Consolidated CDA July 2012 Errata

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A. Errata Approved to December 21, 2012

(Items on this list were approved for inclusion through a SDWG vote).

At 21 December 2012, SDWG had reviewed items through #168 on the DSTU Comments page. Some were approved and some were reserved to the next ballot. The approved items are summarized below, and were incorporated in the Errata Package issued January 22, 2013.

Items 1-20 are shown both as originally recorded on this page and with the numbering assigned by the DST Comments page.

1. Published IG states "HL7 Data Types Release 1 requires the codeSystem attribute unless the underlying data type is Coded Simple or CS, in which case it is prohibited. The displayName and the codeSystemName are optional, but recommended, in all cases".

• Because displayName and codeSystemName are prohibited in CS data type, the recommendation only applies where the data type is NOT CS (e.g. CE or CD).

2. Section 1.8.1, Table "Constraints format example", shows that template constraints are presented in various formats in order to meet different user needs. We have found a handful of discrepancies between the constraints enumerated in the tables and the corresponding constraints enumerated in the list of constraints following each table. We have identified the source of discrepancies, which will resolve this issue in future publications. For now, we declare that the constraints enumerated in the list are the source of truth, and take precedence over the constraints enumerated in the table. We will include this declaration in future implementation guides. Specific discrepancies identified include:

• Table "Comment Activity Constraints Overview" incorrectly lists and links to CONF 9430 and 9431, which do not exist.
• Table "Family History Organizer Constraints Overview" incorrectly lists and links to CONF 8610, 8611, 8613, 8614, and 8615, which do not exist.
• Table "Referenced Frames Observation Constraints Overview" incorrectly lists and links to CONF 15923, which does not exist.

3. Table "Template Ids Alphabetically by Template Type"

• Lists an Implants Section template, which does not exist (see Procedure Implants Section instead).
• Lists a Surgery Description Section template, which does not exist (see Procedure Description Section instead).

4.The implementation is full of constraints like the following: (reviewed and approved on the Sept 20, 2012 SDWG call)

• SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC) (CONF:7321).

Which imply that statusCode should directly contain the string "completed" (i.e. <statusCode>completed</statusCode>) when what is wanted is statusCode/@code="completed" (i.e. <statusCode code="completed"/>) )

5.The medications section contains the following constraint: (reviewed and approved on the Sept 20, 2012 SDWG call)

• SHALL contain exactly one [1..1] title="Medications" (CONF:7793).

other sections do not constrain their titles to a fixed string. This is an error and the correct conformance statement should be this:

• SHALL contain exactly one [1..1] title (CONF:7793).

6.There are many constraints on code elements (observation/code, etc.) requiring @xsi:type to be present when that was not the intent. For example: (reviewed and approved on the Sept 20, 2012 SDWG call)

• SHALL contain exactly one [1..1] code="11323-3" Health status with @xsi:type="CE" (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:9073).

These were data entry errors. There was no intent to require @xsi:type to be present and constrain it to anything other than the default datatype for applicable code element.

7.Inconsistent use of serviceEvent/performer/@typeCode. There are several single value bindings for typeCode throughout consolidation. The general header constraints require "PRF" (Participation physical performer, see conf 14840), but other document type specific header constraints require other codes like "PPRF" (Primary Performer, see conf 8495). SDWG agreed to remove the single value binding from CONF 14840 in the general header constraints, allowing all document types to use whatever codes are appropriate. (Reviewed and approved on the Nov 1, 2012 SDWG call).

8. The H&P constains the following constraint: SHALL contain exactly one [1..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) (CONF:9627). However, this conflicts with CONF 10057 if a "Chief Complaint and Reason for Visit" section is present, which states: SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section. (CONF:10057) . SDWG agreed that CONF 9627 will be removed, and a new constraint will be added that states SHALL either have a "Chief Complaint and Reason for Visit" or separate "Chief Complaint" and "Reason for Visit" sections. (Reviewed and approved on the Nov 1, 2012 SDWG call).

9. Update the heading in the Consultation Note LOINC Document Codes from "Root Level Document Type Code" to "Preferred Code" to align with the other tables. (Reviewed and approved on the Nov 1, 2012 SDWG call).

10. Conf 8903 makes act/code optional, which violates the base CDA spec, which requires 1..1 act/code. "SHOULD contain zero or one [0..1] code with @xsi:type="CE" (CONF:8903)". should be changed to "SHALL contain exactly [1..1] code (CONF:8903)". (Reviewed and approved on the Nov 1, 2012 SDWG call).

11. There are several places in the IG where the "sdwg" namespace prefix is referenced (Conf 2763 and conf 8933). These are typos, and the correct namespace prefix is "sdtc". (Reviewed and approved on the Nov 1, 2012 SDWG call).

12. Several conformance statements (14396,14798, etc.) are missing their value set bindings (i.e. STATIC or DYNAMIC). Recommend adding the value set bindings present in the value set tables at the value set tables. For example: "SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHOULD be selected from ValueSet Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 (CONF:14396)" should be "SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHOULD be selected from ValueSet Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 DYNAMIC (CONF:14396)" (Reviewed and approved on the Nov 1, 2012 SDWG call).

13. For informant, the following constraint is present. "SHALL contain exactly one [1..1] assignedEntity OR exactly one [1..1] relatedEntity (CONF:8002)" followed by this: "SHOULD contain zero or more [0..*] id (CONF:9945 )". Conf 9945 does not indicate whether this applies to assignedEntity or relatedEntity. Assigned entity requires one or more ids according to the CDA schema, and relatedEntity allows no id elements at all. Conf 9945 will be changed to a SHALL constraint that applies only to assignedEntity.

14. Smoking Status Observation templateId and value set OIDs are incorrect (Reviewed and approved on the Nov 29, 2012 SDWG call).

• Update template from 2.16.840.1.113883.10.22.4.78 to 2.16.840.1.113883.10.20.22.4.78
• Update value set reference in CONF:14817 to Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2012-07-01
• Also update Fig 239: 2.16.840.1.113883.10.22.4.9999 should be 2.16.840.1.113883.10.20.22.4.78.

15. In Consolidation AssignedAuthor ID is required to be an NPI

• AssignedAuthor ID is the ID for both Person and AuthoringDevice in the base standard
• Therefore Consolidation requires devices to have NPIs
• Devices don’t have NPIs (only providers and organizations)

16. In Procedure Activity Act [act: templateId 2.16.840.1.113883.10.20.22.4.12(open)] The following conf statement exists (Reviewed and approved on the Nov 29, 2012 SDWG call):

• This code in a procedure activity observation SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:8294).

Should be:

• This code in a procedure activity act SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:8294).

17. Update conformance 14321 in the Cognitive Status Problem Observation From (Reviewed and approved on the Nov 29, 2012 SDWG call):

• SHALL contain exactly one [1..1] id (CONF:14321)

To:

• SHALL contain at least one [1..*] id (CONF:14321)

18. "Allergy - Intolerance Observation" conforms to a template that is not referenced anywhere else in the IG. Conforms to Substance or Device Allergy - Intolerance Observation template (2.16.840.1.113883.10.20.24.3.90). The Substance or Device Allergy - Intolerance Observation template definition will be included in the errata package to be delivered in Dec 2012. (Reviewed and approved on the Nov 29, 2012 SDWG call)

19. Most of consolidation follows a pattern where SHOULD constraints have a minimum cardinality of zero, but several constraints (conf 7290, 8385, etc.) do not follow this pattern:

• SHOULD contain exactly one [1..1] @use, which SHALL be selected from ValueSet PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 (CONF:7290).

The min cardinality for SHOULD constraints will be made consistent throughout the document and set to 0. (Reviewed and approved on the Nov 29, 2012 SDWG call)

20. Update Conformance 15247 (in Family History Organizer) from

• This code SHALL contain zero or one [0..1] @code, which SHOULD be selected from ValueSet FamilyHistoryRelatedSubjectCode 2.16.840.1.113883.1.11.19579 DYNAMIC (CONF:15247).

to

• This code SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet FamilyHistoryRelatedSubjectCode 2.16.840.1.113883.1.11.19579 DYNAMIC (CONF:15247).

(new numbering sequence starts here)

58. The Substance or Device Allergy - Intolerance Observation template (2.16.840.1.113883.10.20.24.3.90) was omitted from the IG.

60. In the example code for Immunization Refusal Reason (2.16.840.1.113883.10.20.22.4.53), correct the value-set OID.

63. In the CCD sample file, in the illustration of a refused immunization, correct @negationInd on substanceAdministration from false to true.

64. Throughout, correct the data-entry error that requires xsi:type='CE' on code and similar elements where that was not the intent.

66. In the Medications Section, do not constrain the title to a fixed string.

67. Throughout, correct the legacy form "statusCode='completed'" to make @code explicit.

72. Throughout, where a value-set binding is missing, update the constraint to match the binding shown in the value-set table.

73. In the US Realm Header (2.16.840.1.113883.10.20.22.1.1), for informant, update the constraint so that it does not require an id in relatedEntity which does not allow an id.

74. In the US Realm Header (2.16.840.1.113883.10.20.22.1.1), in serviceEvent/performer, remove the constraint on @typeCode, so that a document type can specify the values appropriate to that document type.

76. In the History and Physical document (2.16.840.1.113883.10.20.22.1.3), change the requirement for a "Reason for Visit Section" from SHALL to MAY, since this section is not allowed when a "Chief Complaint and Reason for Visit Section" is present.

78. Duplicate of 58.

79. In Policy Activity (2.16.840.1.113883.10.20.22.4.61), correct the requirement for act/code from SHOULD to SHALL, conformant to CDA.

80. In the example code for Medication Information (2.16.840.1.113883.10.20.22.4.23), verify that the medication code is a member of the value set.

81. Throughout, update the namespace prefix sdwg to sdtc.

85. In the IG, in the table listing LOINC codes for Consultation Note (2.16.840.1.113883.10.20.22.1.4), correct the column heading from "Root Level Document Type Code" to "Preferred Code".

86. In the constraints table for Policy Activity (2.16.840.1.113883.10.20.22.4.61), correct the phrase "resultId" to "policyId".

87. In Smoking Status Observation (2.16.840.1.113883.10.20.22.4.78), correct the templateId from 2.16.840.1.113883.10.22.4.78 to 2.16.840.1.113883.10.20.22.4.78, and correct the value-set reference to Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2012-07-01

88. In the example code for Allergy - Intolerance Observation (2.16.840.1.113883.10.20.22.4.7), correct the code and value to match the constraints, i.e. code ASSERTION and a value from the value set.

89. In the Cognitive Status Problem Observation (2.16.840.1.113883.10.20.22.4.73), for id, correct the bounds from 1..1 to 1..*

90. Throughout, correct the representation of @unit, from @unit='1' to simply @unit.

95. In the example code for Allergy - Intolerance Observation (2.16.840.1.113883.10.20.22.4.7), correct the code to be a member of the value set.

96. In 4 references to the Result Observation and Result Organizer, correct "Results" to "Result".

97. In the Constraints table for Tobacco Use Observation (2.16.840.1.113883.10.20.22.4.85), correct the templateId to match the constraint.

100. Duplicate of 90.

102. In Procedure Activity Act (2.16.840.1.113883.10.20.22.4.12), in narrative constraint 8294, correct the phrase "procedure activity observation" to "procedure activity act".

106. (no content)

107. In the CCD sample file, in Health Status Observation (2.16.840.1.113883.10.20.22.4.5), correct the code to be a member of the value set.

143. In Procedure Activity Act, Procedure Activity Observation, and Procedure Activity Procedure, allow more than one entryRelationship/substanceAdministration. (2.16.840.1.113883.10.20.22.4.12, 2.16.840.1.113883.10.20.22.4.13, and 2.16.840.1.113883.10.20.22.4.14)

144. Resolve discrepancies in names and codeSystem OIDs for ICD categories.

145. In the example code for Problem Observation (2.16.840.1.113883.10.20.22.4.4), add @xsi:type='CD' to the value element.

146. Duplicate of 90.

147. In Operative Note (2.16.840.1.113883.10.20.22.1.7), for the description of clinicalDocument/code, correct the reference to Discharge Summary.

150. In each document-level template, record the constraint "1. Conforms to US Realm Header template (2.16.840.1.113883.10.20.22.1.1)."

152. In the US Realm Header (2.16.840.1.113883.10.20.22.1.1), for custodian, change the bounds for addr from 1..* to 0..1, conformant to CDA.

154. Throughout, correct SHALL 0..1 to SHALL 1..1.

156. In three templates, supply a missing value conformance: Advance Directive (2.16.840.1.113883.10.20.22.4.48, CONF 8651); Immunization Refusal Reason (2.16.840.1.113883.10.20.22.4.53, CONF 8995); Vital Sign Observation (2.16.840.1.113883.10.20.22.4.27, CONF 7301)

157. In Policy Activity (2.16.840.1.113883.10.20.22.4.61) remove CONF:8924 which is superceded by th adjacent CONF:16078.

158. Throughout, identify where isBranch flag is missing and supply it. Note: This item was not fully implemented in the January 2013 errata package.

162. In Encounter Activities (2.16.840.1.113883.10.20.22.4.49), restore the constraint which specifies the value of the templateId.

165. In Policy Activity (2.16.840.1.113883.10.20.22.4.61), for playingEntity/name, clarify the guidance in the constraint and move it into an annotation.

166. In Family History Organizer (2.16.840.1.113883.10.20.22.4.45), for relatedSubject/subject, move the constraint for sdtc:id into CDA order. Note: This item was not implemented in the January 2013 errata package.

168. General allowance for aligning example code or sample file with constraints, and narrative block in a sample file with coded entries.