United States Health Information Knowledgebase

 

Personal Information

Reference:2.2.2.1
Definition:Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5
OID:2.16.840.1.113883.3.88.11.83.1
CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
/cda:ClinicalDocument/cda:effectiveTime 1.01 - Document Timestamp R/N
/cda:ClinicalDocument/cda:recordTarget/cda:patientRole Patient Information Entry R/N
cda:id 1.02 - Person ID R/N
cda:addr 1.03 - Person Address R/Y 2.2.2.1.2
cda:telecom 1.04 - Person Phone /Email /URL R/Y 2.2.2.1.3
cda:patient Personal Information
cda:name 1.05 - Person Name R/Y 2.2.2.1.1
cda:administrativeGenderCode/@code 1.06 - Gender R/N 2.2.2.1.4
cda:birthTime 1.07 - Person Date of Birth R/N
cda:maritalStatusCode/@code 1.08 - Marital Status R2/Y 2.2.2.1.5
cda:religiousAffiliationCode/@code 1.09 - Religious Affiliation O/N 2.2.2.1.8
cda:raceCode/@code
sdtc:raceCode/@code 1.10 - Race O/Y 2.2.2.1.6
cda:ethnicGroupCode/@code 1.11 - Ethnicity O/N 2.2.2.1.7
cda:birthplace/cda:place/cda:addr 1.16 - Birth Place O/N 2.2.2.1.9
1.12 - Mother's Maiden Name See Section 2.2.2.3 Support
1.13 - Multiple Birth Indicator Family History
1.14 - Birth Order Family History
1.15 - Age Family History

Optionality Legend: “R” for Required, “R2” for Required if known, “O” for Optional and Repeat = “Y” for Yes or “N” for No


Section ID Constraint ID Definition
2.2.2.1.1 Person Name Constraints The HL7 Clinical Document Architecture indicates how names are to be represented. A person's name appears in a <name> element, as a collection of name parts.
C83-[DE-1.05-CDA-10] A prefix or suffix that is an academic title or credential SHALL be identified by the inclusion of a qualifier attribute containing the value "AC" on the name part
C83-[DE-1.05-CDA-1] Each name part SHALL be identified using one of the tags <given>, <family>, <prefix> or <suffix>
C83-[DE-1.05-CDA-2] The "first" name of the patient SHALL appear in the first <given> tag. In example 1 given below, "Margaret" is the patient's first name
C83-[DE-1.05-CDA-3] The "middle" name of the patient, if it exists, SHALL appear in the second <given> tag. In example 1 given below, "Ross" is the patient's middle name
C83-[DE-1.05-CDA-4] Name parts within a <name> tag SHALL be ordered in proper display order
C83-[DE-1.05-CDA-5] At most one <name> tag SHALL have a use attribute containing the value "L", indicating that it is the legal name of the patient
C83-[DE-1.05-CDA-6] More than one <name> tag MAY be present to retain birth name, maiden name and aliases
C83-[DE-1.05-CDA-7] An alias or former name MAY be identified by the inclusion of a use attribute containing the value "P"
C83-[DE-1.05-CDA-8] Name parts MAY be identified as being a name given at birth or adoption by the inclusion of a qualifier attribute containing the value "BR" for birth or "AD" for adoption
C83-[DE-1.05-CDA-9] A name part SHALL be identified as the patient's preferred name by the inclusion of a qualifier attribute containing the value "CL" on the name part

Person Name Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<name use="L">
<prefix qualifier="AC">Dr.</prefix>
<given>Margaret</given>
<given>Ross</given>
<family>Ellen</family>
</name>
<!-- example 2 -->
<name use="P">
<given qualifier="CL">Meg</given>
<family>Ellen</family>
</name>
<!-- example 3 -->
<name use="P">
<given>Margaret</given>
<given qualifier="BR">Josephine</given>
<family qualifier ="BR">Ross</family>
</name>
<!-- example 4 -->
<name use="P">
<prefix use="AC">Dr.</prefix>
<given>Margaret</given>
<given>Josephine</given>
<family qualifier="BR">Ross</family>
</name>
2.2.2.1.2 Address Constraints The HL7 Clinical Document Architecture indicates how addresses are to be represented. An address appears in a <addr> element, as a collection of address parts
C154--[DE-1.03-3] The <country> SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
C154-[DE-1.03-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-1.03-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
C83-[DE-1.03-CDA-10] A work address SHALL be recorded with a use attribute containing the value "WP"
C83-[DE-1.03-CDA-1] For the address parts that are known, they SHALL be identified using the <streetAddressLine>, <city>, <state>, <postalCode> and <country> tags
C83-[DE-1.03-CDA-2] More than one <streetAddressLine> MAY be present
C83-[DE-1.03-CDA-3] No more than four <streetAddressLine> elements SHALL be present
C83-[DE-1.03-CDA-4] The <country> element SHALL be present for addresses outside of the United States
C83-[DE-1.03-CDA-5] At most one address for a person SHALL have a use attribute with a value containing "HP"
C83-[DE-1.03-CDA-6] At least one address for a patient SHOULD have a use attribute with a value containing "HP"
C83-[DE-1.03-CDA-7] One or more vacation addresses MAY be present for a person
C83-[DE-1.03-CDA-8] A vacation address SHALL be recorded with a use attribute containing the value "HV"
C83-[DE-1.03-CDA-9] One or more work addresses MAY be present

Address Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<addr use="HP">
<streetAddressLine>17 Daws Road</streetAddressLine>
<city>Blue Bell</city> <state>MA</state> <postalCode>00000</postalCode>
<country>US</country>
</addr>
<!-- example 2 -->
<addr use="HV">
<streetAddressLine>41 IDX Dr </streetAddressLine>
<city>South Burlington </city> <state>VT</state> <postalCode>05403</postalCode>
<country>US</country>
</addr>
<!-- example 3 -->
<addr use="WP">
<streetAddressLine>116 Huntington Ave</streetAddressLine>
<streetAddressLine>2nd Floor</streetAddressLine>
<city>Boston</city> <state>MA</state> <postalCode>02116</postalCode>
<country>US</country>
</addr>
2.2.2.1.3 Person Phone/Email/URL Constraints The HL7 Clinical Document Architecture indicates how telecommunications addresses are to be represented. A telecommunications address appears in a <telecom> element.
C83-[DE-1.04-CDA-1] A home phone number SHALL be represented with a use attribute containing the value "HP"
C83-[DE-1.04-CDA-2] A vacation home phone number SHALL be represented with a use attribute containing the value "HV"
C83-[DE-1.04-CDA-3] A work phone number SHALL be represented with a use attribute containing the value "WP"
C83-[DE-1.04-CDA-4] A mobile phone number SHALL be represented with a use attribute containing the value "MC"
C83-[DE-1.04-CDA-5] An e-mail address SHALL appear in a <telecom> element using the 'mailto:' URL scheme (see IETF/RFC-2368), and SHALL encode only a single mailing address, without any headers

Person Phone/Email/URL Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<telecom use="HP" value='tel:+1-999-999-9999'/>
<!-- example 2 -->
<telecom use="WP" value='tel:+1-888-888-8888;ext=9999'/>
<!-- example 3 -->
<telecom use="MC" value='tel:+1-777-777-7777'/>
<!-- example 4 -->
<telecom value='mailto:user@hostname'/>
2.2.2.1.4 Gender Constraints Not Provided
C154-[DE-1.06-1] Gender SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.1.2 V3 Administrative Gender

Gender Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<genderCode code="M" displayName="Male" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGenderCode"/>
<!-- example 2 -->
<genderCode code="F" displayName="Female" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGenderCode"/>
2.2.2.1.5 Marital Status Constraints Not Provided
C154-[DE-1.08-1] Marital Status SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.3.2 Marital Status CDA and HLV3

Marital Status Constraints Example:

<maritalStatusCode code='M' displayName='Married' codeSystem='2.16.840.1.113883.5.2' codeSystemName='MaritalStatusCode'/>
2.2.2.1.6 Race Constraints Race is reported at the discretion of the patient, according to Federal Guidelines for race reporting.
C154-[DE-1.09-1] Race SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.7 Race
C83-[DE-1.09-CDA-1] Second and subsequent raceCode elements MAY be recorded using the sdtc:raceCode extension

Race Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<raceCode code='1004-1' displayName='American Indian' codeSystem='2.16.840.1.113883.6.238' codeSystemName='CDC Race and Ethnicity'/>
<!-- example 2 -->
<sdtc:raceCode code='2058-6' displayName='African American' codeSystem='2.16.840.1.113883.6.238' codeSystemName='CDC Race and Ethnicity'/>
2.2.2.1.7 Ethnicity Constraints Ethnicity is reported at the discretion of the patient, according to Federal Guidelines for ethnicity reporting.
C154-[DE-1.11-1] Ethnicity SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.2 Ethnicity

Ethnicity Constraints Example:

<!-- This example assumes the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<ethnicGroupCode code='2178-2' displayName='Latin American' codeSystem='2.16.840.1.113883.6.238' codeSystemName='CDC Race and Ethnicity'/>
2.2.2.1.8 Religious Affiliation Constraints Religious affiliation is recorded at the discretion of the patient.
C154-[DE-1.10--1] Religious affiliation SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.8 Religious Affiliation
C83-[DE-1.10-CDA-1] The primary religious affiliation MAY appear in the <religiousAffilliationCode> element

Religious Affiliation Constraints Example:

<!-- This example assumes the default namespace is 'urn:hl7-org:v3' -->
<religiousAffilliationCode code='1022' displayName='Independent'
codeSystem='2.16.840.1.113883.5.1076' codeSystemName='ReligiousAffiliation' />
2.2.2.1.9 Birth Place Constraints Not Provided
C154-[DE-1.16-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-1.16-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
C154-[DE-1.16-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
C32-[CT1--12] Person Information See HITSP/C83 Section 2.2.2.1 Personal Information
Scroll To Top