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Section 3.6 Family History
- Section 3.6.3 Extension contains the sentence "The family history section extends the CDA R2 model with the addition of Subject / id, SubjectPerson / deceasedInd, and SubjectPerson / deceasedTime." The two "SubjectPerson" references are incorrect and should be "subject". The correct sentence is "The family history section extends the CDA R2 model with the addition of subject / id, subject / deceasedInd, and subject / deceasedTime."
Section 3.8 Alerts
- Section 188.8.131.52.1.2 Severity Observation - Should include a statement that InversionInd is needed here.
Section 3.12 Vital Signs
- Section 3.12.2 contains a sentence "Vital signs are represented like other results (as defined in section 3.13 Results), with additional vocabulary constraints", which should be changed to "Vital signs are represented like other results (as defined in section 3.13 Results)".
Section 3.14 Procedures
- Section 184.108.40.206, conformance statement 448 should be "a procedure activity MAY have one or more [Act | Observation | Procedure] / participant, the target of which is a product instance template" rather than "a procedure activity MAY have one or more [Act | Observation | Procedure] / participant [@typeCode=”DEV”], the target of which is a product instance template". Participant/@typeCode should not have been restricted to "DEV" when connecting to a product instance template.
Section 5.5 Terminology Conformance
- Table 18 shows an incorrect codeSystem OID for ICD9CM. The incorrect value in the table is "2.16.840.1.113883.6.1". The correct value is "2.16.840.1.113883.6.103".
Section 7.1 Sample
- The sample instance incorrectly asserts a null value for informant / assignedEntity / id, which is mandatory and therefore cannot be null.
- The sample instance contains an incorrect representation of Guarantor, and the following snippet should be removed:
<participant typeCode="IND"> <associatedEntity classCode="GUAR"> <id root="4ff51570-83a9-47b7-91f2-93ba30373141"/> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> </addr> <telecom value="tel:(888)555-1212"/> <associatedPerson> <name> <given>Kenneth</given> <family>Ross</family> </name> </associatedPerson> </associatedEntity> </participant>
- The CCD rendering style sheet incorrectly renders the above snippet as the Guardian. Per CONF-109 ("A patient guardian SHALL be represented with ClinicalDocument / recordTarget / patientRole / patient / guardian"), the style sheet should look to ClinicalDocument / recordTarget / patientRole / patient / guardian for rendering guardian information.
The 2.16.840.1.1138220.127.116.11.21.ent file inappropriately requires that all entryRelationships underneath encounter entries with templateId 2.16.840.1.113818.104.22.168.21 contain @typeCode="RSON". This is a misinterpretation of the following conformance statement which only indicates that you MAY include an indication entryRelationship. It does not preclude other entryRelationships, such as comments or diagnosis which could have other typeCodes.
- An encounter activity MAY contain one or more Encounter / entryRelationship, whose value for "entryRelationship / typeCode" SHALL be "RSON" "Has reason" 2.16.840.1.113883.5.1002 ActRelationshipType STATIC, where the target of the relationship represents the indication for the activity.
Approved SDWG motion 4/16/2015: CCD did not intend to apply this constraint to all encounter/entryRelationships. The Schematron error/warning is inappropriate.