Consolidated CDA (C-CDA)
3.0.0 - STU United States of America flag

Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 3.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: Past Medical History

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PastMedicalHistory Version: 3.0.0
Draft as of 2024-05-07 Computable Name: PastMedicalHistory
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.20:2015-08-01

This section contains a record of the patient’s past complaints, problems, and diagnoses. It contains data from the patient’s past up to the patient’s current complaint or reason for seeking medical care.

Usage:

Formal Views of Template Content

Description of Template, Differentials, Snapshots and how the different presentations work.

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.20
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE History of Past illness Narrative
.... @code 1..1 cs Required Pattern: 11348-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:problem 0..* Entry
..... observation 1..1 ProblemObservation Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
...... effectiveTime C 1..1 IVL_TS If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
should-high: SHOULD contain high

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-highwarningSection.entry:problem.observation.effectiveTimeSHOULD contain high
: high.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.20
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE History of Past illness Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 11348-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:problem 0..* Entry
..... observation C 1..1 ProblemObservation Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:problem-obs 1..1 II
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.4
........ @extension 1..1 st Required Pattern: 2024-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... id 1..* II
...... code 1..1 CD Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 (preferred)
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @code 1..1 cs Fixed Value: completed
...... effectiveTime C 1..1 IVL_TS If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
should-high: SHOULD contain high
....... low 1..1 IVXB_TS The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
...... value 1..1 CD (USCDI) SDOH Problems/Health Concerns
Binding: US Core Condition Codes (preferred)
...... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, profile:act
....... entryRelationship:age 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
........ @inversionInd 1..1 bl Fixed Value: true
........ observation C 1..1 AgeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:prognosis 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ observation C 1..1 PrognosisObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:priority 0..* EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
....... entryRelationship:status 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ observation C 1..1 ProblemStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:reference 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:assessment 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ observation C 1..1 AssessmentScaleObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:dateOfDiagnosis 0..1 EntryRelationship (USCDI) Date of Diagnosis
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
........ act C 1..1 DateOfDiagnosisAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.entry:problem.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Section.entry:problem.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Section.entry:problem.observation.codepreferredhttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
Section.entry:problem.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Section.entry:problem.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Section.entry:problem.observation.entryRelationship:age.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:prognosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:priority.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:status.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:reference.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:assessment.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:problem.observation.entryRelationship:priority.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-highwarningSection.entry:problem.observation.effectiveTimeSHOULD contain high
: high.exists()
should-text-ref-valuewarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.20
..... @extension 1..1 st Required Pattern: 2015-08-01
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE History of Past illness Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 11348-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:problem 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 ProblemObservation Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:problem-obs 1..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.4
........ @extension 1..1 st Required Pattern: 2024-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... @negationInd 0..1 bl The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
...... id 1..* II
...... code 1..1 CD Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 (preferred)
...... derivationExpr 0..1 ST
...... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
....... @integrityCheck 0..1 bin
....... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
....... @language 0..1 cs
....... @mediaType 0..1 cs Binding: MediaType (example)
....... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
....... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
....... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
....... thumbnail 0..1 ED
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 1..1 cs Fixed Value: completed
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... effectiveTime C 1..1 IVL_TS If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
should-high: SHOULD contain high
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @operator 0..1 cs Binding: CDASetOperator (required)
....... low 1..1 IVXB_TS The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
....... center 0..1 TS
....... width 0..1 PQ
....... high 0..1 IVXB_TS (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved.
...... priorityCode 0..1 CE Binding: ActPriority (example)
...... repeatNumber 0..1 IVL_INT
...... languageCode 0..1 CS Binding: AllLanguages (required)
...... value 1..1 CD (USCDI) SDOH Problems/Health Concerns
Binding: US Core Condition Codes (preferred)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 0..1 cs A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
Binding: (unbound) (example): See additional binding

Additional BindingsPurposeDocumentation
Social Determinants of Health Conditions . Preferred Binding
Social Determinant of Health Observations
....... @codeSystem 0..1 oid, uuid, ruid
....... @codeSystemName 0..1 st
....... @codeSystemVersion 0..1 st
....... @displayName 0..1 st
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1 ED
....... qualifier 0..* CR The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
....... translation 0..* CD
...... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
...... methodCode 0..* CE Binding: ObservationMethod (example)
...... targetSiteCode 0..* CD
...... subject 0..1 Subject
...... specimen 0..* Specimen
...... performer 0..* Performer2
...... author 0..* AuthorParticipation Base for all types and resources
...... informant 0..* Informant
...... participant 0..* Participant2
...... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, profile:act
....... entryRelationship:age 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
........ @inversionInd 1..1 bl Fixed Value: true
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 AgeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:prognosis 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 PrognosisObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:priority 0..* EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:status 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 ProblemStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:reference 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ encounter 0..1 Encounter
........ observation 0..1 Observation
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:assessment 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 AssessmentScaleObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:dateOfDiagnosis 0..1 EntryRelationship (USCDI) Date of Diagnosis
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act C 1..1 DateOfDiagnosisAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ encounter 0..1 Encounter
........ observation 0..1 Observation
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
...... reference 0..* Reference
...... precondition 0..* Precondition
...... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
...... referenceRange 0..* InfrastructureRoot
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: REFV
....... observationRange 1..1 ObservationRange
...... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:problem.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:problem.observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.templateId:problem-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Section.entry:problem.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Section.entry:problem.observation.codepreferredhttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
Section.entry:problem.observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Section.entry:problem.observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Section.entry:problem.observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Section.entry:problem.observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Section.entry:problem.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Section.entry:problem.observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.effectiveTime.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.effectiveTime.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
Section.entry:problem.observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Section.entry:problem.observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:problem.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Section.entry:problem.observation.value.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.value.codeexample
Section.entry:problem.observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Section.entry:problem.observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Section.entry:problem.observation.entryRelationship:age.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:age.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:prognosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:prognosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:priority.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:priority.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:status.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:status.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:reference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:reference.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:assessment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:assessment.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.referenceRange.typeCoderequiredFixed Value: REFV
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:problem.observation.entryRelationship:priority.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-highwarningSection.entry:problem.observation.effectiveTimeSHOULD contain high
: high.exists()
should-text-ref-valuewarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorSection.entry:problem.observation.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Section

Summary

Mandatory: 9 elements(1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Section.templateId
  • The element 1 is sliced based on the value of Section.entry

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.20
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE History of Past illness Narrative
.... @code 1..1 cs Required Pattern: 11348-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:problem 0..* Entry
..... observation 1..1 ProblemObservation Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
...... effectiveTime C 1..1 IVL_TS If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
should-high: SHOULD contain high

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-highwarningSection.entry:problem.observation.effectiveTimeSHOULD contain high
: high.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.20
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE History of Past illness Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 11348-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:problem 0..* Entry
..... observation C 1..1 ProblemObservation Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:problem-obs 1..1 II
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.4
........ @extension 1..1 st Required Pattern: 2024-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... id 1..* II
...... code 1..1 CD Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 (preferred)
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @code 1..1 cs Fixed Value: completed
...... effectiveTime C 1..1 IVL_TS If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
should-high: SHOULD contain high
....... low 1..1 IVXB_TS The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
...... value 1..1 CD (USCDI) SDOH Problems/Health Concerns
Binding: US Core Condition Codes (preferred)
...... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, profile:act
....... entryRelationship:age 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
........ @inversionInd 1..1 bl Fixed Value: true
........ observation C 1..1 AgeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:prognosis 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ observation C 1..1 PrognosisObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:priority 0..* EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
....... entryRelationship:status 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ observation C 1..1 ProblemStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:reference 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:assessment 0..1 EntryRelationship
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ observation C 1..1 AssessmentScaleObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
....... entryRelationship:dateOfDiagnosis 0..1 EntryRelationship (USCDI) Date of Diagnosis
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
........ act C 1..1 DateOfDiagnosisAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.entry:problem.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Section.entry:problem.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Section.entry:problem.observation.codepreferredhttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
Section.entry:problem.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Section.entry:problem.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Section.entry:problem.observation.entryRelationship:age.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:prognosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:priority.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:status.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:reference.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:assessment.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:problem.observation.entryRelationship:priority.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-highwarningSection.entry:problem.observation.effectiveTimeSHOULD contain high
: high.exists()
should-text-ref-valuewarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.20
..... @extension 1..1 st Required Pattern: 2015-08-01
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE History of Past illness Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 11348-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:problem 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 ProblemObservation Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:problem-obs 1..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.4
........ @extension 1..1 st Required Pattern: 2024-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... @negationInd 0..1 bl The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
...... id 1..* II
...... code 1..1 CD Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 (preferred)
...... derivationExpr 0..1 ST
...... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
....... @integrityCheck 0..1 bin
....... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
....... @language 0..1 cs
....... @mediaType 0..1 cs Binding: MediaType (example)
....... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
....... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
....... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
....... thumbnail 0..1 ED
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 1..1 cs Fixed Value: completed
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... effectiveTime C 1..1 IVL_TS If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
should-high: SHOULD contain high
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
....... @operator 0..1 cs Binding: CDASetOperator (required)
....... low 1..1 IVXB_TS The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
....... center 0..1 TS
....... width 0..1 PQ
....... high 0..1 IVXB_TS (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved.
...... priorityCode 0..1 CE Binding: ActPriority (example)
...... repeatNumber 0..1 IVL_INT
...... languageCode 0..1 CS Binding: AllLanguages (required)
...... value 1..1 CD (USCDI) SDOH Problems/Health Concerns
Binding: US Core Condition Codes (preferred)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 0..1 cs A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
Binding: (unbound) (example): See additional binding

Additional BindingsPurposeDocumentation
Social Determinants of Health Conditions . Preferred Binding
Social Determinant of Health Observations
....... @codeSystem 0..1 oid, uuid, ruid
....... @codeSystemName 0..1 st
....... @codeSystemVersion 0..1 st
....... @displayName 0..1 st
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1 ED
....... qualifier 0..* CR The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
....... translation 0..* CD
...... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
...... methodCode 0..* CE Binding: ObservationMethod (example)
...... targetSiteCode 0..* CD
...... subject 0..1 Subject
...... specimen 0..* Specimen
...... performer 0..* Performer2
...... author 0..* AuthorParticipation Base for all types and resources
...... informant 0..* Informant
...... participant 0..* Participant2
...... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, profile:act
....... entryRelationship:age 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
........ @inversionInd 1..1 bl Fixed Value: true
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 AgeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:prognosis 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 PrognosisObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:priority 0..* EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:status 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 ProblemStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:reference 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ encounter 0..1 Encounter
........ observation 0..1 Observation
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:assessment 0..1 EntryRelationship
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act 0..1 Act
........ encounter 0..1 Encounter
........ observation C 1..1 AssessmentScaleObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
....... entryRelationship:dateOfDiagnosis 0..1 EntryRelationship (USCDI) Date of Diagnosis
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ realmCode 0..* CS
........ typeId 0..1 II
......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
......... @assigningAuthorityName 0..1 st
......... @displayable 0..1 bl
......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
......... @extension 1..1 st
........ templateId 0..* II
........ @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
........ @inversionInd 0..1 bl
........ @contextConductionInd 0..1 bl
........ @negationInd 0..1 bl
........ sequenceNumber 0..1 INT
........ seperatableInd 0..1 BL
........ act C 1..1 DateOfDiagnosisAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
........ encounter 0..1 Encounter
........ observation 0..1 Observation
........ observationMedia 0..1 ObservationMedia
........ organizer 0..1 Organizer
........ procedure 0..1 Procedure
........ regionOfInterest 0..1 RegionOfInterest
........ substanceAdministration 0..1 SubstanceAdministration
........ supply 0..1 Supply
...... reference 0..* Reference
...... precondition 0..* Precondition
...... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
...... referenceRange 0..* InfrastructureRoot
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: REFV
....... observationRange 1..1 ObservationRange
...... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:problem.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:problem.observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.templateId:problem-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Section.entry:problem.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Section.entry:problem.observation.codepreferredhttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
Section.entry:problem.observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Section.entry:problem.observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Section.entry:problem.observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Section.entry:problem.observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Section.entry:problem.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Section.entry:problem.observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.effectiveTime.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.effectiveTime.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
Section.entry:problem.observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Section.entry:problem.observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:problem.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Section.entry:problem.observation.value.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.value.codeexample
Section.entry:problem.observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Section.entry:problem.observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Section.entry:problem.observation.entryRelationship:age.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:age.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:prognosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:prognosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:priority.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:priority.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:status.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:status.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:reference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:reference.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:assessment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:assessment.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Section.entry:problem.observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:problem.observation.referenceRange.typeCoderequiredFixed Value: REFV
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:problem.observation.entryRelationship:priority.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-highwarningSection.entry:problem.observation.effectiveTimeSHOULD contain high
: high.exists()
should-text-ref-valuewarningSection.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorSection.entry:problem.observation.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Section

Summary

Mandatory: 9 elements(1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Section.templateId
  • The element 1 is sliced based on the value of Section.entry

 

Other representations of profile: CSV, Excel