C-CDA on FHIR
1.2.0 - STU 1 United States of America flag

C-CDA on FHIR, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 1.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ccda-on-fhir/ and changes regularly. See the Directory of published versions

Resource Profile: Consultation Note

Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note Version: 1.2.0
Active as of 2024-03-12 Computable Name: ConsultationNote

The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.

A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).

2024 Publication of C-CDA ↔ FHIR US Core Mapping

The current release of this IG adds relevant mapping content from C-CDA ↔ FHIR mapping project which was related to the original C-CDA on FHIR work. These mappings are included under the "Mapping" heading and will undergo future updates for additional content.

Usage:

Formal Views of Profile Content

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

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... type S1..1CodeableConceptConsultation Note
Binding: ConsultDocumentType (required)
... encounter S1..1Reference(US Core Encounter Profile)encompassingEncounter
... Slices for section 0..*BackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
.... section:allergies_and_intolerances_section S1..1BackboneElementAllergies and Intolerances Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptAllergies and adverse reactions
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry S0..*Reference(US Core AllergyIntolerance Profile)A reference to data that supports this section
.... section:history_of_present_illness_section S1..1BackboneElementHistory of Present Illness Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHistory of present illness
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10164-2
..... text S1..1NarrativeThis section contains only human readable content
.... section:problem_section 1..1BackboneElementProblem Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProblem list
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry S0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:medications_section 0..1BackboneElementMedications Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of medication use
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)A reference to data that supports this section
.... section:physical_exam_section 0..1BackboneElementPhysical Exam Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptPhysical findings
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29545-1
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:results_section 0..1BackboneElementResults Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptRelevant diagnostic tests/laboratory data
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 30954-2
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(US Core Laboratory Result Observation Profile)A reference to data that supports this section
.... section:advance_directives_section S0..1BackboneElementAdvance Directives Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptAdvance directives
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 42348-3
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry S0..*Reference(Consent)A reference to data that supports this section
.... section:assessment_and_plan_section 0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
..... title 1..1stringtitle
..... code 1..1CodeableConceptAssessment (evaluation) and plan
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51847-2
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(US Core Condition Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:assessment_section 0..1BackboneElementAssessment Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptAssessments (evaluation)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51848-0
..... text 1..1NarrativeThis section contains only human readable content
.... section:chief_complaint_and_reason_for_visit_section 0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
..... title 1..1stringtitle
..... code 1..1CodeableConceptChief complaint and reason for visit
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46239-0
..... text 1..1NarrativeThis section contains only human readable content
.... section:chief_complaint_section 0..1BackboneElementChief Complaint Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptChief complaint
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10154-3
..... text 1..1NarrativeThis section contains only human readable content
.... section:family_history_section 0..1BackboneElementFamily History Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptFamily history
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10157-6
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:functional_status_section 0..1BackboneElementFunctional Status Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptFunctional status
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47420-5
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:general_status_section 0..1BackboneElementGeneral Status Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptPhysical findings of General status
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10210-3
..... text 1..1NarrativeThis section contains only human readable content
.... section:past_medical_history_section 0..1BackboneElementPast Medical History Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptPast Medical History
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11348-0
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:immunizations_section 0..1BackboneElementImmunizations Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of immunization
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11369-6
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(US Core Immunization Profile)A reference to data that supports this section
.... section:medical_equipment_section 0..1BackboneElementMedical Equipment Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of medical device use
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46264-8
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry S0..*Reference(Device | US Core Procedure Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:mental_status_section 0..1BackboneElementMental Status Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptMental status
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10190-7
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:nutrition_section 0..1BackboneElementNutrition Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptDiet and nutrition
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 61144-2
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(NutritionOrder | ClinicalImpression)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:plan_of_treatment_section 0..1BackboneElementPlan of Treatment Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptPlan of treatment
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 18776-5
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:procedures_section 0..1BackboneElementProcedures Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of Procedures
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47519-4
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(US Core Procedure Profile)A reference to data that supports this section
.... section:reason_for_visit_section 0..1BackboneElementReason for Visit Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptReason for visit
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29299-5
..... text 1..1NarrativeThis section contains only human readable content
.... section:review_of_systems_section 0..1BackboneElementReview of Systems Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptReview of systems
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10187-3
..... text 1..1NarrativeThis section contains only human readable content
.... section:social_history_section 0..1BackboneElementSocial History Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptSocial history
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29762-2
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(US Core Smoking Status Observation Profile)Smoking status
.... section:vital_signs_section 0..1BackboneElementVital Signs Section
..... title 1..1stringtitle
..... code 1..1CodeableConceptVital signs
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
..... text 1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..*Reference(Vital Signs Profile)A reference to data that supports this section

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typerequiredConsultDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language S1..1codelanguage
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... versionNumber 0..*stringVersion-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
... data_enterer_extension S0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
... informant_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
... information_recipient_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile)informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
... participant_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
... performer_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
... authorization_extension S0..*Reference(Consent)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
... order_extension S0..*Reference(ServiceRequest)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ1..1Identifieridentifier
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptConsultation Note
Binding: ConsultDocumentType (required)
... subject SΣ0..1Reference(US Core Patient Profile | Group)Who and/or what the composition is about
... encounter SΣ1..1Reference(US Core Encounter Profile)encompassingEncounter
... date SΣ1..1dateTimedate
... author SΣ1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson)Who and/or what authored the composition
... title SΣ1..1stringDocument Title
... Slices for attester 0..*BackboneElementAttests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... attester:legal_attester S0..1BackboneElementattester
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.


Fixed Value: legal
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:professional_attester S0..*BackboneElementattester
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.


Fixed Value: professional
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:personal_attester S0..*BackboneElementattester
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.


Fixed Value: personal
..... party S1..1Reference(US Core Patient Profile | RelatedPerson)party
... custodian SΣ1..1Reference(US Core Organization Profile)custodian
... Slices for section C0..*BackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... section:allergies_and_intolerances_section SC1..1BackboneElementAllergies and Intolerances Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptAllergies and adverse reactions
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry SC0..*Reference(US Core AllergyIntolerance Profile)A reference to data that supports this section
.... section:history_of_present_illness_section SC1..1BackboneElementHistory of Present Illness Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptHistory of present illness
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10164-2
..... text SC1..1NarrativeThis section contains only human readable content
.... section:problem_section C1..1BackboneElementProblem Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptProblem list
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:medications_section C0..1BackboneElementMedications Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of medication use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)A reference to data that supports this section
.... section:physical_exam_section C0..1BackboneElementPhysical Exam Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptPhysical findings
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29545-1
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:results_section C0..1BackboneElementResults Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptRelevant diagnostic tests/laboratory data
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 30954-2
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Laboratory Result Observation Profile)A reference to data that supports this section
.... section:advance_directives_section SC0..1BackboneElementAdvance Directives Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptAdvance directives
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 42348-3
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry SC0..*Reference(Consent)A reference to data that supports this section
.... section:assessment_and_plan_section C0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptAssessment (evaluation) and plan
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51847-2
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Condition Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:assessment_section C0..1BackboneElementAssessment Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptAssessments (evaluation)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51848-0
..... text C1..1NarrativeThis section contains only human readable content
.... section:chief_complaint_and_reason_for_visit_section C0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptChief complaint and reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46239-0
..... text C1..1NarrativeThis section contains only human readable content
.... section:chief_complaint_section C0..1BackboneElementChief Complaint Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptChief complaint
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10154-3
..... text C1..1NarrativeThis section contains only human readable content
.... section:family_history_section C0..1BackboneElementFamily History Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptFamily history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10157-6
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:functional_status_section C0..1BackboneElementFunctional Status Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptFunctional status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47420-5
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:general_status_section C0..1BackboneElementGeneral Status Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptPhysical findings of General status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10210-3
..... text C1..1NarrativeThis section contains only human readable content
.... section:past_medical_history_section C0..1BackboneElementPast Medical History Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptPast Medical History
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11348-0
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:immunizations_section C0..1BackboneElementImmunizations Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of immunization
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11369-6
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Immunization Profile)A reference to data that supports this section
.... section:medical_equipment_section C0..1BackboneElementMedical Equipment Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of medical device use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46264-8
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry SC0..*Reference(Device | US Core Procedure Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:mental_status_section C0..1BackboneElementMental Status Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptMental status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10190-7
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:nutrition_section C0..1BackboneElementNutrition Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptDiet and nutrition
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 61144-2
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(NutritionOrder | ClinicalImpression)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:plan_of_treatment_section C0..1BackboneElementPlan of Treatment Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptPlan of treatment
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 18776-5
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:procedures_section C0..1BackboneElementProcedures Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptHistory of Procedures
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47519-4
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Procedure Profile)A reference to data that supports this section
.... section:reason_for_visit_section C0..1BackboneElementReason for Visit Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptReason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29299-5
..... text C1..1NarrativeThis section contains only human readable content
.... section:review_of_systems_section C0..1BackboneElementReview of Systems Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptReview of systems
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10187-3
..... text C1..1NarrativeThis section contains only human readable content
.... section:social_history_section C0..1BackboneElementSocial History Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptSocial history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29762-2
..... text C1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Smoking Status Observation Profile)Smoking status
.... section:vital_signs_section C0..1BackboneElementVital Signs Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code 1..1CodeableConceptVital signs
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)