 wholeOrganization
Organization
classCode*: <= ORG
0..1 asOrganizationPartOf
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 representedOrganization
文書情報
0..* assignedEntity
Person
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
ParentDocument
0..* parentDocument
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
versionNumber: INT [0..1]
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
ObservationRange
clinicalStatement
Observation
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* observationRange
referenceRange
typeCode*: <= REFV
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
Criterion
0..1 receivedOrganization
0..* criterion
precondition
typeCode*: <= PRCN
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
Organization
受取者
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
AssignedEntity
0..1 representedOrganization
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 assignedPerson
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
1..* assignedAuthor
0..1 representedOrganization
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
author
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
作成者
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
AssignedCustodian
classCode*: <= ASSIGNED
0..1 assignedCustodian
custodian
typeCode*: <= CST
1..1 representedCustodianOrganization
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..1 assignedEntity
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
bodyChoice
dataEnterer
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
externalActChoice
Organization
1..1 bodyChoice
component
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 providerOrganization
0..1 patient
Patient
1..* patientRole
患者情報
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
PREF RMIM
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
(POCD_RM000040JP00)
This RMIM is used for patient referral document
component
1..* section
0..*
GuardianChoice
author
Person
0..* externalActChoice
component
0..* guardian
Guardian
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* section
1..1 guardianChoice
0..* clinicalStatement
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Organization
0..1 scopingOrganization
0..* associatedEntity
Person
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
33
診療情報提供書の本文の記述
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..1 wholeOrganization
Organization
classCode*: <= ORG
0..1 asOrganizationPartOf
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 representedOrganization
ParentDocument
0..* parentDocument
0..* assignedEntity
Person
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
versionNumber: INT [0..1]
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
ObservationRange
clinicalStatement
Observation
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* observationRange
referenceRange
typeCode*: <= REFV
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
Criterion
0..1 receivedOrganization
0..* criterion
precondition
typeCode*: <= PRCN
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
Organization
AssignedEntity
0..1 representedOrganization
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 assignedPerson
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
1..* assignedAuthor
0..1 representedOrganization
author
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
AssignedCustodian
classCode*: <= ASSIGNED
0..1 assignedCustodian
custodian
typeCode*: <= CST
1..1 representedCustodianOrganization
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..1 assignedEntity
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
bodyChoice
dataEnterer
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
externalActChoice
Organization
1..1 bodyChoice
component
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 providerOrganization
0..1 patient
Patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
PREF RMIM
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
(POCD_RM000040JP00)
This RMIM is used for patient referral document
component
1..* section
0..*
GuardianChoice
author
Person
0..* externalActChoice
component
0..* guardian
Guardian
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* section
1..1 guardianChoice
0..* clinicalStatement
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Organization
0..1 scopingOrganization
0..* associatedEntity
Person
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
34
診療情報提供書 本文例 レベル1、2での記述
bodyChoice
1..1 bodyChoice
component
0..1 wholeOrganization
Organization
classCode*: <= ORG
0..1 asOrganizationPartOf
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 representedOrganization
StructuredBody
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
clinicalStatement
Observation
ParentDocument
0..* parentDocument
0..* assignedEntity
AssignedEntity
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
authenticator
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
versionNumber: INT [0..1]
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
classCode*: <= DOCBODY
moodCode*: <=ObservationRange
EVN
confidentialityCode: CE CWE [0..1]
referenceRange
<=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
0..* observationRange
typeCode*: <= REFV
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
component
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
entryRelationship
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
Criterion
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
typeCode*: <= COMP
precondition
contextConductionInd*:
BL [1..1] "true"
0..1 receivedOrganization
0..* criterion
typeCode*: <= PRCN
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
Organization
AssignedEntity
0..1 representedOrganization
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 assignedPerson
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
1..* assignedAuthor
0..1 representedOrganization
1..* section
author
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Section
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
AssignedCustodian
classCode*: <= ASSIGNED
custodian
typeCode*: <= CST
1..1 representedCustodianOrganization
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
bodyChoice
bodyChoice
0..1 assignedEntity
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
0..1 assignedCustodian
dataEnterer
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
externalActChoice
Organization
1..1
1..1 bodyChoice
bodyChoice
component
component
StructuredBody
StructuredBody
typeCode*:
<=<=
COMP
typeCode*:
COMP
contextConductionInd*:
BLBL
[1..1]
"true"
contextConductionInd*:
[1..1]
"true"
0..1 providerOrganization
0..1 patient
Patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
classCode*:
classCode*: <= DOCBODY
moodCode*:
moodCode*: <= EVN
confidentialityCode:
confidentialityCode: CE CWE [0..1]
<=
<= x_BasicConfidentialityKind
x_BasicConfidentialityKind
languageCode:
languageCode: CS CNE [0..1] <=
HumanLanguage
HumanLanguage
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
typeCode*:
typeCode*: <=
<= COMP
COMP
contextConductionInd*:
contextConductionInd*: BL [1..1] "true"
PREF RMIM
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
(POCD_RM000040JP00)
This RMIM is used for patient referral document
component
1..* section
section
0..*
GuardianChoice
author
Person
0..* externalActChoice
component
component
0..* guardian
Guardian
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
Section
classCode*: <= DOCSECT
classCode*:
moodCode*: <= EVN
moodCode*:
id: IIII [0..1]
[0..1]
id:
code: CE
CE CWE
CWE [0..1] <= DocumentSectionType
code:
title: ST
ST [0..1]
[0..1]
title:
text*: ED
ED [0..1]
text*:
confidentialityCode: CE CWE [0..1] <=
confidentialityCode:
x_BasicConfidentialityKind
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
languageCode:
HumanLanguage
HumanLanguage
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* section
1..1 guardianChoice
0..* clinicalStatement
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Organization
0..1 scopingOrganization
0..* associatedEntity
Person
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
35
診療情報提供書 本文例 レベル1、2での記述
bodyChoice
<!‐‐ ********** CDA Body ********** ‐‐>
<component contextConductionInd="true">
<structuredBody>
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
<!‐‐ 目的（区分） ‐‐>
<component contextConductionInd="true">
<section>
<code code="MD0020200"
codeSystem="1.2.392.200119.5.3.1" displayName="目的" />
<title>目的</title>
<text>胃潰瘍投薬治療後の経過観察</text>
</section>
</component>
1..1 bodyChoice
StructuredBody
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
1..* section
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
<!‐‐ 連絡（留意）事項 ‐‐>
<component contextConductionInd="true">
<section>
<code code="MD0020330"
codeSystem="1.2.392.200119.5.3.1" displayName="連絡事項" />
<title>連絡事項</title>
<text>平成17年9月8日当科入院、投薬治療、胸
腹部ＣＴ施行いたしました。投薬治療により、潰瘍が消滅しました。
ご本人の希望もあり、今後の経過観察につき御高診の程、よろし
くお願い申し上げます。</text>
</section>
</component>
36
診療情報提供書 本文例
bodyChoice
1..1 bodyChoice
component
0..1 wholeOrganization
Organization
classCode*: <= ORG
0..1 asOrganizationPartOf
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 representedOrganization
StructuredBody
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
clinicalStatement
Observation
ParentDocument
0..* parentDocument
0..* assignedEntity
AssignedEntity
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
authenticator
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
versionNumber: INT [0..1]
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
classCode*: <= DOCBODY
moodCode*: <=ObservationRange
EVN
confidentialityCode: CE CWE [0..1]
referenceRange
<=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
0..* observationRange
typeCode*: <= REFV
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
component
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
entryRelationship
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
Criterion
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
typeCode*: <= COMP
precondition
contextConductionInd*:
BL [1..1] "true"
0..1 receivedOrganization
0..* criterion
typeCode*: <= PRCN
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
Organization
AssignedEntity
0..1 representedOrganization
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 assignedPerson
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
1..* assignedAuthor
0..1 representedOrganization
1..* section
author
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Section
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
AssignedCustodian
classCode*: <= ASSIGNED
custodian
typeCode*: <= CST
1..1 representedCustodianOrganization
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
bodyChoice
bodyChoice
0..1 assignedEntity
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
0..1 assignedCustodian
dataEnterer
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
externalActChoice
Organization
1..1
1..1 bodyChoice
bodyChoice
component
component
StructuredBody
StructuredBody
typeCode*:
<=<=
COMP
typeCode*:
COMP
contextConductionInd*:
BLBL
[1..1]
"true"
contextConductionInd*:
[1..1]
"true"
0..1 providerOrganization
0..1 patient
Patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
classCode*:
classCode*: <= DOCBODY
moodCode*:
moodCode*: <= EVN
confidentialityCode:
confidentialityCode: CE CWE [0..1]
<=
<= x_BasicConfidentialityKind
x_BasicConfidentialityKind
languageCode:
languageCode: CS CNE [0..1] <=
HumanLanguage
HumanLanguage
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
typeCode*:
typeCode*: <=
<= COMP
COMP
contextConductionInd*:
contextConductionInd*: BL [1..1] "true"
PREF RMIM
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
(POCD_RM000040JP00)
This RMIM is used for patient referral document
component
1..* section
section
0..*
GuardianChoice
author
Person
0..* externalActChoice
component
component
0..* guardian
Guardian
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
Section
classCode*: <= DOCSECT
classCode*:
moodCode*: <= EVN
moodCode*:
id: IIII [0..1]
[0..1]
id:
code: CE
CE CWE
CWE [0..1] <= DocumentSectionType
code:
title: ST
ST [0..1]
[0..1]
title:
text*: ED
ED [0..1]
text*:
confidentialityCode: CE CWE [0..1] <=
confidentialityCode:
x_BasicConfidentialityKind
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
languageCode:
HumanLanguage
HumanLanguage
本文
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* section
1..1 guardianChoice
0..* clinicalStatement
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Organization
0..1 scopingOrganization
0..* associatedEntity
Person
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
37
診療情報提供書 本文例 レベル1、2での記述
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code="MD0022780"
codeSystem="1.2.392.200119.5.3.1" codeSystemName="JMIX"
displayName="現投与" />
<title>現在の処方</title>
<text>
component
<table>
<tbody>
<tr>
<td>実施済</td>
<td>処方</td>
<td>皮膚科</td>
<td>○○康裕</td>
<td>外来</td>
<td>昼</td>
<td>院内</td>
<td>000149 会計済</td>
</tr>
</tbody>
</table>
<table>
<tbody>
<tr>
<td>Rp1</td>
<td>ジルテック錠 10mg</td>
<td>1 錠</td>
<td>１日１回 朝食後</td>
<td>14 日</td>
</tr>
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
bodyChoice
1..1 bodyChoice
StructuredBody
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
1..* section
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
38
CDA R2 Clinical Statement
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
ObservationRange
clinicalStatement
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
Observation
Constraint: relatedDocument.typeCode
A conformant CDA document can have a single
relatedDocument with typeCode "APND"; a single
relatedDocument with typeCode "RPLC"; a single
relatedDocument with typeCode "XFRM"; two
relatedDocuments with typeCodes "XFRM" and
"RPLC"; or two relatedDocuments with typeCodes
"XFRM" and "APND".
OrganizationPartOf
0..1 wholeOrganization
Organization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 asOrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..* parentDocument
0..1 representedOrganization
0..* assignedEntity
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
0..1 receivedOrganization
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)
typeCode*: <= x_ActRelationshipDocument
Organization
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
authorization
author
typeCode*: <= AUTH
typeCode*: <= CST
classCode*: <= ASSIGNED
DrugOrOtherMaterial
EncompassingEncounter
ManufacturedProduct
classCode*: <= ENC
0..* asMaintainedEntity
MaintainedEntity
classCode*: <= MNT
effectiveTime: IVL<TS> [0..1]
1..1 maintainingPerson
Person
Material
CustodianOrganization
typeCode*: <= LOC
classCode*: <= ORG
classCode*: <= MMAT
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
determinerCode*: <= KIND
name: ON [0..1]
code: CE CWE [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
<= MaterialEntityClassType
1..1 manufacturedDrugOrOtherMaterial
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
typeCode*: <= PRD
EntityChoice
Organization
Device
Birthplace
classCode*: <= BIRTHPL
0..1 birthplace
0..1 providerOrganization
1..* patientRole
recordTarget
PatientRole
0..1 patient
Patient
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
LanguageCommunication
(LanguageCommunication)
0..*
languageCommunication
0..* guardian
Guardian
Organization
This RMIM is used to generate
the CDA specification.
0..1 playingEntityChoice
ParticipantRole
0..1 representedOrganization
AssignedEntity
classCode*: <= ROL
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..1 assignedPerson
Person
RelatedEntity
0..1 relatedPerson
classCode*: <= RoleClassMutualRelationship
code: CE CWE [0..1] <=
PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
effectiveTime: IVL<TS> [0..1]
0..* informantChoice
informant
typeCode*: <= INF
contextControlCode*: CS CNE [1..1] <= "OP"
0..* associatedEntity
0..1 associatedPerson
author
0..*
0..* specimenRole
specimen
typeCode*: <= SPC
subject
AssignedEntity
0..1 representedOrganization
Organization
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
Entity
classCode*: <= ENT
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
code: CE CWE [0..1] <= EntityCode
desc: ED [0..1]
typeCode*: <= REFV
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
Criterion
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
0..1 assignedPerson
0..* criterion
precondition
typeCode*: <= PRCN
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
0..1 manufacturerOrganization
classCode*: <= SBADM
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
AssignedEntity
0..1 representedOrganization
code:
CD CWE [0..1] <= SubstanceAdministrationActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime:
GTS [0..1]
0..1 assignedPerson
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
routeCode: CE CWE [0..1] <= RouteOfAdministration
approachSiteCode: SET<CD> CWE [0..*] <= ActSite
doseQuantity: IVL<PQ> [0..1]
rateQuantity: IVL<PQ> [0..1]
maxDoseQuantity: RTO<PQ,PQ> [0..1]
administrationUnitCode: CE CWE [0..1] <=
AdministrableDrugForm bodyChoice
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1] <=
DrugEntity
name: EN [0..1]
classCode*: <= SBADM
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= SubstanceAdministrationActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
routeCode: CE CWE [0..1] <= RouteOfAdministration
approachSiteCode: SET<CD> CWE [0..*] <= ActSite
doseQuantity: IVL<PQ> [0..1]
rateQuantity: IVL<PQ> [0..1]
maxDoseQuantity: RTO<PQ,PQ> [0..1]
administrationUnitCode: CE CWE [0..1] <=
AdministrableDrugForm
ManufacturedProduct
classCode*: <= MANU
id: SET<II> [0..*]
1..1 manufacturedProduct
consumable
typeCode*: <= CSM
Material
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1]
<= MaterialEntityClassType
name: EN [0..1]
lotNumberText: ST [0..1]
1..1 manufacturedDrugOrOtherMaterial
0..1 manufacturedProduct *
product
Supply
typeCode*: <= PRD
classCode*: <= SPLY
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: SET<CE> CWE [0..*] <= ActPriority
repeatNumber: IVL<INT> [0..1]
independentInd: BL [0..1]
quantity: PQ [0..1]
expectedUseTime: IVL<TS> [0..1]
EntityChoice
Device
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1]
<= ManufacturerModelName
softwareName: SC CWE [0..1]
<= SoftwareName
classCode*: <= DOCBODY
moodCode*: <= EVN
text: ED [1..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
classCode*: <= SPLY
languageCode: CS CNE [0..1] <=
HumanLanguage
moodCode*: <= x_DocumentSubstanceMood
id: SET<II>
[0..*]
1..1 bodyChoice
code: CD CWE [0..1]
<= ActCode
StructuredBody
text: ED [0..1]
classCode*: <= DOCBODY
moodCode*:
EVN
statusCode: CS CNE
[0..1]<=<=
ActStatus
confidentialityCode: CE CWE [0..1]
effectiveTime: GTS<=[0..1]
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
priorityCode: SET<CE>
CWE [0..*] <= ActPriority
HumanLanguage
repeatNumber: IVL<INT> [0..1]
component
independentInd:
BL [0..1]
typeCode*: <= COMP
quantity: PQ [0..1]
contextConductionInd*: BL [1..1] "true"
expectedUseTime: IVL<TS> [0..1]
0..* specimenRole
SpecimenRole
specimen
typeCode*: <= SPC
classCode*: <= SPEC
id: SET<II> [0..*]
PlayingEntity
externalActChoice
classCode*: <= ENT
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
quantity: SET<PQ> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
Procedure
0..1 specimenPlayingEntity
0..1 playingEntityChoice
ParticipantRole
classCode*: <= ROL
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
component
1..* section
SubstanceAdministration
DrugOrOtherMaterial
LabeledDrug
NonXMLBody
Procedure
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
0..* observationRange
referenceRange
RegionOfInterest
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
Supply
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
classCode*: <= ROIOVL
moodCode*: <= EVN
id*: SET<II> [1..*]
code*: CS CNE [1..1] <= ROIOverlayShape
value*: LIST<INT> [1..*]
0..1
0..* participantRole
participant
typeCode*: <= ParticipationType
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
awarenessCode: CE CWE [0..1] <= TargetAwareness
0..1 scopingEntity
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
classCode*:
<= PROC
0..*
classCode*: <= DOCSECT
moodCode*:
author <= x_DocumentProcedureMood
moodCode*: <= EVN
id: SET<II> [0..*] id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
code:0..*
CD CWE [0..1]
title: ST [0..1]
text*: ED [0..1]
informant
negationInd:
BL [0..1]
confidentialityCode: CE CWE [0..1]
text: ED [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
statusCode: CS CNE
[0..1] <= ActStatus
HumanLanguage
0..1 relatedSubject
RelatedSubject
effectiveTime: IVL<TS> [0..1]
0..1
0..*
participantRole
subject
classCode*: <= x_DocumentSubject
typeCode*: <= SBJ
priorityCode: CE CWE [0..1] <= ActPriority
code: CE CWE [0..1] <= PersonalRelationshipRoleType
participant
contextControlCode*: CS CNE [1..1] <= "OP"
addr: SET<AD> [0..*]
languageCode:
awarenessCode: CE CWE [0..1]
<= TargetAwareness CS CNE [0..1] <= HumanLanguage
typeCode*:
<=[0..*]
ParticipationType
telecom: SET<TEL>
methodCode: SET<CE> CWE [0..*]
contextControlCode*: CS CNE [1..1] <= "OP"
approachSiteCode: SET<CD> CWE [0..*]
time: IVL<TS> [0..1]
0..1 subject
targetSiteCode: SET<CD> CWE [0..*]
SubjectPerson
awarenessCode: CE CWE
[0..1] <= TargetAwareness
Entity
classCode*: <= ENT
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
code: CE CWE [0..1] <= EntityCode
desc: ED [0..1]
classCode*: <= PROC
moodCode*: <= x_DocumentProcedureMood
id: SET<II> [0..*]
code: CD CWE [0..1]
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
methodCode: SET<CE> CWE [0..*]
approachSiteCode: SET<CD> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
ExternalAct
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
0..* externalActChoice
reference
ExternalObservation
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
Encounter
ExternalProcedure
classCode*: <= ENC
moodCode*: <= x_DocumentEncounterMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActEncounterCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
classCode*: <= PROC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
0..* section
ExternalDocument
0..* clinicalStatement
Organizer
classCode*: <= x_ActClassDocumentEntryOrganizer
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
0..* clinicalStatement
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
seperatableInd: BL [0..1]
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
classCode*:
Encounter
0..1 scopingEntity
0..1 scopingOrganization
Person
classCode*: <= SPEC
id: SET<II> [0..*]
0..* clinicalStatement
0..*
informant
CDA R-MIM
informantChoice
1..1 guardianChoice
SpecimenRole
0..1 specimenPlayingEntity
typeCode*: <= PRCN
0..1 assignedPerson
(POCD_RM000040)
INSTANCE
code: CE CWE [0..1] <= EntityCode
quantity: SET<PQ> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
PlayingEntity
languageCode: CS CNE [0..1] <= HumanLanguage
modeCode: CE CWE [0..1] <= LanguageAbilityMode
classCode*: <= ENT
proficiencyLevelCode: CE CWE [0..1] <= LanguageAbilityProficiency
determinerCode*: <=
preferenceInd: BL [0..1]
GuardianChoice
Person
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1]
<= ManufacturerModelName
softwareName: SC CWE [0..1]
<= SoftwareName
0..* criterion
precondition
classCode*: <= ROIOVL
moodCode*: <= EVN
id*: SET<II> [1..*]
code*:
CS CNE [1..1] <= ROIOverlayShape
AssignedEntity
0..1 representedOrganization
value*: LIST<INT> [1..*]
0..1 manufacturedProduct *
product
classCode*: <= PLC
determinerCode*: <= INSTANCE
name: EN [0..1]
addr: AD [0..1]
1..1 place
Organization
0..1 location
Place
dataEnterer
0..1 assignedPerson
0..1 healthCareFacility
classCode*: <= SDLOC
id: SET<II> [0..*]
code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType
0..1 serviceProviderOrganization
Organization
0..1 assignedEntity
Place
<= CSM
HealthCareFacility
name: EN [0..1]
lotNumberText: ST [0..1]
0..1 representedOrganization
AssignedEntity
responsibleParty
consumable
typeCode*:
location
1..1 representedCustodianOrganization
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
SubstanceAdministration
typeCode*: <= RESP
moodCode*: <= EVN
classCode*: <= MANU
componentOf
id: SET<II> [0..*]
typeCode*: <=id:
COMP
0..* assignedEntity
SET<II> [0..*]
<= ActEncounterCode
0..1 encompassingEncounter code: CE CWE [0..1]
1..1
manufacturedProduct
encounterParticipant
effectiveTime*: IVL<TS> [1..1]
typeCode*: <= x_EncounterParticipant
dischargeDispositionCode: CE CWE [0..1]
time: IVL<TS> [0..1]
<= EncounterDischargeDisposition
ObservationRange
clinicalStatement
Observation
Criterion
Consent
0..1 assignedEntity
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1] <=
DrugEntity
name: EN [0..1]
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
ObservationMedia
classCode*: <= CONS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= completed
LabeledDrug
custodian
AssignedCustodian
typeCode*: <= x_ServiceEventPerformer
functionCode: CE CWE [0..1] <= ParticipationFunction
time: IVL<TS> [0..1]
classCode*: <=
ACT
typeCode*:
<= PRF
0..1 assignedPerson
moodCode*: <= RQO
time: IVL<TS> [0..1]
id*: SET<II> [1..*]
modeCode:
code: CE CWE
[0..1] <= ActCodeCE CWE [0..1] <= ParticipationMode
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
AuthoringDevice
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1] <= ManufacturerModelName
softwareName: SC CWE [0..1] <= SoftwareName
performer
priorityCode: CE CWE [0..1] <= ActPriority
1..* assignedAuthor
1..1 assignedCustodian
0..1 assignedAuthorChoice
0..* assignedEntity
performer
Order
0..1 manufacturerOrganization 0..* consent
Person
subject
AssignedEntity
documentationOf
0..1
typeCode*: <= FLFS
typeCode*: <= REFV
RegionOfInterest
0..1
classCode*: <= ACT
moodCode*: <= EVN
representedOrganization
id: SET<II> [0..*]
code: CE CWE [0..1]
effectiveTime: IVL<TS> [0..1]
0..* assignedEntity
0..* order
typeCode*: <= DOC
referenceRange
Constraint: ParentDocument.text
ParentDocument.text can be used to indicate
the MIME type of the related document. It is
not to be used to embed the related document,
and thus ParentDocument.text.BIN is precluded
from use.
informant
ServiceEvent
0..* intendedRecipient
0..1 representedOrganization
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* serviceEvent
inFulfillmentOf
IntendedRecipient
Organization
author
0..*
ParentDocument
Person
Organization
0..* clinicalStatement
0..*
0..* observationRange
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
<= ENC
moodCode*: <= x_DocumentEncounterMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActEncounterCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
Constraint: Section.text
Section.text.mediaType
fixed as "text/x-hl7-text+xml".
See section "Section Narrative
Block" for details.
Constraint: Organizer
Act
classCode*: <= x_ActClassDocumentEntryAct
moodCode*: <= x_DocumentActMood
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
The Organizer clone can be the source
of the component relationship or
the reference relationship, but not
the entryRelationship relationship.
0..* clinicalStatement
Organizer
classCode*: <= x_ActClassDocumentEntryOrganizer
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
seperatableInd: BL [0..1]
Act
classCode*: <= x_ActClassDocumentEntryAct
moodCode*: <= x_DocumentActMood
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
39
本文 (レベル３)で身体所見を記述
clinicalStatement
Observation
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
entryRelationship
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
OrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
0..1 wholeOrganization
Organization
classCode*: <= ORG
0..1 asOrganizationPartOf
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 representedOrganization
ParentDocument
0..* parentDocument
0..* assignedEntity
Person
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedEntity
legalAuthenticator
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
versionNumber: INT [0..1]
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
0..*
author
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
Organization
ObservationRange
clinicalStatement
Observation
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
0..* observationRange
referenceRange
typeCode*: <= REFV
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
Criterion
0..1 receivedOrganization
0..* criterion
precondition
typeCode*: <= PRCN
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
IntendedRecipient
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
0..1 informationRecipient
Organization
AssignedEntity
0..1 representedOrganization
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
0..1 assignedPerson
0..* assignedEntity
ObservationMedia
performer
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
1..* assignedAuthor
0..1 representedOrganization
author
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
Person
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..1 assignedAuthorChoice
AssignedCustodian
classCode*: <= ASSIGNED
0..1 assignedCustodian
custodian
typeCode*: <= CST
bodyChoice
1..1 representedCustodianOrganization
CustodianOrganization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..1 assignedEntity
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
bodyChoice
dataEnterer
1..1 bodyChoice
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
component
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Organization
component
0..1 patient
PatientRole
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
desc: ED [0..1]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
PREF RMIM
This RMIM is used for patient referral document
component
1..* section
0..*
author
Guardian
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
ExternalObservation
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
1..* section
(POCD_RM000040JP00)
0..* guardian
0..* externalActChoice
reference
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
component
GuardianChoice
Person
externalActChoice
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 providerOrganization
Patient
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
1..1 bodyChoice
Section
classCode*: <= DOCSECT
typeCode*: <= COMP
moodCode*:
<= EVN
contextConductionInd*:
BL [1..1] "true"
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1] <=
x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
0..* section
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
1..1 guardianChoice
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Organization
entry
0..* clinicalStatement
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
0..1 scopingOrganization
0..* associatedEntity
Person
AssociatedEntity
participant
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
40
レベル3での記述
clinicalStatement
Observation
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
bodyChoice
1..1 bodyChoice
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
StructuredBody
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
1..* section
Section
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
0..* clinicalStatement
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
41
CDA R2 レベル3の記述例
Clinical Statement
<component contextConductionInd="true">
<section>
<code code="MD0018730" codeSystem="1.2.392.200119.5.3.1"
codeSystemName="JMIX" displayName="身体所見" />
<title>身体所見</title>
<entry contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<code code="3137‐7"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="身長" />
<statusCode code="completed" />
<value xsi:type="PQ" value="170" unit="cm" />
</observation>
</entry>
<entry contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<code code="3141‐9"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="体重" />
<statusCode code="completed" />
<value xsi:type="PQ" value="58" unit="kg" />
</observation>
</entry>
</section>
</component>
42
スタイルシートによる表示制御 (CDA.xsl)
<name use="IDE">
<family>日本</family>
<given>次郎</given>
</name>
<name use="SYL">
<family>ニホン</family>
<given>ジロウ</given>
</name>
<desc>職業 会社員</desc>
<administrativeGenderCode code="M"
codeSystem="2.16.840.1.113883.5.1" />
XMLインスタンス
<table class="patient" cellspacing="0">
<tr>
<td class="patient‐fname‐hd" rowspan="2">患者氏名</td>
<td class="patient‐fname" colspan="4">
<xsl:apply‐templates
select="hl7:recordTarget/hl7:patientRole/hl7:patient/hl7:name" />
</td>
</tr>
<tr>
<td class="patient‐name" colspan="2">
<xsl:value‐of
select="hl7:recordTarget/hl7:patientRole/hl7:patient/hl7:name" />
<xsl:template
match="/hl7:ClinicalDocument/hl7:recordTarget/hl7:pat
ientRole/hl7:patient/hl7:name">
<xsl:if test="@use='SYL'">
<xsl:value-of select="hl7:family" />
<xsl:text />
<xsl:value-of select="hl7:given" />
</xsl:if>
</xsl:template>
XSLスタイルシート
43
外部参照文書
<component contextConductionInd="true">
<section>
<code code="MD0018800"
codeSystem="1.2.392.200119.5.3.1" displayName="検査結果" />
<title>検査結果</title>
<text>心電図検査を添付致します</text>
<entry contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<code code="9A110" codeSystem="890E7152‐1875‐
4A59‐8BF9‐A5CFA9AD66EB" codeSystemName="LC10" displayName="標
準１２誘導心電図検査" />
<reference typeCode="SPRT">
<externalDocument>
<code code="1"
codeSystem="1.2.392.200119.5.2" codeSystemName="MFER"
displayName="１２誘導心電図" />
< text mediaType =" application/mwf " representation ="B64" integrityCheck="Bpu2X6j9J3ah5ulHZZ1JX8wX0Ks=">
< reference value
="0153_130_20030801_093501.mwf"/>
</text>
</externalDocument>
</reference>
</observation>
</entry>
</section>
</component>
<xsl:choose>
<xsl:when test="hl7:section/hl7:entry/hl7:observation/hl7:reference/hl7:externalDo
cument">
<xsl:element name="a">
<xsl:attribute name="href">
<xsl:value‐of
select="hl7:section/hl7:entry/hl7:observation/hl7:reference/hl7:externalD
ocument/hl7:text" />
</xsl:attribute>
<xsl:if test="hl7:section/hl7:entry/hl7:observation">
<xsl:for‐each select="hl7:section">
<xsl:apply‐templates
select="child::hl7:entry/hl7:observation" />
</xsl:for‐each>
</xsl:if>
</xsl:element>
</xsl:when>
スタイルシート
診療情報提供書
44
CDA レベル１ ・ レベル２ ・ レベル３
<component typeCode="COMP" contextConductionInd="true">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<code code=“MD0022780" codeSystem="1.2.392.200119.5.1" codeSystemName=“JMIX" codeSystemVersion="1.0"
レベル２
displayName="現投与" />
<title>現投与</title>
<text> <table>
<tr><td>Rp1</td><td>ジルテック錠 10mg</td><td>1 錠 １日１回</td><td>朝食後</td><td>14 日</td></tr>
<tr><td>Rp2</td><td>ポララミン復効錠 6mg</td><td>1 錠</td><td>かゆい時</td><td> 14 回</td><tr>
<tr><td>Rp3</td><td>トプシムローション 10g</td><td>4 本 １日２回</td><td>頭</td><tr>
レベル１
<tr><td>Rp4 </td><td>混用 ヒルドイド軟膏 20g</td><td>0.5 本</td></tr>
<tr><td></td><td>リンデロン‐Ｖ軟膏 5g</td><td>2 本</td><td>１日２回</td><td>体幹、四肢</td><tr>
</table></text>
<entry typeCode="COMP" contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<manufacturedLabeledDrug classCode="MMAT" determinerCode="KIND">
<code code="1005653" codeSystem="0.2.440.200194.10.9.1" codeSystemName="DrugCode"
レベル３
codeSystemVersion="1.0" displayName="ジルテック錠 10mg" />
レベル３
<name>ジルテック錠 10mg</name>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
45
CDAで診療文書の記述
entryRelationship
Organization
classCode*: <= ORG
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
name: SET<ON> [0..*]
telecom: SET<TEL> [0..*]
addr: SET<AD> [0..*]
standardIndustryClassCode: CE CWE [0..1]
<= OrganizationIndustryClass
0..1 asOrganizationPartOf
classCode*: <= PART
id*: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
statusCode: CS CNE [0..1] <=
RoleStatus
effectiveTime: IVL<TS> [0..1]
文書情報
Constraint: ParentDocument.text
ParentDocument.text can be used to indicate
the MIME type of the related document. It is
not to be used to embed the related document,
and thus ParentDocument.text.BIN is precluded
from use.
ParentDocument
0..* assignedEntity
AssignedEntity
authenticator
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
typeCode*: <= AUTHEN
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
認証者
0..1 assignedEntity
legalAuthenticator
typeCode*: <= LA
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
signatureCode*: CS CNE [1..1] <= ParticipationSignature
0..1 assignedPerson
0..1 receivedOrganization
ClinicalDocument
relatedDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: II [1..1]
code*: CE CWE [1..1] <= DocumentType
title: ST [0..1]
effectiveTime*: TS [1..1]
confidentialityCode*: CE CWE [1..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <= HumanLanguage
setId: II [0..1]
versionNumber: INT [0..1]
copyTime: TS [0..1] (Deprecated)
typeCode*: <= x_ActRelationshipDocument
classCode*: <= DOCCLIN
moodCode*: <= EVN
id*: SET<II> [1..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
親文書
0..* clinicalStatement
0..*
author
0..* assignedEntity
ServiceEvent
0..* serviceEvent
documentationOf
typeCode*: <= DOC
行為者
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1]
effectiveTime: IVL<TS> [0..1]
AssignedEntity
0..1 representedOrganization
performer
typeCode*: <= x_ServiceEventPerformer
functionCode: CE CWE [0..1] <= ParticipationFunction
time: IVL<TS> [0..1]
0..*
informant
0..1 assignedPerson
IntendedRecipient
classCode*: <= ACT
moodCode*: <= RQO
id*: SET<II> [1..*]
code: CE CWE [0..1] <= ActCode
priorityCode: CE CWE [0..1] <= ActPriority
0..* intendedRecipient
informationRecipient
typeCode*: <= x_InformationRecipient
Organization
0..1 representedOrganization
AssignedAuthor
classCode*: <= ASSIGNED
id*: SET<II> [1..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
AuthorChoice
AssignedEntity
0..1 representedOrganization
Organization
1..* assignedAuthor
authorization
author
typeCode*: <= AUTH
インフォームドコンセント
typeCode*: <= AUT
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time*: TS [1..1]
作成者
Person
Consent
classCode*: <= CONS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CE CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= completed
1..1 assignedCustodian
0..1 assignedAuthorChoice
custodian
AssignedCustodian
文書管理者
typeCode*: <= CST
classCode*: <= ASSIGNED
AuthoringDevice
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1] <= ManufacturerModelName
softwareName: SC CWE [0..1] <= SoftwareName
1..1 representedCustodianOrganization
0..* asMaintainedEntity
MaintainedEntity
classCode*: <= MNT
effectiveTime: IVL<TS> [0..1]
1..1 maintainingPerson
Person
classCode*: <= ORG
determinerCode*: <= INSTANCE
id*: SET<II> [1..*]
name: ON [0..1]
telecom: TEL [0..1]
addr: AD [0..1]
0..1 assignedPerson
0..1 healthCareFacility
1..1 manufacturedDrugOrOtherMaterial
bodyChoice
typeCode*: <= ENT (Transcriptionist)
contextControlCode*: CS CNE [1..1] <= "OP"
time: TS [0..1]
classCode*: <= DOCBODY
moodCode*: <= EVN
text: ED [1..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
非XMLデータ
Organization
PatientRole
0..1 patient
Patient
classCode*: <= DOCBODY
moodCode*: <= EVN
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
患者情報
1..* patientRole
recordTarget
typeCode*: <= RCT
contextControlCode*: CS CNE [1..1] <= "OP"
classCode*: <= PAT
id: SET<II> [1..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
classCode*: <= PSN
determinerCode*: <= INSTANCE
id: II [0..1] (Deprecated)
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
maritalStatusCode: CE CWE [0..1] <= MaritalStatus
religiousAffiliationCode: CE CWE [0..1] <= ReligiousAffiliation
raceCode: CE CWE [0..1] <= Race
ethnicGroupCode: CE CWE [0..1] <= Ethnicity
LanguageCommunication
(LanguageCommunication)
languageCode: CS CNE [0..1] <= HumanLanguage
modeCode: CE CWE [0..1] <= LanguageAbilityMode
proficiencyLevelCode: CE CWE [0..1] <= LanguageAbilityProficiency
preferenceInd: BL [0..1]
CDA R-MIM
(POCD_RM000040)
This RMIM is used to generate
the CDA specification.
入力点
component
author
Person
0..* guardian
Guardian
0..*
classCode*: <= GUARD
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Organization
informant
RelatedSubject
0..1
classCode*: <= x_DocumentSubject
code: CE CWE [0..1] <= PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
informantChoice
1..1 guardianChoice
0..1 representedOrganization
AssignedEntity
0..1 assignedPerson
Person
RelatedEntity
0..1 relatedPerson
Organization
0..* informantChoice
情報提供者
classCode*: <= RoleClassMutualRelationship
code: CE CWE [0..1] <=
PersonalRelationshipRoleType
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
effectiveTime: IVL<TS> [0..1]
informant
typeCode*: <= INF
contextControlCode*: CS CNE [1..1] <= "OP"
0..1 subject
0..1 relatedSubject
classCode*: <= DOCSECT
moodCode*: <= EVN
id: II [0..1]
code: CE CWE [0..1] <= DocumentSectionType
title: ST [0..1]
text*: ED [0..1]
confidentialityCode: CE CWE [0..1]
<= x_BasicConfidentialityKind
languageCode: CS CNE [0..1] <=
HumanLanguage
本文
participant
関係者
typeCode*: <= ParticipationType
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
awarenessCode: CE CWE [0..1] <= TargetAwareness
関連患者
participant
ExternalObservation
外部参照情報
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
Encounter
ExternalProcedure
classCode*: <= PROC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
ExternalDocument
classCode*: <= DOC
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= DocumentType
text: ED [0..1]
setId: II [0..1]
versionNumber: INT [0..1]
0..* clinicalStatement
Organizer
検体
classCode*: <= x_ActClassDocumentEntryOrganizer
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
statusCode*: CS CNE [1..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
0..* clinicalStatement
component
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
seperatableInd: BL [0..1]
entry
typeCode*: <= x_ActRelationshipEntry
contextConductionInd*: BL [1..1] "true"
Constraint: Section.text
Section.text.mediaType
fixed as "text/x-hl7-text+xml".
See section "Section Narrative
Block" for details.
0..* associatedEntity
0..* externalActChoice
reference
typeCode*: <= x_ActRelationshipExternalReference
seperatableInd: BL [0..1]
classCode*: <= ENC
moodCode*: <= x_DocumentEncounterMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActEncounterCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
0..* section
SubjectPerson
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
administrativeGenderCode: CE CWE [0..1] <= AdministrativeGender
birthTime: TS [0..1]
ExternalAct
classCode*: <= ACT
moodCode*: <= EVN
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
受診情報
Entity
classCode*: <= ENT
determinerCode*: <= INSTANCE
id: SET<II> [0..*]
code: CE CWE [0..1] <= EntityCode
desc: ED [0..1]
subject
typeCode*: <= SBJ
contextControlCode*: CS CNE [1..1] <= "OP"
awarenessCode: CE CWE [0..1] <= TargetAwareness
classCode*: <= PROC
moodCode*: <= x_DocumentProcedureMood
id: SET<II> [0..*]
code: CD CWE [0..1]
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
methodCode: SET<CE> CWE [0..*]
approachSiteCode: SET<CD> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
処置・手術
0..* participantRole
0..1 scopingEntity
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
Section
0..1 scopingOrganization
AssociatedEntity
Procedure
0..1 specimenPlayingEntity
classCode*: <= ROL
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
1..* section
0..*
classCode*: <= SPEC
id: SET<II> [0..*]
ParticipantRole
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..*
languageCommunication
物品情報
typeCode*: <= SPC
検体情報
0..1 playingEntityChoice
component
GuardianChoice
SpecimenRole
specimen
externalActChoice
classCode*: <= ENT
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
quantity: SET<PQ> [0..*]
name: SET<PN> [0..*]
desc: ED [0..1]
StructuredBody
typeCode*: <= COMP
contextConductionInd*: BL [1..1] "true"
0..1 providerOrganization
classCode*: <= SPLY
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: SET<CE> CWE [0..*] <= ActPriority
repeatNumber: IVL<INT> [0..1]
independentInd: BL [0..1]
quantity: PQ [0..1]
expectedUseTime: IVL<TS> [0..1]
0..* specimenRole
PlayingEntity
1..1 bodyChoice
component
Birthplace
classCode*: <= BIRTHPL
観察情報
Supply
typeCode*: <= PRD
転記者
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
0..1 manufacturedProduct *
product
classCode*: <= DEV
determinerCode*: <= INSTANCE
code: CE CWE [0..1] <= EntityCode
manufacturerModelName: SC CWE [0..1]
<= ManufacturerModelName
softwareName: SC CWE [0..1]
<= SoftwareName
NonXMLBody
1..1 place
0..1 birthplace
consumable
Device
0..1 location
Place
dataEnterer
typeCode*: <= PRCN
投薬情報
1..1 manufacturedProduct
製品情報
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1]
<= MaterialEntityClassType
name: EN [0..1]
lotNumberText: ST [0..1]
EntityChoice
0..1 representedOrganization
AssignedEntity
classCode*: <= PLC
determinerCode*: <= INSTANCE
name: EN [0..1]
addr: AD [0..1]
ManufacturedProduct
classCode*: <= MANU
id: SET<II> [0..*]
Material
0..1 assignedPerson
classCode*: <= SDLOC
id: SET<II> [0..*]
code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType
Organization
Criterion
0..* criterion
precondition
classCode*: <= SBADM
moodCode*: <= x_DocumentSubstanceMood
id: SET<II> [0..*]
code: CD CWE [0..1] <= SubstanceAdministrationActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: GTS [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
routeCode: CE CWE [0..1] <= RouteOfAdministration
approachSiteCode: SET<CD> CWE [0..*] <= ActSite
doseQuantity: IVL<PQ> [0..1]
rateQuantity: IVL<PQ> [0..1]
maxDoseQuantity: RTO<PQ,PQ> [0..1]
administrationUnitCode: CE CWE [0..1] <=
AdministrableDrugForm
typeCode*: <= CSM
typeCode*: <= x_EncounterParticipant
time: IVL<TS> [0..1]
HealthCareFacility
0..1 serviceProviderOrganization
0..1 assignedEntity
Place
0..* assignedEntity
encounterParticipant
location
CustodianOrganization
Note:
Observation.value has cardinality
[0..*], which doesn't show up in the
Visio representation.
SubstanceAdministration
classCode*: <= MMAT
determinerCode*: <= KIND
code: CE CWE [0..1] <=
DrugEntity
name: EN [0..1]
typeCode*: <= RESP
受診情報
typeCode*: <= LOC
classCode*: <= OBS
moodCode*: <= EVN
id: SET<II> [0..*]
languageCode: CS CNE [0..1] <= HumanLanguage
value*: ED [1..1]
LabeledDrug
AssignedEntity
0..1 representedOrganization
responsibleParty
ObservationMedia
performer
DrugOrOtherMaterial
0..1 assignedEntity
EncompassingEncounter
classCode*: <= ENC
moodCode*: <= EVN
id: SET<II> [0..*]
typeCode*: <= COMP
0..1 encompassingEncounter code: CE CWE [0..1] <= ActEncounterCode
effectiveTime*: IVL<TS> [1..1]
dischargeDispositionCode: CE CWE [0..1]
<= EncounterDischargeDisposition
typeCode*: <= REFV
0..1 manufacturerOrganization
componentOf
classCode*: <= PSN
determinerCode*: <= INSTANCE
name: SET<PN> [0..*]
0..* assignedEntity
typeCode*: <= PRF
time: IVL<TS> [0..1]
modeCode: CE CWE [0..1] <= ParticipationMode
0..1 assignedPerson
0..* consent
classCode*: <= ROIOVL
moodCode*: <= EVN
id*: SET<II> [1..*]
code*: CS CNE [1..1] <= ROIOverlayShape
value*: LIST<INT> [1..*]
subject
オーダ情報
受取者
classCode*: <=
x_InformationRecipientRole
id*: SET<II> [0..*]
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
0..1 informationRecipient
classCode*: <= OBS
moodCode*: <= EVN.CRT
code: CD CWE [0..1] <= ActCode
text: ED [0..1]
value: ANY [0..1]
interpretationCode: CE CNE [0..1] <= ObservationInterpretation
0..* observationRange
referenceRange
受診・検査
注目領域
0..1
Order
typeCode*: <= FLFS
classCode*: <= OBS
moodCode*: <= x_ActMoodDocumentObservation
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ObservationType
negationInd: BL [0..1]
derivationExpr: ST [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
repeatNumber: IVL<INT> [0..1]
languageCode: CS CNE [0..1] <= HumanLanguage
value: ANY [0..1]
interpretationCode: SET<CE> CNE [0..*]
methodCode: SET<CE> CWE [0..*]
targetSiteCode: SET<CD> CWE [0..*]
RegionOfInterest
0..* order
inFulfillmentOf
Person
ObservationRange
clinicalStatement
Observation
0..* parentDocument
0..1 representedOrganization
Person
Organization
typeCode*: <= x_ActRelationshipEntryRelationship
inversionInd: BL [0..1]
contextConductionInd*: BL [1..1] "true"
sequenceNumber: INT [0..1]
negationInd: BL [0..1]
seperatableInd: BL [0..1]
Constraint: relatedDocument.typeCode
A conformant CDA document can have a single
relatedDocument with typeCode "APND"; a single
relatedDocument with typeCode "RPLC"; a single
relatedDocument with typeCode "XFRM"; two
relatedDocuments with typeCodes "XFRM" and
"RPLC"; or two relatedDocuments with typeCodes
"XFRM" and "APND".
OrganizationPartOf
0..1 wholeOrganization
Constraint: Organizer
Act
classCode*: <= x_ActClassDocumentEntryAct
moodCode*: <= x_DocumentActMood
id: SET<II> [0..*]
code*: CD CWE [1..1] <= ActCode
negationInd: BL [0..1]
text: ED [0..1]
statusCode: CS CNE [0..1] <= ActStatus
effectiveTime: IVL<TS> [0..1]
priorityCode: CE CWE [0..1] <= ActPriority
languageCode: CS CNE [0..1] <= HumanLanguage
その他
The Organizer clone can be the source
of the component relationship or
the reference relationship, but not
the entryRelationship relationship.
関係者
classCode*: <= RoleClassAssociative
id: SET<II> [0..*]
code: CE CWE [0..1] <= RoleCode
addr: SET<AD> [0..*]
telecom: SET<TEL> [0..*]
Person
typeCode*: <= ParticipationType
functionCode: CE CWE [0..1] <= ParticipationFunction
contextControlCode*: CS CNE [1..1] <= "OP"
time: IVL<TS> [0..1]
0..1 associatedPerson
ヘッダ部
叙述部
エントリー部
外部
参照部
46
CDA XMLファイル構成
CDA XML文書
CDA.xsd
POCD_MT000040.xsd
coreschemas
datatypes.xsd
POCD_MT000040JP00.xsd
datattypes‐base.xsd
refVoc.xsd
InfrastructureRoot.xsd
CDA xsl
voc.xsd
narrative.xsd
47
本規格は以下の部分でCDAの原則とは異なる
1.
可読性はCDA文書と共に特殊なスタイルシートを提供する
よう送信者に要求してはならない。全てのCDA文書は一つ
のスタイルシートと一般的な市場で入手し得る表示ツール
で表現できなければならない
•
•
2.
本規格では診療情報提供書の提供者が責任
を持って表示ツールを提供すること
提供書を受信側で表示漏れが発生しないよう
全ての内容が表示可能であること
可読性は認証済みの内容に適用する。認証されておらず
表示される必要のない本質的に機械処理のためにある文
書の付加情報をもつ可能性がある
•
CDA
Schema
XSL
Ext.
Doc
Viewer
提供者は原則として診療情報提供書に記載
されている内容およびスタイルシート、ビュー
アなどの添付書類を含め、全ての情報に対し
認証する。
48
叙述部と構造化部は共に独立した記述とする
3.
4.
構造化された内容が叙述部から導出されている場
合は、叙述部から導出した機械処理可能な部分に
よりプロセス（例：著者、コーディング者、自然言語
処理アルゴリズム、特殊なソフトウェア）を記述する
ためのメカニズムが存在しなければならない
叙述部が構造化された内容から導出されている場
合は、叙述部が構造化されたデータから生成され
たというプロセスを識別するためのメカニズムが存
在しなければならない
叙述部は自然言語記述を含み定形化できない全て
を記述する
叙述部と構造化部は独立して両者とも見読性を持
ちコンピュータ処理が可能
Narrative
Human
Structured
Computer
Narrative
Human
(Natural language)
Structured
Computer
49
記述例(紹介状)
50
記述例(逆紹介)
51
記述例(患者情報提供書)
52
本論はレベル２までで記載
Semanticの相互利用性を図るにはレベル３までの記述が必要だが
検査などを除いてコード体系が未整備
レベル３で出力できるシステムが無く、新規開発要素が大きい
レベル３で受け取っても受信サイドのシステムで内部展開できるほどメッセー
ジ交換は成熟していない
V1.0では（WEB等で実績のある）文字検索などで利用できるよう規定する
レベル２でも記述項目内容のばらつきが大きい
未定義部分はレベル１でも問題がないこと
記載部分は十分参照できるようスタイルシートなど整備する
検査などは外部ドキュメントとしてV2.5等メッセージ交換として実績のある方法を取る
53
本規格 （V1)では一部を除いてレベル２で記述
Semanticな相互利用性を行うにはレベル３までの記述が必要だが
検査等の一部を除いてコード体系・規格が未整備
レベル３で出力・受信できるシステムが無い
新規開発要素が大きく現状では多大な投資になる
将来へ向かったシステムが重要
標準化されていないバラバラのシステムの展開を防止
レベル１，２（Narrative部）は将来も残りうる
将来も自然言語の記述は残る
将来のシステムからも重要な情報として必要になる
将来を見た実装・データの活用が可能である
今後技術・規格化の推移に沿ってSemanticな利用、Ontologyを生かした記述の可能性へ
54
ISO/HL7 27932:2009
Data Exchange Standards -- HL7 Clinical Document Architecture, Release 2
HELICS
HS007 患者診療情報提供書及び電子診療データ提供書（患者への情報提供）
HS008 診療情報提供書（電子紹介状）診療情報提供書（電子紹介状）
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違い棚に 金盥に 鹿爪らしく 齎らして 悦ばせに 遠奔千走 鬱

399KB - Yamaha

医療・社会福祉施設における熱的快適性に関する研究 - 西村研究室

ダウンロード - 東京工業大学

resultados_jornada

A-DECORADOS HYUNDAI

PACKING LIST/ パッキングリスト / 装箱单 - Kikusui Electronics Corp.

ダウンロード - フナコシ

ISPS 関連のPSC指摘欠陥 （Class NK &amp

Positive Control Template SE1 - タカラバイオ株式会社 遺伝子工学研究