Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection | Version: 2.1 | |||
| Draft as of 2023-09-29 | Computable Name: PlanofTreatmentSection | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09 | ||||
This section, formerly known as “Plan of Care”, contains data that define pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. These are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed.
This section may also contain information about ongoing care of the patient, clinical reminders, patient’s values, beliefs, preferences, care expectations, and overarching care goals.
Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures.
Values may include the importance of quality of life over longevity. These values are taken into account when prioritizing all problems and their treatments.
Beliefs may include comfort with dying or the refusal of blood transfusions because of the patient’s religious convictions.
Preferences may include liquid medicines over tablets, or treatment via secure email instead of in person.
Care expectations may range from being treated only by female clinicians, to expecting all calls to be returned within 24 hours.
Overarching goals described in this section are not tied to a specific condition, problem, health concern, or intervention. Examples of overarching goals could be to minimize pain or dependence on others, or to walk a daughter down the aisle for her marriage.
The plan may also indicate that patient education will be provided.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Section | CDAR2.Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component | ||
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.10 | |
  extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| code | 1..1 | CE | ||
 code | 1..1 | cs | Required Pattern: 18776-5 | |
 codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | ||
| text | 1..1 | xhtml | ||
 Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply | |
 entry:plannedObs | 0..* | Entry | ||
  observation | 1..1 | PlannedObservation | Base for all types and resources | |
| entry:plannedEnc | 0..* | Entry | ||
| encounter | 1..1 | PlannedEncounter | Base for all types and resources | |
| entry:plannedAct | 0..* | Entry | ||
| act | 1..1 | PlannedAct | Base for all types and resources | |
| entry:plannedProc | 0..* | Entry | ||
| procedure | 1..1 | PlannedProcedure | Base for all types and resources | |
| entry:plannedMed | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedMedicationActivity | Base for all types and resources | |
| entry:plannedSupply | 0..* | Entry | ||
| supply | 1..1 | PlannedSupply | Base for all types and resources | |
| entry:instruction | 0..* | Entry | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entry:handoffCommParticipants | 0..* | Entry | ||
| act | 1..1 | HandoffCommunicationParticipants | Base for all types and resources | |
| entry:nutrition | 0..* | Entry | ||
| act | 1..1 | NutritionRecommendation | Base for all types and resources | |
| entry:plannedImmunization | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedImmunizationActivity | Base for all types and resources | |
| entry:goal | 0..* | Entry | ||
| observation | 1..1 | GoalObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section | 1..1 | CDAR2.Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.10 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| code | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
| @code | 1..1 | cs | Required Pattern: 18776-5 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | ||
| text | S | 1..1 | xhtml | |
| Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply | |
| entry:plannedObs | 0..* | Entry | ||
| observation | 1..1 | PlannedObservation | Base for all types and resources | |
| entry:plannedEnc | 0..* | Entry | ||
| encounter | 1..1 | PlannedEncounter | Base for all types and resources | |
| entry:plannedAct | 0..* | Entry | ||
| act | 1..1 | PlannedAct | Base for all types and resources | |
| entry:plannedProc | 0..* | Entry | ||
| procedure | 1..1 | PlannedProcedure | Base for all types and resources | |
| entry:plannedMed | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedMedicationActivity | Base for all types and resources | |
| entry:plannedSupply | 0..* | Entry | ||
| supply | 1..1 | PlannedSupply | Base for all types and resources | |
| entry:instruction | 0..* | Entry | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entry:handoffCommParticipants | 0..* | Entry | ||
| act | 1..1 | HandoffCommunicationParticipants | Base for all types and resources | |
| entry:nutrition | 0..* | Entry | ||
| act | 1..1 | NutritionRecommendation | Base for all types and resources | |
| entry:plannedImmunization | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedImmunizationActivity | Base for all types and resources | |
| entry:goal | 0..* | Entry | ||
| observation | 1..1 | GoalObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Section.code | extensible | DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
| Path | Conformance | ValueSet / Code |
| Section.nullFlavor | required | NullFlavor |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.templateId:primary.nullFlavor | required | NullFlavor |
| Section.code | extensible | DocumentSectionType |
| Section.code.nullFlavor | required | NullFlavor |
| Section.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Section.entry:plannedObs.nullFlavor | required | NullFlavor |
| Section.entry:plannedObs.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedEnc.nullFlavor | required | NullFlavor |
| Section.entry:plannedEnc.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedAct.nullFlavor | required | NullFlavor |
| Section.entry:plannedAct.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedProc.nullFlavor | required | NullFlavor |
| Section.entry:plannedProc.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedMed.nullFlavor | required | NullFlavor |
| Section.entry:plannedMed.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedSupply.nullFlavor | required | NullFlavor |
| Section.entry:plannedSupply.typeCode | required | XActRelationshipEntry |
| Section.entry:instruction.nullFlavor | required | NullFlavor |
| Section.entry:instruction.typeCode | required | XActRelationshipEntry |
| Section.entry:handoffCommParticipants.nullFlavor | required | NullFlavor |
| Section.entry:handoffCommParticipants.typeCode | required | XActRelationshipEntry |
| Section.entry:nutrition.nullFlavor | required | NullFlavor |
| Section.entry:nutrition.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedImmunization.nullFlavor | required | NullFlavor |
| Section.entry:plannedImmunization.typeCode | required | XActRelationshipEntry |
| Section.entry:goal.nullFlavor | required | NullFlavor |
| Section.entry:goal.typeCode | required | XActRelationshipEntry |
| Section.component.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Section
Summary
Mandatory: 9 elements (11 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Section
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section | CDAR2.Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.10 | |
| extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| code | 1..1 | CE | ||
| code | 1..1 | cs | Required Pattern: 18776-5 | |
| codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | ||
| text | 1..1 | xhtml | ||
| Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply | |
| entry:plannedObs | 0..* | Entry | ||
| observation | 1..1 | PlannedObservation | Base for all types and resources | |
| entry:plannedEnc | 0..* | Entry | ||
| encounter | 1..1 | PlannedEncounter | Base for all types and resources | |
| entry:plannedAct | 0..* | Entry | ||
| act | 1..1 | PlannedAct | Base for all types and resources | |
| entry:plannedProc | 0..* | Entry | ||
| procedure | 1..1 | PlannedProcedure | Base for all types and resources | |
| entry:plannedMed | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedMedicationActivity | Base for all types and resources | |
| entry:plannedSupply | 0..* | Entry | ||
| supply | 1..1 | PlannedSupply | Base for all types and resources | |
| entry:instruction | 0..* | Entry | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entry:handoffCommParticipants | 0..* | Entry | ||
| act | 1..1 | HandoffCommunicationParticipants | Base for all types and resources | |
| entry:nutrition | 0..* | Entry | ||
| act | 1..1 | NutritionRecommendation | Base for all types and resources | |
| entry:plannedImmunization | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedImmunizationActivity | Base for all types and resources | |
| entry:goal | 0..* | Entry | ||
| observation | 1..1 | GoalObservation | Base for all types and resources | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section | 1..1 | CDAR2.Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.10 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| code | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
| @code | 1..1 | cs | Required Pattern: 18776-5 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | ||
| text | S | 1..1 | xhtml | |
| Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply | |
| entry:plannedObs | 0..* | Entry | ||
| observation | 1..1 | PlannedObservation | Base for all types and resources | |
| entry:plannedEnc | 0..* | Entry | ||
| encounter | 1..1 | PlannedEncounter | Base for all types and resources | |
| entry:plannedAct | 0..* | Entry | ||
| act | 1..1 | PlannedAct | Base for all types and resources | |
| entry:plannedProc | 0..* | Entry | ||
| procedure | 1..1 | PlannedProcedure | Base for all types and resources | |
| entry:plannedMed | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedMedicationActivity | Base for all types and resources | |
| entry:plannedSupply | 0..* | Entry | ||
| supply | 1..1 | PlannedSupply | Base for all types and resources | |
| entry:instruction | 0..* | Entry | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entry:handoffCommParticipants | 0..* | Entry | ||
| act | 1..1 | HandoffCommunicationParticipants | Base for all types and resources | |
| entry:nutrition | 0..* | Entry | ||
| act | 1..1 | NutritionRecommendation | Base for all types and resources | |
| entry:plannedImmunization | 0..* | Entry | ||
| substanceAdministration | 1..1 | PlannedImmunizationActivity | Base for all types and resources | |
| entry:goal | 0..* | Entry | ||
| observation | 1..1 | GoalObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Section.code | extensible | DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
| Path | Conformance | ValueSet / Code |
| Section.nullFlavor | required | NullFlavor |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.templateId:primary.nullFlavor | required | NullFlavor |
| Section.code | extensible | DocumentSectionType |
| Section.code.nullFlavor | required | NullFlavor |
| Section.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Section.entry:plannedObs.nullFlavor | required | NullFlavor |
| Section.entry:plannedObs.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedEnc.nullFlavor | required | NullFlavor |
| Section.entry:plannedEnc.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedAct.nullFlavor | required | NullFlavor |
| Section.entry:plannedAct.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedProc.nullFlavor | required | NullFlavor |
| Section.entry:plannedProc.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedMed.nullFlavor | required | NullFlavor |
| Section.entry:plannedMed.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedSupply.nullFlavor | required | NullFlavor |
| Section.entry:plannedSupply.typeCode | required | XActRelationshipEntry |
| Section.entry:instruction.nullFlavor | required | NullFlavor |
| Section.entry:instruction.typeCode | required | XActRelationshipEntry |
| Section.entry:handoffCommParticipants.nullFlavor | required | NullFlavor |
| Section.entry:handoffCommParticipants.typeCode | required | XActRelationshipEntry |
| Section.entry:nutrition.nullFlavor | required | NullFlavor |
| Section.entry:nutrition.typeCode | required | XActRelationshipEntry |
| Section.entry:plannedImmunization.nullFlavor | required | NullFlavor |
| Section.entry:plannedImmunization.typeCode | required | XActRelationshipEntry |
| Section.entry:goal.nullFlavor | required | NullFlavor |
| Section.entry:goal.typeCode | required | XActRelationshipEntry |
| Section.component.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Section
Summary
Mandatory: 9 elements (11 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1 based on FHIR 5.0.0. Generated 2023-09-29
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