Specification - Extended

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

Document Description

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

Existing Wording

The Consult Note, Referral Note, and Transfer Summary document templates have a subtle inconsistency in their conformance statements for the ClinicalDocument/code. Every other document template whose code comes from a specific value set is written like this: (Discharge Summary, R2.1) 3. SHALL contain exactly one [1..1] code (CONF:1198-17178). a. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet DischargeSummaryDocumentTypeCode urn:oid:2.16.840.1.113883.11.20.4.1 DYNAMIC (CONF:1198-17179). But for the three templates mentioned above, it's written like this instead: (Consult Note, R2.1) 3. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ConsultDocumentType urn:oid:2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:1198-17176). I think this difference actually matters, because (as I understand it) the wording in the first case explicitly prohibits a code/@nullFlavor, whereas in the second, it would be allowed (ie it SHALL be selected from ConsultDocumentType if you have a @code, but if you don't then that's okay too). In any case, it's also inconsistent with the wording in C-CDA R1.1, so if these different wordings actually do have different meanings, then we're breaking backwards compatibility. (Consult Note, R1.1) 3. SHALL contain exactly one [1..1] code (CONF:17176). a. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ConsultDocumentType 2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:17177). (The Referral Note and Transfer Summary templates don't exist in R1.1, so those aren't as worrisome, but the different wording is still unusual there.)

Proposed Wording

(Consult Note, R2.1) 3. SHALL contain exactly one [1..1] code (CONF:1198-17176). a. This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ConsultDocumentType urn:oid:2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:1198-17177).