Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: EncounterDiagnosis - Detailed Descriptions

Active as of 2022-05-13

Definitions for the 2.16.840.1.113883.10.20.22.4.80 resource profile.

1. Act
Control1..1
2. Act.classCode
Control1..1
Typecode
Requirements

SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-14889).

Pattern ValueACT
3. Act.moodCode
Control1..1
Typecode
Requirements

SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-14890).

Pattern ValueEVN
4. Act.realmCode
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
5. Act.typeId
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
6. Act.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
SlicingThis element introduces a set of slices on Act.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • ,
  • value @ extension
7. Act.templateId:primary
SliceNameprimary
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain exactly one [1..1] templateId (CONF:1198-14895) such that it

8. Act.templateId:primary.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
9. Act.templateId:primary.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring
10. Act.templateId:primary.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean
11. Act.templateId:primary.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.80" (CONF:1198-14896).

Pattern Value2.16.840.1.113883.10.20.22.4.80
12. Act.templateId:primary.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32542).

Pattern Value2015-08-01
13. Act.id
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
14. Act.code
Control1..1
BindingThe codes SHALL be taken from v3 Code System ActCode; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

SHALL contain exactly one [1..1] code (CONF:1198-19182).

15. Act.code.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
16. Act.code.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control1..1
Typestring
Requirements

This code SHALL contain exactly one [1..1] @code="29308-4" Diagnosis (CONF:1198-19183).

Pattern Value29308-4
17. Act.code.codeSystem
Definition

Specifies the code system that defines the code.

Control1..1
Typestring
Requirements

This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32160).

Pattern Value2.16.840.1.113883.6.1
18. Act.code.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring
19. Act.code.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring
20. Act.code.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring
21. Act.code.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring
22. Act.code.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring
23. Act.code.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
24. Act.code.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
25. Act.code.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
26. Act.negationInd
Control0..1
Typeboolean
27. Act.text
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
28. Act.statusCode
Control0..1
BindingThe codes SHALL be taken from ActStatus
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
29. Act.effectiveTime
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS
30. Act.priorityCode
Control0..1
BindingThe codes SHALL be taken from ActPriority; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
31. Act.languageCode
Control0..1
BindingThe codes SHALL be taken from HumanLanguage
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
32. Act.subject
Control0..1
TypeElement
33. Act.subject.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationTargetSubject
Typecode
Default ValueSBJ
Fixed ValueSBJ
34. Act.subject.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
35. Act.subject.awarenessCode
Control0..1
BindingThe codes SHALL be taken from TargetAwareness; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
36. Act.subject.relatedSubject
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedSubject
37. Act.specimen
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Specimen
38. Act.performer
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Performer2
39. Act.author
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Author
40. Act.informant
Control0..*
TypeElement
41. Act.informant.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationInformationGenerator
Typecode
Default ValueINF
Fixed ValueINF
42. Act.informant.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
43. Act.informant.assignedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/AssignedEntity
44. Act.informant.relatedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedEntity
45. Act.participant
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Participant2
46. Act.entryRelationship
Control0..*
TypeElement
InvariantsDefined on this element
act-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act (: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1)
SlicingThis element introduces a set of slices on Act.entryRelationship. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • profile @ observation
47. Act.entryRelationship.typeCode
Control1..1
Typecode
48. Act.entryRelationship.inversionInd
Control0..1
Typeboolean
49. Act.entryRelationship.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
50. Act.entryRelationship.sequenceNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/INT
51. Act.entryRelationship.negationInd
Control0..1
Typeboolean
52. Act.entryRelationship.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
53. Act.entryRelationship.observation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation
54. Act.entryRelationship.regionOfInterest
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
55. Act.entryRelationship.observationMedia
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
56. Act.entryRelationship.substanceAdministration
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
57. Act.entryRelationship.supply
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
58. Act.entryRelationship.procedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
59. Act.entryRelationship.encounter
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
60. Act.entryRelationship.organizer
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
61. Act.entryRelationship.act
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
62. Act.entryRelationship:problemObservation
SliceNameproblemObservation
Control1..*
TypeElement
Requirements

SHALL contain at least one [1..*] entryRelationship (CONF:1198-14892) such that it

InvariantsDefined on this element
act-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act (: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1)
63. Act.entryRelationship:problemObservation.typeCode
Control1..1
Typecode
Requirements

SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-14893).

Pattern ValueSUBJ
64. Act.entryRelationship:problemObservation.inversionInd
Control0..1
Typeboolean
65. Act.entryRelationship:problemObservation.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
66. Act.entryRelationship:problemObservation.sequenceNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/INT
67. Act.entryRelationship:problemObservation.negationInd
Control0..1
Typeboolean
68. Act.entryRelationship:problemObservation.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
69. Act.entryRelationship:problemObservation.observation
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation(ProblemObservation)
Requirements

SHALL contain exactly one [1..1] Problem Observation (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2015-08-01) (CONF:1198-14898).

70. Act.entryRelationship:problemObservation.regionOfInterest
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
71. Act.entryRelationship:problemObservation.observationMedia
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
72. Act.entryRelationship:problemObservation.substanceAdministration
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
73. Act.entryRelationship:problemObservation.supply
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
74. Act.entryRelationship:problemObservation.procedure
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
75. Act.entryRelationship:problemObservation.encounter
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
76. Act.entryRelationship:problemObservation.organizer
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
77. Act.entryRelationship:problemObservation.act
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
78. Act.reference
Control0..*
TypeElement
79. Act.reference.typeCode
Control1..1
Typecode
80. Act.reference.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
81. Act.reference.externalAct
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalAct
82. Act.reference.externalObservation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalObservation
83. Act.reference.externalProcedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure
84. Act.reference.externalDocument
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalDocument
85. Act.precondition
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Precondition