The CDA Header begins immediately under the ClinicalDocument root element and continues up to the component/nonXMLBody or component/structuredBody element that begins the CDA Body.

The CDA Header contains a series of XML elements nested directly under ClinicalDocument that help identify and classify the document (elements marked with * are required):

  • id*: A unique identifier for the document
  • typeId*: A “document type” identifier – for all C-CDA documents this is:
    <typeId root=”2.16.840.1.113883.1.3″ extension=”POCD_HD000040″/>
  • code*: A LOINC code that indicates what type of document this is (e.g. Discharge Summary, Progress Note, etc.)
  • title: Descriptive title (may be self-evident from ClinicalDocument/code)
  • templateId: Identifiers of the document templates and header templates used

Another set of XML elements nested directly under ClinicalDocument provide basic document information (elements marked with * are required):

  • effectiveTime*: Time-stamp when original document was created.
  • confidentialyCode*: N=Normal, R=Restricted, V=Very Restricted
  • realmCode: Allows for geographical variance. For MU2 C-CDA: <realmCode code=”US”/>
  • languageCode: Uses IETF code such as en-US for US English
  • setId, versionNumber: For management of multiple versions

Yet another set of XML elements nested directly under ClinicalDocument provide information about the involved parties (elements marked with * are required):

  • recordTarget*: the patient referenced in the document. See recordTarget article for additiona information.
  • author*: person/machine that created document content
  • dataEnterer: transcriptionist
  • informant: person who provided information (e.g. family member of patient who could not speak)
  • custodian*: organization that maintains the document
  • informationRecipient: person who should get a copy
  • legalAuthenticator: person who formally signs-off
  • authenticator: attests to accuracy, but no legal standing
  • participant: other involved parties

The element ClinicalDocument/documentationOf/serviceEvent declares the primary “service event” and when it took place, as well as the performers of the activity.

Additional optional XML elements in the CDA Header, nested directly under ClinicalDocument, include:

  • inFulfillmentOf/order: Order being fulfilled by this document (e.g. X-Ray order for a Diagnostic Imaging Report)
  • authorization/consent: Various “consents” relevant to the document (e.g. consent to perform procedure being documented)
  • componentOf/encompassingEncounter: Clinical encounter during which the “Service Event” occurred (e.g. hospital stay)
  • relatedDocument/parentDocument: Allows the document to be declared as a revision (append/replace/transform) of a previous document

Other CDA PRO Know Articles Referenced In This Article

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