# CDA - clinicalDocument - ANS IG document core v0.1.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **CDA - clinicalDocument**

## Logical Model: CDA - clinicalDocument 

| | |
| :--- | :--- |
| *Official URL*:https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-clinical-document | *Version*:0.1.0 |
| Draft as of 2025-12-15 | *Computable Name*:FRCDAClinicalDocument |

 
L’élément de l’en-tête CDA ‘ClinicalDocument’ est l’élément racine d’un document médical. 

**Utilisations:**

* Ce Profil de modèle logique nest utilisé par aucun profil dans ce guide dimplémentation

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/ans.document.fr.core|current/StructureDefinition/fr-cda-clinical-document)

### Formal Views of Profile Content

 [Description of Profiles, Differentials, Snapshots and how the different presentations work](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](StructureDefinition-fr-cda-clinical-document.csv), [Excel](StructureDefinition-fr-cda-clinical-document.xlsx) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "fr-cda-clinical-document",
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/tools/StructureDefinition/logical-target",
      "_valueBoolean" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
            "valueCode" : "not-applicable"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/tools/StructureDefinition/xml-namespace",
      "valueUri" : "urn:hl7-org:v3"
    },
    {
      "url" : "http://hl7.org/fhir/tools/StructureDefinition/xml-name",
      "valueString" : "ClinicalDocument"
    },
    {
      "url" : "http://hl7.org/fhir/tools/StructureDefinition/type-profile-style",
      "valueUri" : "cda"
    },
    {
      "url" : "http://hl7.org/fhir/tools/StructureDefinition/logical-container",
      "valueUri" : "http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument"
    }
  ],
  "url" : "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-clinical-document",
  "version" : "0.1.0",
  "name" : "FRCDAClinicalDocument",
  "title" : "CDA - clinicalDocument",
  "status" : "draft",
  "date" : "2025-12-15T10:54:30+00:00",
  "publisher" : "Agence du Numérique en Santé (ANS) - 2-10 Rue d'Oradour-sur-Glane, 75015 Paris",
  "contact" : [
    {
      "name" : "Agence du Numérique en Santé (ANS) - 2-10 Rue d'Oradour-sur-Glane, 75015 Paris",
      "telecom" : [
        {
          "system" : "url",
          "value" : "https://esante.gouv.fr"
        }
      ]
    }
  ],
  "description" : "L'élément de l'en-tête CDA 'ClinicalDocument' est l’élément racine d’un document médical.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "FR",
          "display" : "FRANCE"
        }
      ]
    }
  ],
  "fhirVersion" : "4.0.1",
  "mapping" : [
    {
      "identity" : "rim",
      "uri" : "http://hl7.org/v3",
      "name" : "RIM Mapping"
    }
  ],
  "kind" : "logical",
  "abstract" : false,
  "type" : "http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument",
  "baseDefinition" : "http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument",
  "derivation" : "constraint",
  "differential" : {
    "element" : [
      {
        "id" : "ClinicalDocument",
        "path" : "ClinicalDocument",
        "constraint" : [
          {
            "key" : "FRCDAPerformerRequire",
            "severity" : "error",
            "human" : "performer est obligatoire et son attribut nullFlavor interdit pour l’évènement documenté principal",
            "expression" : "documentationOf.serviceEvent.performer.count() >= 1",
            "source" : "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-clinical-document"
          }
        ]
      },
      {
        "id" : "ClinicalDocument.realmCode",
        "path" : "ClinicalDocument.realmCode",
        "short" : "Type de consentement Périmètre d’utilisation : France.",
        "min" : 1,
        "max" : "1"
      },
      {
        "id" : "ClinicalDocument.typeId",
        "path" : "ClinicalDocument.typeId",
        "short" : "Référence au standard CDA R2.",
        "min" : 1
      },
      {
        "id" : "ClinicalDocument.templateId",
        "path" : "ClinicalDocument.templateId",
        "short" : "Déclarations de conformité.",
        "min" : 3
      },
      {
        "id" : "ClinicalDocument.id",
        "path" : "ClinicalDocument.id",
        "short" : "Identifiant unique du document."
      },
      {
        "id" : "ClinicalDocument.code",
        "path" : "ClinicalDocument.code",
        "short" : "Type de document."
      },
      {
        "id" : "ClinicalDocument.title",
        "path" : "ClinicalDocument.title",
        "short" : "Titre du document.",
        "min" : 1
      },
      {
        "id" : "ClinicalDocument.effectiveTime",
        "path" : "ClinicalDocument.effectiveTime",
        "short" : "Date et heure de création du document."
      },
      {
        "id" : "ClinicalDocument.confidentialityCode",
        "path" : "ClinicalDocument.confidentialityCode",
        "short" : "Niveau de confidentialité du document."
      },
      {
        "id" : "ClinicalDocument.languageCode",
        "path" : "ClinicalDocument.languageCode",
        "short" : "Langue principale du document.",
        "min" : 1
      },
      {
        "id" : "ClinicalDocument.setId",
        "path" : "ClinicalDocument.setId",
        "short" : "Identifiant du lot de versions du même document.",
        "min" : 1
      },
      {
        "id" : "ClinicalDocument.versionNumber",
        "path" : "ClinicalDocument.versionNumber",
        "short" : "Numéro de version du document.",
        "min" : 1
      },
      {
        "id" : "ClinicalDocument.copyTime",
        "path" : "ClinicalDocument.copyTime",
        "max" : "0"
      },
      {
        "id" : "ClinicalDocument.recordTarget",
        "path" : "ClinicalDocument.recordTarget",
        "short" : "Patient/Usager concerné par le document.",
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/RecordTarget",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-record-target"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.author",
        "path" : "ClinicalDocument.author",
        "short" : "Professionnel ou patient/usager ou système, auteur du document incluant la structure de rattachement de l'auteur.",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/Author",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-author"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.dataEnterer",
        "path" : "ClinicalDocument.dataEnterer",
        "short" : "Opérateur de saisie.",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/DataEnterer",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-data-enterer"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.informant",
        "path" : "ClinicalDocument.informant",
        "short" : "Informateur (informant), ayant fourni des informations utiles aux actes en rapport avec la production du document.",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/Informant",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-informant"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.custodian",
        "path" : "ClinicalDocument.custodian",
        "short" : "Structure conservant le document et garantissant son cycle de vie.",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/Custodian",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-custodian"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.informationRecipient",
        "path" : "ClinicalDocument.informationRecipient",
        "short" : "Destinataire prévu du document.",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/InformationRecipient",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-information-recipient"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.legalAuthenticator",
        "path" : "ClinicalDocument.legalAuthenticator",
        "short" : "Professionnel ou patient/usager ou système responsable du document.",
        "min" : 1,
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/LegalAuthenticator",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-legal-authenticator"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.authenticator",
        "path" : "ClinicalDocument.authenticator",
        "short" : "Professionnel attestant la validité du document",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/Authenticator",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-authenticator"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.participant",
        "path" : "ClinicalDocument.participant",
        "short" : "Participant, différent de l'auteur, du responsable, de l'opérateur de saisie, de l'informateur ou du destinataire.",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/Participant1",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-participant"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.inFulfillmentOf",
        "path" : "ClinicalDocument.inFulfillmentOf",
        "short" : "Prescription",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-inFulfillment-of"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.documentationOf",
        "path" : "ClinicalDocument.documentationOf",
        "short" : "Evènement documenté et notamment le cadre d'exercice.",
        "min" : 1,
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-documentation-of"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.relatedDocument",
        "path" : "ClinicalDocument.relatedDocument",
        "short" : "Document de référence (à remplacer, transformé, …).",
        "max" : "1",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/RelatedDocument",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-related-document"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.authorization",
        "path" : "ClinicalDocument.authorization",
        "short" : "Consentement associé au document.",
        "type" : [
          {
            "code" : "http://hl7.org/cda/stds/core/StructureDefinition/Authorization",
            "profile" : [
              "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-cda-authorization"
            ]
          }
        ]
      },
      {
        "id" : "ClinicalDocument.componentOf",
        "path" : "ClinicalDocument.componentOf",
        "short" : "Prise en charge du patient/usager et notamment la date et le secteur d'activité.",
        "min" : 1
      }
    ]
  }
}

```
